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preoperative diagnosis:, nuclear sclerotic cataract, right eye.,postoperative diagnosis:, nuclear sclerotic cataract, right eye.,operative procedures:, kelman phacoemulsification with posterior chamber intraocular lens, right eye.,anesthesia:, topical.,complications:, none.,indication: , this is a 40-year-old male, who has been noticing problems with blurry vision. they were found to have a visually significant cataract. the risks, benefits, and alternatives of cataract surgery to the right eye were discussed and they did agree to proceed.,description of procedure:, after informed consent was obtained, the patient was taken to the operating room. a drop of tetracaine was instilled in the right eye and the right eye was prepped and draped in the usual sterile ophthalmic fashion. a paracentesis was created at ** o'clock. the anterior chamber was filled with viscoat. a clear corneal incision was made at ** o'clock with the 3-mm diamond blade. a continuous curvilinear capsulorrhexis was begun with a cystotome and completed with utrata forceps. the lens was hydrodissected with a syringe filled with 2% xylocaine and found to rotate freely within the capsular bag. the nucleus was removed with the phacoemulsification handpiece in a stop and chop fashion. the residual cortex was removed with the irrigation/aspiration handpiece. the capsular bag was filled with provisc and a model si40, 15.0 diopter, posterior chamber intraocular lens was inserted into the capsular bag without complications and was found to rotate and center well. the residual provisc was removed with the irrigation/aspiration handpiece. the wounds were hydrated and the eye was filled to suitable intraocular pressure with balanced salt solution. the wounds were found to be free from leak. zymar and pred forte were instilled postoperatively. the eye was covered with the shield.,the patient tolerated the procedure well and there were no complications. he will follow up with us in one day.

type of consultation:, wound care consult.,history of present illness:, the patient is a 62-year-old woman with a past medical history significant for prior ileojejunal bypass for weight loss (1980) and then subsequent gastric banding (2002 dr. x) who was transferred to this facility following a complicated surgical and postoperative course after takedown of the prior gastroplasty and bypass (07/08/2008, dr. y). the patient has been followed by cardiothoracic surgery (dr. z) as an outpatient. she had a history of daily postprandial vomiting, regurgitation, and heartburn. she underwent a preop assessment of her gerd and postprandial vomiting including nuclear gastric emptying studies, which showed increased esophageal retention with normal gastric emptying. preoperative barium swallow demonstrated moderated esophageal dysmotility with incomplete emptying and a small hiatal hernia. it was recommended that she undergo an exploratory laparotomy and possible redo fundoplication and possible gastrectomy. she had already undergone multiple egds with dilatations without success. she continued to have abdominal discomfort.,on 07/07/2008, she was admitted to hospital. she underwent an exploratory laparotomy with esophagogastrectomy with esophagogastric anastomosis and dor fundoplication, repair of hiatal hernia, small bowel resection x2 with primary anastomosis, extensive lysis of adhesions, insertion of a red-rubber j tube, and esophagogastroduodenoscopy. she also had her ileojejunal bypass reversed. postoperatively, she was able to be extubated. she was started on tpn, given the risk of not being able to tolerate enteral nutrition. her operative note confirmed that the stomach pouch was enlarged with outlet obstruction where the band was. there was 2 hours of extensive lysis of adhesions. it took 2 hours to identify the colon. a defect was repaired in the transverse colon. the bypass segment of the anastomosis was seen between the proximal jejunum and the distal ileum, which was divided and the proximal jejunum was reconnected to the atretic blind limb of the small bowel. a red feeding tube was placed proximal to the anastomosis then tended to cross the anastomosis into the distal atretic small bowel for enteral feeds. the hiatal hernia was repaired as noted. the obstructed proximal gastric segment was resected. an anastomosis was made between the proximal intestine and the stomach and distal esophagus with dor fundoplication. omentectomy was performed due to devascularization. the wound was able to be closed with staples.,postoperatively, the patient was started on iv antibiotics. she was able to be extubated. however, on 07/14/2008, she coded with shortness of breath and chest pain. she had respiratory failure, required endotracheal intubation and icu management. ct scan of the abdomen and the pelvis confirmed that she had an anastomotic leak. sputum cultures were positive esbl klebsiella. blood cultures were negative. she was managed closely for sepsis with an elevated white cell count. she was also febrile. her chest x-ray also showed left lower lobe consolidation. she had scattered contrast material in the anterior abdomen and left upper quadrant due to the anastomotic leak. her antibiotics were adjusted. of note, the patient did have a jp drain placed out to the surface during her initial surgery. followup ct scan on 07/16/2008 confirmed the anastomosis as the likely site of a fistula, as there was continued extraluminal enteric contrast seen within anterior abdomen just beneath the peritoneum as well as the left upper quadrant adjacent to the spleen. no enteric contrast was seen surrounding the patient's known ge junction leak. a jp drain was noted at the posterior aspect of the fundoplication. there was only a small amount of pelvic fluid. follow up scan again on 07/25/2008 showed no abscess formation. on 08/05/2008, she did underwent an advancement of the #14 french red-rubber catheter feeding tube distal to the dehiscence of fistula into the distal small bowel. at the beginning of the procedure, the catheter did appear to traverse through an anastomotic suture line in the wound dehiscence. at some point during her course, the patient did undergo a second operative procedure, but i do not have any operative note at this time. she subsequently was left with a large open abdominal defect, which was being managed by the wound care nurses, which at the time of her transfer to this facility was being managed with a "wound manager system." to low-continuous wall suction. she was also transferred on tube feedings via the red rubber catheter 20 ml per hour. she is only to have her tube feeds increased by 10 ml a week to ensure tolerance. during her course, she was started on tpn. she was transferred on tpn here.,at the time of her transfer, the patient was no longer on iv antibiotics. she is on fragmin for dvt prophylaxis. during her course, she did have to undergo a tracheostomy. this has subsequently been removed and this site is healing. the tracheostomy was removed on 08/06/2008, i believe. at the time of her tracheostomy (on 07/22/2008), the patient also underwent a flexible bronchoscopy, which showed some secretions in the left airway (right was clear), which did not appear to be purulent. of note also, pathology of her partial stomach resection showed helicobacter pylori gastritis. there were no other significant abnormalities noted in the small intestine or omentum. on 08/11/2008, the patient was transferred to healthsouth monroeville ltac for continued medical management, wound care, and rehab therapies.1,past medical history: ,history of diabetes with peripheral neuropathy - on lyrica and cymbalta preoperatively. history of hypothyroidism, history of b12 deficiency related to prior gastric surgeries, history of osteoarthritis, history of valvular disease (no details available), and cardiac arrhythmias.,past surgical history:, status post bilateral total knee replacements, status post right rotator cuff repair, status post sigmoid colectomy - no further details available, status post right breast lumpectomy for benign lesion, history of bladder repair, status post hysterectomy/tonsillectomy/appendectomy, history of lumbar spinal fusion - no further details available. history of mrsa in knees (previous surgery).,allergies:, multiple including tetracycline, erythromycin, morphine, sulfa drugs, betadine, adhesive tapes, and bandage.,social history:, prior to admission, the patient lived alone in a one storied dwelling. she does have some equipment at home including a powered wheelchair, which she uses for longer distance. she does have some ambulatory devices also. she used to smoke, but quit about 10 years ago. she smoked 1 to 2 packs a day from age 18 to 54. she does not smoke.,family history:, remarkable for cardiac disease with early death of her father at age 43 and mother had alzheimer.,review of systems: , according to her notes, the patient's weight 07/10/2008 was 256 pounds. she has a bmi of 44 indicating morbid obesity. she had had a significant weight loss in the 6 months prior to this of 7%. as noted, she is on tpn and enteral feeds. her prealbumin level noted on 07/10/2008 was low at 7. prior to admission, the patient ate a regular diet, but had most likely weight loss and inadequate intake due to her chronic postprandial vomiting and esophageal dysmotility. she is currently npo with ng to suction. the patient has no complaints of abdominal pain or discomfort at the time of this exam. she was awake and alert. mrsa screen on 07/14/2008 was negative.,physical examination:,general: the patient is a morbidly obese woman, who is in no acute distress at the time of this exam. she is lying comfortably on a low air loss mattress. she had just been assisted with cleaning up and had no complaints of pain or discomfort.,vital signs: temperature is 98.9, pulse is 95, blood pressure is 123/69, and weight is 239 pounds.,heent: normocephalic/atraumatic. extraocular muscles intact. her mentation is good.,neck: stout. there is good range of motion.,cor: regular rate and rhythm. no murmurs appreciated.,lungs: fairly clear anteriorly.,abdomen: remarkable for a large open abdominal wound with a collection system in place covering the entire wound in midline. there is a jp drain and a red rubber catheter present. at present, the wound manager system is somewhat collapsed. she had just been on her side. it is connected to low continuous wall suction and removing fluid.,musculoskeletal: there is picc line present in the right upper extremity. no significant pedal edema. bilateral knee scars from prior surgeries.,skin: reported intact at this time (not seen by me).,neurological: cranial nerves ii through xii grossly intact. she is able to answer questions appropriately. she is able to raise both arms over head. she is able to raise her legs, but does need assistance. she has fair bed mobility and requires much assistance for any turning. gait and transfers not tested.,summary: , in summary, the patient is a 62-year-old woman with a remote history of ileojejunal bypass followed by gastric banding to facilitate weight loss. however, she subsequently developed reflux associated with postprandial vomiting, which was found to be secondary to esophageal retention. on 07/08/2008, she underwent exploratory laparotomy with esophagogastrectomy with esophagogastric anastomosis and dor fundoplication, hiatal hernia repair, small bowel resection, and lysis of adhesions. she has had a fairly rocky postoperative course and has subsequently underwent some type of re-exploration after she was noted to have enteric contents draining from her jp drain with confirmed anastomotic leak. she has undergone placement on an ng tube. at present, she is on enteral feeds as well as tpn. during all these, she also coded and had respiratory failure, requiring vent management, but this has improved. her trach has been removed and this site is healing. from the wound standpoint, her largest problem at this point is the abdominal wound, which is open. a wound manager system is currently in place, which is connected to low intermittent wall suction for drainage of the enteral contents still present. at present, the drainage is quite yellow in appearance. she has no significant complaints of pain at this time. at some point in her notes, there was mention of a negative pressure wound therapy being used to this wound, but this cannot be confirmed at this time. i will plan to contact dr. z's office to see whether or not they wanted to resume a wound vac system to this wound. for now, we will continue with wound manager system. we will need to keep track of in's and out's of drainage from this site. her fluid status will need to be monitored. in an attempt to get her mobilized, we will need extra care to be sure that this wound dressing/management system stays in place. she is eager and motivated to get mobilized. we will plan to ask plastic (dr. a) to be involved in following this wound also. again, i will plan to call the surgeon's office for further directions. she is to follow up with dr. z in 2 weeks.,later in afternoon, i was able to reach dr. z's office. i was called back by one of his nurses, who advised me that a wound vac (negative pressure wound therapy) was not to be used on this wound. they are using the wound manager system. she did report that the confusion came about with the inability during her discharge summary dictation that she was only able to cite a "wound vac" when describing the system that was in place on the patient. she was using a formatted discharge summary program. at present, the patient has had some leakage from the system. according to my discussion with our wound care coordinator at this time, this system has been removed, with leakage repaired, and replaced with another wound manager system with suctioning continuing. pictures were also taken of the wound bed. there were several staples apparently in place. i was not present at the time that this system had to be changed.

chief complaint:, falls at home.,history of present illness:, the patient is an 82-year-old female who fell at home and presented to the emergency room with increased anxiety. family members who are present state that the patient had been increasingly anxious and freely admitted that she was depressed at home. they noted that she frequently came to the emergency room for "attention." the patient denied any chest pain or pressure and no change to exercise tolerance. the patient denied any loss of consciousness or incontinence. she denies any seizure activity. she states that she "tripped" at home. family states she frequently takes darvocet for her anxiety and that makes her feel better, but they are afraid she is self medicating. they stated that she has numerous medications at home, but they were not sure if she was taking them. the patient been getting along for a number of years and has been doing well, but recently has been noting some decline primarily with regards to her depression. the patient denied si or hi.,physical examination:,general: the patient is pleasant 82-year-old female in no acute distress.,vital signs: stable.,heent: negative.,neck: supple. carotid upstrokes are 2+.,lungs: clear.,heart: normal s1 and s2. no gallops. rate is regular.,abdomen: soft. positive bowel sounds. nontender.,extremities: no edema. there is some ecchymosis noted to the left great toe. the area is tender; however, metatarsal is nontender.,neurological: grossly nonfocal.,hospital course: , a psychiatric evaluation was obtained due to the patient's increased depression and anxiety. continue paxil and xanax use was recommended. the patient remained medically stable during her hospital stay and arrangements were made for discharge to a rehabilitation program given her recent falls.,discharge diagnoses:,1. falls ,2. anxiety and depression.,3. hypertension.,4. hypercholesterolemia.,5. coronary artery disease.,6. osteoarthritis.,7. chronic obstructive pulmonary disease.,8. hypothyroidism.,condition upon discharge: , stable.,discharge medications: , tylenol 650 mg q.6h. p.r.n., xanax 0.5 q.4h. p.r.n., lasix 80 mg daily, isordil 10 mg t.i.d., kcl 20 meq b.i.d., lactulose 10 g daily, cozaar 50 mg daily, synthroid 75 mcg daily, singulair 10 mg daily, lumigan one drop both eyes at bed time, nitroquick p.r.n., pravachol 20 mg daily, feldene 20 mg daily, paxil 20 mg daily, minipress 2 mg daily, provera p.r.n., advair 250/50 one puff b.i.d., senokot one tablet b.i.d., timoptic one drop ou daily, and verapamil 80 mg b.i.d.,allergies: , none.,activity: , per pt.,follow-up: , the patient discharged to a skilled nursing facility for further rehabilitation.

preoperative diagnosis,mammary hypertrophy with breast ptosis.,postoperative diagnosis,mammary hypertrophy with breast ptosis.,operation,suction-assisted lipectomy of the breast with removal of 350 cc of breast tissue from both sides and two mastopexies.,anesthesia,general endotracheal anesthesia.,procedure,the patient was placed in the supine position. under effects of general endotracheal anesthesia, markings were made preoperatively for the mastopexy. an eccentric circle was drawn around the nipple and a wedge drawn from the inferior border of the areola to the inframammary fold. a stab incision was made bilaterally and tumescent infiltration of anesthesia, lactated ringers with 1 cc of epinephrine to 1000 cc of lactated ringers was infused with a tumescent blunt needle. 200 cc was infiltrated on each side. this was followed by power-assisted liposuction and manual liposuction with removal of 350 cc of supernatant fat from both sides utilizing a radial tunneling technique with a 4-mm cannula. this was followed by the epithelialization of skin between the inner circle corresponding to the diameter of the areola 4 cm diameter and the outer eccentric circle with a tangent at the 6 o'clock position. this would result in an elevation of the nipple-areolar complex with transposition. the epithelialization of the wedge inferiorly equalized the circumference distance between the inner circle and the outer circle. hemostasis was achieved with electrocautery. after the epithelialization was performed on both sides, nipple-areolar complex was transposed to new nipple position and the wedge was closed with transposition of the nipple-areolar complex beneath the transposed nipple. closure was performed with interrupted 3-0 pds suture on deep subcutaneous tissue and dermal skin closure with running subcuticular 4-0 monocryl suture. dermabond was applied followed by adaptic and kerlix in the suturing spaces supportive mildly compressive dressing. the patient tolerated the procedure well. the patient was returned to recovery room in satisfactory condition.

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

chief complaint: , dental pain.,history of present illness: , this is a 45-year-old caucasian female who states that starting last night she has had very significant pain in her left lower jaw. the patient states that she can feel an area with her tongue and one of her teeth that appears to be fractured. the patient states that the pain in her left lower teeth kept her up last night. the patient did go to clinic but arrived there later than 7 a.m., so she was not able to be seen there will call line for dental care. the patient states that the pain continues to be very severe at 9/10. she states that this is like a throbbing heart beat in her left jaw. the patient denies fevers or chills. she denies purulent drainage from her gum line. the patient does believe that there may be an area of pus accumulating in her gum line however. the patient denies nausea or vomiting. she denies recent dental trauma to her knowledge.,past medical history:,1. coronary artery disease.,2. hypertension.,3. hypothyroidism.,past surgical history: ,coronary artery stent insertion.,social habits: , the patient denies alcohol or illicit drug usage. currently she does have a history of tobacco abuse.,medications:,1. plavix.,2. metoprolol.,3. synthroid.,4. potassium chloride.,allergies:,1. penicillin.,2. sulfa.,physical examination:,general: this is a caucasian female who appears of stated age of 45 years. she is well-nourished, well-developed, in no acute distress. the patient is pleasant but does appear to be uncomfortable.,vital signs: afebrile, blood pressure 145/91, pulse of 78, respiratory rate of 18, and pulse oximetry of 98% on room air.,heent: head is normocephalic. pupils are equal, round and reactive to light and accommodation. sclerae are anicteric and noninjected. nares are patent and free of mucoid discharge. mucous membranes are moist and free of exudate or lesion. bilateral tympanic membranes are visualized and free of infection or trauma. dentition shows significant decay throughout the dentition. the patient has had extraction of teeth 17, 18, and 19. the patient's tooth #20 does have a small fracture in the posterior section of the tooth and there does appear to be a very minor area of fluctuance and induration located at the alveolar margin at this site. there is no pus draining from the socket of the tooth. no other acute abnormality to the other dentition is visualized.,diagnostic studies: , none.,procedure note: ,the patient does receive an injection of 1.5 ml of 0.5% bupivacaine for inferior alveolar nerve block on the left mandibular teeth. the patient undergoes this all procedure without complication and does report some mild decrease of her pain with this and patient was also given two vicodin here in the emergency department and a dose of keflex for treatment of her dental infection.,assessment: ,dental pain with likely dental abscess. ,plan: , the patient was given a prescription for vicodin. she is also given prescription for keflex, as she is penicillin allergic. she has tolerated a dose of keflex here in the emergency department well without hypersensitivity. the patient is strongly encouraged to follow up with dental clinic on monday, and she states that she will do so. the patient verbalizes understanding of treatment plan and was discharged in satisfactory condition from the er.,

name of procedure:, successful stenting of the left anterior descending.,description of procedure:, angina pectoris, tight lesion in left anterior descending.,technique of procedure:, standard judkins, right groin.,catheters used: , 6 french judkins, right; wire, 14 bmw; balloon for predilatation, 25 x 15 crosssail; stent 2.5 x 18 cypher drug-eluting stent.,anticoagulation: ,the patient was on aspirin and plavix, received 3000 of heparin and was begun on integrilin.,complications: , none.,informed consent: , i reviewed with the patient the pros, cons, alternatives and risks of catheter and sedation exactly as i had done before during his diagnostic catheterization, plus i reviewed the risks of intervention including lack of success, need for emergency surgery, need for later restenosis and further procedures.,hemodynamic data: , the aortic pressure was in the physiologic range.,angiographic data: , left coronary artery: the left main coronary artery showed insignificant disease. the left anterior descending showed fairly extensive calcification. there was 90% stenosis in the proximal to midportion of the vessel. insignificant disease in the circumflex.,successful stenting: , a wire crossed the lesion. we first predilated with a balloon, then advanced, deployed and post dilated the stent. final angiography showed 0% stenosis, no tears or thrombi, excellent intimal appearance.,physical examination,vital signs: blood pressure 160/88, temperature 98.6, pulse 83, respirations 30. he is saturating at 96% on 4 l nonrebreather.,general: the patient is a 74 year-old white male who is cooperative with the examination and alert and oriented x3. the patient cannot speak and communicates through writing.,heent: very small moles on face. however, pupils equal, round and regular and reactive to light and accommodation. extraocular movements are intact. oropharynx is moist.,neck: supple. tracheostomy site is clean without blood or discharge.,heart: regular rate and rhythm. no gallop, murmur or rub.,chest: respirations congested. mild crackles in the left lower quadrant and left lower base.,abdomen: soft, nontender and nondistended. positive bowel sounds.,extremities: no clubbing, cyanosis or edema.,neurologic: cranial nerves ii-xii grossly intact. no focal deficit.,genitalia: the patient does have a right scrotal swelling, very much larger than the other side, not reproducible and mobile to touch.,conclusions,1. successful stenting of the left anterior descending. initially, there was 90% stenosis. after stenting with a drug-eluting stent, there was 0% residual.,2. insignificant disease in the other coronaries.,plan:, the patient will be treated with aspirin, plavix, integrilin, beta blockers and statins. i have discussed this with him, and i have answered his questions.

rice, stands for the most important elements of treatment for many injuries---rest, ice, compression, and elevation.,rest:,stop using the injured part as soon as you realize that an injury has taken place. use crutches to avoid bearing weight on injuries of the foot, ankle, knee, or leg. use splints for injuries of the hand, wrist, elbow, or arm. continued exercise or activity could cause further injury, increased pain, or a delay in healing.,ice:,ice helps stop bleeding from injured blood vessels and capillaries. sudden cold causes the small blood vessels to contract. this contraction decreases the amount of blood that can collect around the wound. the more blood that collects, the longer the healing time. ice can be safely applied in many ways:,* for injuries to small areas, such as a finger, toe, foot, or wrist, immerse the injured area for 15 to 35 minutes in a bucket of ice water. use ice cubes to keep the water cold, adding more as the ice cubes dissolve.,* for injuries to larger areas, use ice packs. avoid placing the ice directly on the skin. before applying the ice, place a towel, cloth, or one or two layers of an elasticized compression bandage on the skin to be iced. to make the ice pack, put ice chips or ice cubes in a plastic bag or wrap them in a thin towel. place the ice pack over the cloth. the pack may sit directly on the injured part, or it may be wrapped in place.,* ice the injured area for about 30 minutes.,* remove the ice to allow the skin to warm for 15 minutes.,* reapply the ice.,* repeat the icing and warming cycles for 3 hours. follow the instructions below for compression and elevation. if pain and swelling persist after 3 hours call our office. you may need to change the icing schedule after the first 3 hours. regular ice treatment is often discontinued after 24 to 48 hours. at that point, heat is sometimes more comfortable.,compression:,compression decreases swelling by slowing bleeding and limiting the accumulation of blood and plasma near the injured site. without compression, fluid from adjacent normal tissue seeps into the injured area. to apply compression safely to an injury:,* use an elasticized bandage (ace bandage) for compression, if possible. if you do not have one available, any kind of cloth will suffice for a short time.,* wrap the injured part firmly, wrapping over the ice. begin wrapping below the injury site and extend above the injury site.,* be careful not to compress the area so tightly that the blood supply is impaired. signs of deprivation of the blood supply include pain, numbness, cramping, and blue or dusky nails. remove the compression bandage immediately if any of theses symptoms appears. leave the bandage off until all signs of impaired circulation disappear. then rewrap the area--less tightly this time.,elevation:,elevating the injured part above the level of the heart is another way to decrease swelling and pain at the injury site. elevate the iced, compressed area in whatever way is most convenient. prop an injured leg on a solid object or pillows. elevate an injured arm by lying down and placing pillows under the arm or on the chest with the arm folded across.

preoperative diagnosis: , bilateral renal mass.,postoperative diagnosis:, bilateral renal mass.,operation: , right hand-assisted laparoscopic cryoablation of renal lesions x2. lysis of adhesions and renal biopsy.,anesthesia: , general endotracheal.,estimated blood loss:, 100 ml.,fluids: , crystalloid.,the patient was bowel prepped and was given preoperative antibiotics.,brief history: , the patient is a 73-year-old male, who presented to us with a referral from dr. x's office with bilateral renal mass and renal insufficiency. the patient's baseline creatinine was around 1.6 to 1.7. the patient was found to have a 3 to 4-cm exophytic right renal mass, 1-cm renal mass inferior to that, and about 2-cm left renal mass. since the patient had bilateral renal disease and the patient had renal insufficiency, the best option at this time had been cryoprocedure for the kidney versus partial nephrectomy, one kidney at a time. the patient understood all his options, had done some research on cryotherapy and wanted to proceed with the procedure. the patient had a renal biopsy done, which showed a possibility of an oncocytoma, which also would indicate that if this is not truly a cancerous lesion, but there is an associated risk of renal cell carcinoma that the patient will benefit from a cryo of the kidney.,risk of anesthesia, bleeding, infection, pain, hernia, bowel obstruction, ileus, injury to bowel, postoperative bleeding, etc., were discussed. the patient understood the risk of delayed bleeding, the needing for nephrectomy, renal failure, renal insufficiency, etc., and wanted to proceed with the procedure.,details of the or: ,the patient was brought to the or. anesthesia was applied. the patient was given preoperative antibiotics. the patient was bowel prepped. the patient was placed in right side up, left side down, semiflank, with kidney rest up. all the pressure points are very well padded using foam and towels. the left knee was bent and the right knee was straight. there was no tension on any of the joints. all pressure points were well padded. the patient was taped to the table using 2-inch wide tape all the way around. a foley catheter and og tube were in place prior to prepping and draping the patient. a periumbilical incision measuring about 6 cm was made. the incision was carried through the subcutaneous tissue through the fascia using sharp dissection. the peritoneum was open. abdomen was entered. there were some adhesions on the right side of the abdomen, which were released using metz. two 12-mm ports were placed in the anteroaxillary line and one in the midclavicular line. a gel porter was placed. pneumoperitoneum was obtained. all ports were placed under direct vision, and the right colon was reflected medially. duodenum was cauterized. minimal dissection was done on the hilum and the gerota's was opened laterally, and the renal masses were clearly visualized all the way around. pictures were taken. superficial biopsies were taken of 2 renal lesions using 3 different probes. the 2 lesions were frozen. the 2 probes were 2.4 mm and the other one was 3.1 mm in diameter. so the r3.8 and r2.4 long probes were used. freezing/thawing, two cycles were done. the temperatures were -131, -137, -150 and the freezing time was 5 and 10 minutes each and passive sign was done. the exact times or exact temperatures are on the chart. there was a nice ice ball with each freezing and with passive sign. the probes were removed.,the probes were placed directly percutaneously through the skin into the renal lesions.,after freezing/thawing, the probes were removed and to seal with surgicel were placed. pictures were taken after following total of 20 minutes were spent looking at the renal mass to make sure that there was no delayed bleeding. from the time the probes were removed, until the time the laparoscope was removed, was total of 30 minutes. so the masses were visualized for a total of 30 minutes without any pneumoperitoneum. pneumoperitoneum was obtained again. fibrin glue was placed over it just for precautionary measure. there was about a total of 100 ml of blood loss overall with the entire procedure. please note that towels were used to prep off the colon and the liver to ensure there was no freezing of any other organ. the kidney was kept in the left hand at all times. careful attention was drawn to make sure that the probe was deep enough, at least 3.5 to 4 cm in, to get the medial aspect of the tumors frozen. the laparoscopic vacuum ultrasound showed that there was complete resolution of these lesions. at the end of the procedure, after freezing/thawing and putting the fibrin glue, surgicel, and endoseal, the colon was reflected medially. please note that the perirenal fat was placed over the lesion to ensure that the frozen area of the kidney was not exposed to the bowel. lap count was correct. please note that renal biopsy for permanent section was performed on the superficial aspect of the lesions. no deeper biopsies were done to minimize the risk of bleeding. the 12-mm ports were closed using 0-vicryl and the middle incision. the hand-port incision was closed using looped #1 pds from both sides and was tied in the middle. please note that the pneumoperitoneum was closed using 0-vicryl in running fashion. after closing the abdomen, 4-0 monocryl was used to close the skin and dermabond was applied.,the patient was brought to recovery in a stable condition.

admission diagnosis:, morbid obesity. bmi is 51.,discharge diagnosis: , morbid obesity. bmi is 51.,procedure: , laparoscopic gastric bypass.,service: , surgery.,consult: , anesthesia and pain.,history of present illness: , ms. a is a 27-year-old woman, who suffered from morbid obesity for many years. she has made multiple attempts at nonsurgical weight loss without success. she underwent a preoperative workup and clearance for gastric bypass and was found to be an appropriate candidate. she underwent her procedure.,hospital course: , ms. a underwent her procedure. she tolerated without difficulty. she was admitted to the floor post procedure. her postoperative course has been unremarkable. on postoperative day 1, she was hemodynamically stable, afebrile, normal labs, and she was started on a clear liquid diet, which she has tolerated without difficulty. she has ambulated and had no complaints. today, on postoperative day 2, the patient continues to do well. pain controlled with p.o. pain medicine, ambulating without difficulty, tolerating a liquid diet. at this point, it is felt that she is stable for discharge. her drain was discontinued.,discharge instructions:, liquid diet x1 week, then advance to pureed and soft as tolerated. no heavy lifting, greater than 10 pounds x4 weeks. the patient is instructed to not engage in any strenuous activity, but maintain mobility. no driving for 1 to 2 weeks. she must be able to stop in an emergency and be off narcotic pain medicine. she may shower. she needs to keep her wounds clean and dry. she needs to follow up in my office in 1 week for postoperative evaluation. she is instructed to call for any problems of shortness of breath, chest pain, calf pain, temperature greater than 101.5, any redness, swelling, or foul smelling drainage from her wounds, intractable nausea, vomiting, and abdominal pain. she is instructed just to resume her discharge medications.,discharge medications:, she was given a scripts for lortab elixir, flexeril, ursodiol, and colace.

the patient tolerated the procedure well and was sent to the recovery room in stable condition.

preoperative diagnosis: , infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer.,postoperative diagnosis:, infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer.,procedures:,1. removal of antibiotic spacer.,2. revision total hip arthroplasty.,implants,1. hold the zimmer trabecular metal 50 mm acetabular shell with two 6.5 x 30 mm screws.,2. zimmer femoral component, 13.5 x 220 mm with a size aa femoral body.,3. a 32-mm femoral head with a +0 neck length.,anesthesia: ,regional.,estimated blood loss: , 500 cc.,complications:, none.,drains: , hemovac times one and incisional vac times one.,indications:, the patient is a 66-year-old female with a history of previous right bipolar hemiarthroplasty for trauma. this subsequently became infected. she has undergone removal of this prosthesis and placement of antibiotic spacer. she currently presents for stage ii reconstruction with removal of antibiotic spacer and placement of a revision total hip.,description of procedure: ,the patient was brought to the operating room by anesthesia personnel. she was placed supine on the operating table. a foley catheter was inserted. a formal time out was obtained in identifying the correct patient, operative site. preoperative antibiotics were held for intraoperative cultures. the patient was placed into the lateral decubitus position with the right side up. the previous surgical incision was identified. the right lower extremity was prepped and draped in standard fashion. the old surgical incision was reopened along its proximal extent. immediately encountered was a large amount of fibrous scar tissue. dissection was carried sharply down through this scar tissue. soft tissue plains were extremely difficult to visualize due to all the scarring. there was no native tissue to orient oneself with. we carried our dissection down through the scar tissue to what seemed to be a fascial layer. we incised through the fascial layer down to some scarred gluteus maximus muscle and down over what was initially felt to be the greater trochanter. dissection was carried down through soft tissue and the distal located antibiotic spacer was exposed. this was used as a landmark to orient remainder of the dissection. the antibiotic spacer was exposed and followed distally to expose the proximal femur. dissection was continued posteriorly and proximally to expose the acetabulum. a cobra retractor was able to be inserted across the superior aspect of the acetabulum to enhance exposure. once improved visualization was obtained, the antibiotic spacer was removed from the femur. this allowed further improved visualization of the acetabulum. the acetabulum was filled with soft tissue debris and scar tissue. this was removed with sharp excision with a knife as well as with a rongeur and a bovie. once soft tissue was removed, the acetabulum was reamed. reaming was started with a 46-mm reamer and carried up sequentially to prepare for 50-mm shell. the 50 mm shell was trialed and had good stability and fit. attention was then turned to continue preparation of the femur. the canal was then debrided with femoral canal curettes. some fibrous tissue was removed from the canal. the length of the femoral stem was then checked with this canal curette in place. following x-rays, we prepared to begin reaming the femur. this femur was reamed over a guide rod using flexible reaming rods. the canal was reamed up to 13.5 mm distally in preparation for 14 mm stem. the stem was selected and initially size a body was placed in trial. the body was too tight proximally to fit. the proximal canal was then reamed for a size aa body. a longer stem with an anterior bow was selected and a size aa trial was assembled. this fit nicely in the canal and had good fit and fill. intraoperative radiographs were obtained to determine component position. intraoperative radiographs revealed satisfactory length of the component past the distal of fractures in the femur. the remainder of the trial was then assembled and the hip was relocated and trialed. initially, it was found to be unstable posteriorly. we changed from a 10 degree lip liner to 20 degree lip liner. again, the hip was trialed and found to be unstable posteriorly. this was due to reversion of the femoral component. as we attempted to seat the prosthesis, the stent continued to attempt to turn in retroversion. the stem was extracted and retrialed. improved stability was obtained and we decided to proceed with the real components. a 20 degree liner was inserted into the acetabular shell. the real femoral components were assembled and inserted into the femoral canal. again, the hip was trialed. the components were found to be in relative retroversion. the real components were then backed down and the neck was placed in the more anteversion and reinserted. again, the stem attempted to follow in the relative retroversion. along with this time, however, it was improved from previous attempts. the femoral head trial was placed back on the components and the hip relocated. it was taken to a range of motion and found to have improved stability compared to previous trialing. decision was made to accept the component position. the real femoral head was selected and implanted. the hip was then taken again to a range of motion. it was stable at 90 degrees of flexion with 20 degrees of adduction and 40 degrees of internal rotation. the patient reached full extension and had no instability anteriorly.,the wound was then irrigated again with pulsatile lavage. six liters of pulsatile lavage was used during the procedure.,the wound was then closed in a layered fashion. a hemovac drain was placed deep to the fascial layer. the subcutaneous tissues were closed with #1 pds, 2-0 pds, and staples in the skin. an incisional vac was then placed over the wound as well. sponge and needle counts were correct at the close of the case.,disposition:, the patient will be weightbearing as tolerated with posterior hip precautions.

preoperative diagnoses:,1. left superficial femoral artery subtotal stenosis.,2. arterial insufficiency, left lower extremity.,postoperative diagnoses:,1. left superficial femoral artery subtotal stenosis.,2. arterial insufficiency, left lower extremity.,operations performed:,1. left lower extremity angiogram.,2. left superficial femoral artery laser atherectomy.,3. left superficial femoral artery percutaneous transluminal balloon angioplasty. ,4. left external iliac artery angioplasty.,5. left external iliac artery stent placement.,6. completion angiogram.,findings: ,this patient was brought to the or with a non-severe stenosis of the proximal left superficial femoral artery in the upper one-third of his thigh. he is also known to have severe calcific disease involving the entire left external iliac system as well as the common femoral and deep femoral arteries.,our initial plan today was to perform an atherectomy with angioplasty and stenting of the left superficial femoral artery as necessary. however, whenever we started the procedure, it became clear that there was a severe stenosis of the left superficial femoral artery at its takeoff from the left common femoral artery. the area was severely calcified including the external iliac artery extending up underneath the left inguinal ligament. indeed, this ultimately was dissected due to manipulation of sheath catheters and sheath through the area. ultimately, this wound up being a much more complex case than initially anticipated.,because of the above, we ultimately performed a laser atherectomy of the left superficial femoral artery, which then had to be angioplastied to obtain a satisfactory result. the completion angiogram showed that there was a dissection of the left external iliac artery, which precluded flow down into the left lower extremity. we then had to come up and perform angioplasty and stenting of the left external iliac artery as well as aggressively dilating the takeoff of the less superficial femoral artery from the common femoral artery.,the left superficial femoral artery was dilated with a 6-mm balloon.,the left external iliac artery and common femoral arteries were dilated with an 8-mm balloon.,a 2.5-mm clearpath laser probe was used to initially arthrectomize and debulk the superficial femoral artery starting at its takeoff from the common femoral artery and extending down to the tight stenotic area in the upper one-third of the thigh. after the laser atherectomy was performed, the area still did not look good and so an angioplasty was then done, which looked good; however, as noted above, after we had dealt with the superficial femoral artery, we then had proximal inflow problems, which had to be dealt by angioplasty and stenting.,the patient had good dorsalis pedis pulses bilaterally upon completion.,the right common femoral artery was used for access in an up-and-over technique.,procedure: , with the patient in the supine position under general anesthesia, the abdomen and lower extremities were prepped and draped in the sterile fashion.,the right common femoral artery was punctured percutaneously, and a #5-french sheath was initially placed. we used a pigtail catheter to go up and over the aortic bifurcation and placed a stiff amplatz guidewire down into the left common femoral artery. we then heparinized the patient and placed a #7-french raby sheath over the amplatz wire. a selective left lower extremity angiogram was then done with the above-noted findings.,we then used a clearpath 2.5-mm laser probe to laser the proximal superficial femoral artery. because of the findings as noted above, this became more involved than initially hoped for. once the laser atherectomy had been completed, the vessel still did not look good, so we used a 6-mm balloon to thoroughly dilate the area. once that had been done, it looked good and we performed what we felt would be a completion angiogram only to find out that we had a more proximal problem precluding flow down into the left femoral artery.,once that was discovered, we then had to proceed with angioplasty and stenting of the left external iliac artery right down to the acetabular level.,once we had dealt with our run-on problems, we then did another completion angiogram, which showed a good flow through the entire area and down into the left lower extremity.,following completion of the above, all wires, sheaths, and catheters were removed from the right common femoral artery. firm pressure was held over the puncture site for 20 minutes followed by application of a sterile coverlet dressing and a firm pressure dressing.,the patient tolerated the procedure well throughout. he had good palpable dorsalis pedis pulses bilaterally on completion. he was taken to the recovery room in satisfactory condition. protamine was given to partially reverse the heparin.

preoperative diagnosis:, refractory pneumonitis.,postoperative diagnosis: , refractory pneumonitis.,procedure performed: , bronchoscopy with bronchoalveolar lavage.,anesthesia: , 5 mg of versed.,indications: , a 69-year-old man status post trauma, slightly prolonged respiratory failure status post tracheostomy, requires another bronchoscopy for further evaluation of refractory pneumonitis.,procedure: , the patient was sedated with 5 mg of versed that was placed on the endotracheal tube. bronchoscope was advanced. both right and left mainstem bronchioles and secondary and tertiary bronchioles were cannulated sequentially, lavaged out. relatively few tenacious secretions were noted. these were lavaged out. specimen collected for culture. no obvious other abnormalities were noted. the patient tolerated the procedure well without complication.

summary: ,the patient has attended physical therapy from 11/16/06 to 11/21/06. the patient has 3 call and cancels and 3 no shows. the patient has been sick for several weeks due to a cold as well as food poisoning, so has missed many appointments.,subjective: ,the patient states pain still significant, primarily 1st seen in the morning. the patient was evaluated 1st thing in the morning and did not take his pain medications, so objective findings may reflect that. the patient states overall functionally he is improving where he is able to get out in the house and visit and do activities outside the house more. the patient does feel like he is putting on more muscle girth as well. the patient states he is doing well with his current home exercise program and feels like pool therapy is also helping as well.,objective: , physical therapy has consisted of:,1. pool therapy incorporating endurance and general lower and upper extremity strengthening.,2. clinical setting incorporating core stabilization and general total body strengthening and muscle wasting.,3. the patient has just begun this, so it is on a very beginners level at this time.,assessment, done on 12/21/06,strength,activities

reason for consultation: , we were asked to see the patient in regards to a brain tumor.,history of present illness: ,she was initially diagnosed in september of this year with a glioblastoma multiforme. she presented with several lesions in her brain and a biopsy confirmed the diagnosis. she was seen by dr. x in our group. because of her living arrangement, she elected to have treatment through the hospital radiation department and oncology department. details of her treatment are not available at the time of this dictation. her family has a packet of temodar 100-mg pills. she is admitted now with increasing confusion. a ct shows increase in size of the lesions compared to the preoperative scan. we are asked to comment on her treatment at this point. she herself is confused and is unable to provide further history. ,past medical history: , from her old chart: no known past medical history prior to the diagnosis.,social history: ,she was living alone and is now living in assisted living. ,medications,1. dilantin 300 mg daily.,2. haloperidol 1 mg h.s.,3. dexamethasone 4 mg q.i.d. ,4. docusate 100 mg b.i.d.,5. pen-vk 500 mg daily.,6. ibuprofen 600 mg daily.,7. zantac 150 mg twice a day.,8. temodar 100 mg daily.,9. magic mouthwash daily.,10. tylenol #3 as needed.,review of systems,: unable.,physical examination,general: elderly woman, confused. ,heent: normal conjunctivae. ears and nose normal. mouth normal.,neck: supple.,chest: clear.,heart: normal.,abdomen: soft, positive bowel sounds.,neurologic: alert, cranial nerves intact. left arm slightly weak. left leg slightly weak.,impression and plan:, glioblastoma multiforme, uncertain as to where she is in cancer treatment. given the number of pills in the patient's family's hands, it sounds like she has only been treated recently and therefore it is not surprising that she is showing increased problems related to increased size of the tumor. we will have to talk with dr. y in the clinic to get a better handle on her treatment regimen. at this point, i will hold temodar today and consider restarting it tomorrow if we can get her treatment plan clarified.

reason for visit: , this is a cosmetic consultation.,history of present illness:, the patient is a very pleasant 34-year-old white female who is a nurse in the operating room. she knows me through the operating room and has asked me to possibly perform cosmetic surgery on her. she is very bright and well informed about cosmetic surgery. she has recently had some neck surgery for a re-fusion of her neck and is currently on methadone for chronic pain regarding this. her current desires are that she obtain a breast augmentation and liposuction of her abdomen, and she came to me mostly because i offer transumbilical breast augmentation. her breasts are reportedly healthy without any significant problems. her weight is currently stable.,past medical and surgical history: , negative. past surgical history is significant for a second anterior cervical fusion and diskectomy in 02/05 and in 09/06. she has had no previous cosmetic or aesthetic surgery.,family history and social history:, significant for huntington disease in her mother and diabetes in her father. her brother has an aneurysm. she does occasionally smoke and has been trying to quit recently. she is currently smoking about a pack a day. she drinks about once a week. she is currently a registered nurse, circulator, and scrub technician in the operating room at hopkins. she has no children.,review of systems: ,a 12-system review is significant for some musculoskeletal pain, mostly around her neck and thoracic region. she does have occasional rash on her chest and problems with sleep and anxiety that are related to her chronic pain. she has considered difficult airway due to anterior cervical disk fusion and instability. her last mammogram was in 2000. she has a size 38c breast.,medications: , current medications are 5 mg of methadone three times a day and amitriptyline at night as needed.,allergies: , none.,findings: , on exam today, the patient has good posture, good physique, good skin tone. she is tanned. her lower abdomen has some excess adiposity. there is some mild laxity of the lower abdominal skin. her umbilicus is oval shaped and of adequate caliber for a transumbilical breast augmentation. there was no piercing in that region. her breasts are c shaped. they are not ptotic. they have good symmetry with no evidence of tubular breast deformity. she has no masses or lesions noted. the nipples are of appropriate size and shape for a woman of her age. her scar on her neck from her anterior cervical disk fusion is well healed. hopefully, our scars would be similar to this.,impression and plan: , hypomastia. i think her general physique and body habitus would accommodate about 300 to 350 cubic centimeter implant nicely. this would make her fill out her clothes much better, and i think transumbilical technique in her is a good option. i have discussed with her the other treatment options, and she does not want scars around her breasts if at all possible. i think her lower abdominal skin is of good tone. i think suction lipectomy in this region would bring down her size and accentuate her waist nicely. i am a little concerned about the lower abdominal skin laxity, and i will discuss with her further that in the near future if this continues to be a problem, she may need a mini tummy tuck. i do think that a liposuction is a reasonable alternative and we could see how much skin tightening she gets after the adiposity is removed. i will try to set this up in the near future. i will try to set this up to get the instrumentation from the instrumentation rep for the transumbilical breast augmentation procedure. due to her neck issues, we may not be able to perform her surgery but i will check with dr. x to see if she is comfortable giving her deep sedation and no general anesthetic with her neck being fused.

preoperative diagnosis: , gangrene osteomyelitis, right second toe.,postoperative diagnosis: , gangrene osteomyelitis, right second toe.,operative report: ,the patient is a 58-year-old female with poorly controlled diabetes with severe lower extremity lymphedema. the patient has history of previous right foot infection requiring first ray resection. the patient has ulcerations of right second toe dorsally at the proximal interphalangeal joint, which has failed to respond to conservative treatment. the patient now has exposed bone and osteomyelitis in the second toe. the patient has been on iv antibiotics as an outpatient and has failed to respond to these and presents today for surgical intervention.,after an iv was started by the department of anesthesia, the patient was taken back to the operating room and placed on the operative table in the supine position. a restraint belt was placed around the patient's waist using copious amounts of webril and an ankle pneumatic tourniquet was placed around the patient's right ankle and the patient was made comfortable by the department of anesthesia. after adequate amounts of sedation had been given to the patient, we administered a block of 10 cc of 0.5% marcaine plain in proximal digital block around the second digit. the foot and ankle were then prepped in the normal sterile orthopedic manner. the foot was elevated and an esmarch bandage applied to exsanguinate the foot. the tourniquet was then inflated to 250 mmhg and the foot was brought back onto the table. using band-aid scissors, the stockinet was cut and reflected and using a wet and dry sponge, the foot was wiped, cleaned, and the second toe identified.,using a skin scrape, a racket type incision was planned around the second toe to allow also remodelling of previous operative site. using a fresh #10 blade, skin incision was made circumferentially in the racket-shaped manner around the second digit. then, using a fresh #15 blade, the incision was deepened and was taken down to the level of the second metatarsophalangeal joint. care was taken to identify bleeders and cautery was used as necessary for hemostasis. after cleaning up all the soft tissue attachments, the second digit was disarticulated down to the level of the metatarsophalangeal joint. the head of the second metatarsal was inspected and was noted to have good glistening white cartilage with no areas of erosion evident by visual examination. attention was then directed to closure of the wound. all remaining tissue was noted to be healthy and granular in appearance with no necrotic tissue evident. areas of subcutaneous tissue were then removed through a sharp dissection in order to allow better approximation of the skin edges. due to long-standing lower extremity lymphedema and postoperative changes on previous surgery, i thought that we were unable to close the incision in entirety. therefore, after copious amounts of irrigation using sterile saline, it was determined to use modified dental rolls using #4-0 gauze to remove tension from the skin. deep vertical mattress sutures were used in order to reapproximate more closely, the skin edges and bring the plantar flap of skin up to the dorsal skin. this was obtained using #2-0 nylon suture. following this, the remaining exposed tissue from the wound was covered using moist to dry saline soaked 4 x 4 gauze. the wound was then dressed using 4 x 4 gauze fluffed with abdominal pads, then using kling and kerlix and an ace bandage to provide compression. the tourniquet was deflated at 42 minutes' time and hemostasis was noted to be achieved. the ace bandage was extended up to just below the knee and no bleeding striking to the bandages was appreciated. the patient tolerated the procedure well and was escorted to the postanesthesia care unit with vital signs stable and vascular status intact, as was evidenced by capillary bleeding, which was present during the procedure. sedation was given postoperative introductions, which include to remain nonweightbearing to her right foot. the patient was instructed to keep the foot elevated and to apply ice behind her knee as necessary, no more than 20 minutes each hour. the patient was instructed to continue her regular medications. the patient was to continue iv antibiotic course and was given prescription for vicoprofen to be taken q.4h. p.r.n. for moderate to severe pain #30. the patient will followup with podiatry on monday morning at 8:30 in the podiatry clinic for dressing change and evaluation of her foot at that time.,the patient was instructed as to signs and symptoms of infection, was instructed to return to the emergency department immediately if these should present. the second digit was sent to pathology for gross and micro.

preoperative diagnoses:,1. severe menometrorrhagia unresponsive to medical therapy.,2. anemia.,3. symptomatic fibroid uterus.,postoperative diagnoses:,1. severe menometrorrhagia unresponsive to medical therapy.,2. anemia.,3. symptomatic fibroid uterus.,procedure: , total abdominal hysterectomy.,anesthesia: ,general.,estimated blood loss: , 150 ml.,complications: , none.,finding: ,large fibroid uterus.,procedure in detail: ,the patient was prepped and draped in the usual sterile fashion for an abdominal procedure. a scalpel was used to make a pfannenstiel skin incision, which was carried down sharply through the subcutaneous tissue to the fascia. the fascia was nicked in the midline and incision was carried laterally bilaterally with curved mayo scissors. the fascia was then bluntly and sharply dissected free from the underlying rectus abdominis muscles. the rectus abdominis muscles were then bluntly dissected in the midline and this incision was carried forward inferiorly and superiorly with care taken to avoid bladder and bowel. the peritoneum was then bluntly entered and this incision was carried forward inferiorly and superiorly with care taken to avoid bladder and bowel. the o'connor-o'sullivan instrument was then placed without difficulty. the uterus was grasped with a thyroid clamp and the entire pelvis was then visualized without difficulty. the gia stapling instrument was then used to separate the infundibulopelvic ligament in a ligated fashion from the body of the uterus. this was performed on the left infundibulopelvic ligament and the right infundibulopelvic ligament without difficulty. hemostasis was noted at this point of the procedure. the bladder flap was then developed free from the uterus without difficulty. careful dissection of the uterus from the pedicle with the uterine arteries and cardinal ligaments was then performed using #1 chromic suture ligature in an interrupted fashion on the left and right side. this was done without difficulty. the uterine fundus was then separated from the uterine cervix without difficulty. this specimen was sent to pathology for identification. the cervix was then developed with careful dissection. jorgenson scissors were then used to remove the cervix from the vaginal cuff. this was sent to pathology for identification. hemostasis was noted at this point of the procedure. a #1 chromic suture ligature was then used in running fashion at the angles and along the cuff. hemostasis was again noted. figure-of-eight sutures were then used in an interrupted fashion to close the cuff. hemostasis was again noted. the entire pelvis was washed. hemostasis was noted. the peritoneum was then closed using 2-0 chromic suture ligature in running pursestring fashion. the rectus abdominis muscles were approximated using #1 chromic suture ligature in an interrupted fashion. the fascia was closed using 0 vicryl in interlocking running fashion. foundation sutures were then placed in an interrupted fashion for further closing the fascia. the skin was closed with staple gun. sponge and needle counts were noted to be correct x2 at the end of the procedure. instrument count was noted to be correct x2 at the end of the procedure. hemostasis was noted at each level of closure. the patient tolerated the procedure well and went to recovery room in good condition.

procedure: , primary right shoulder arthroscopic rotator cuff repair with subacromial decompression.,patient profile:, this is a 42-year-old female. refer to note in patient chart for documentation of history and physical. due to the nature of the patient's increasing pain, surgery is recommended. the alternatives, risks and benefits of surgery were discussed with the patient. the patient verbalized understanding of the risks as well as the alternatives to surgery. the patient wished to proceed with operative intervention. a signed and witnessed informed consent was placed on the chart. prior to initiation of the procedure, patient identification and proposed procedure were verified by the surgeon in the pre-op area, and the operative site was marked by the patient and verified by the surgeon.,pre-op diagnosis: , acute complete tear of the supraspinatus, shoulder impingement syndrome.,post-op diagnosis:, acute complete tear of the supraspinatus, shoulder impingement syndrome.,anesthesia: , general - endotracheal.,findings:,acromion:,1. there was a medium-sized (5 - 10 mm) anterior acromial spur.,2. the subacromial bursa was inflamed.,3. the subacromial bursa was thickened.,4. there was thickening of the coracoacromial ligament.,ligaments / capsule: , joint capsule within normal limits.,labrum: , the labrum is within normal limits.,rotator cuff: , full thickness tear of the supraspinatus tendon, 5 mm anterior to posterior, by 10 mm medial to lateral. muscles and tendons: the biceps tendon is within normal limits.,joint:, normal appearance of the glenoid and humeral surfaces.,description of procedure:,patient positioning: , following induction of anesthesia, the patient was placed in the beach-chair position on the standard operating table. all body parts were well padded and protected to make sure there were no pressure points. subsequently, the surgical area was prepped and draped in the appropriate sterile fashion with betadine.,incision type:,1. scope ports: anterior portal.,2. scope ports: posterior portal.,3. scope ports: accessory anterior portal.,instruments and methods:,1. the arthroscope and instruments were introduced into the shoulder joint through the arthroscopic portals.,2. the subacromial space and bursa, biceps tendon, coracoacromial and glenohumeral ligaments, biceps tendon, rotator cuff, supraspinatus, subscapularis, infraspinatus, teres minor, capsulo-labral complex, capsule, glenoid labrum, humeral head, and glenoid, including the inner and outer surfaces of the rotator cuff, were visualized and probed.,3. the subacromial bursa, subacromial soft tissues and frayed rotator cuff tissue were resected and debrided using a motorized resector and 4.5 synovial resector.,4. the anterior portion of the acromion and acromial spur were resected with the 5.5 acromionizer burr. approximately 5 mm of bone was removed. the coracoacromial ligament was released with the bony resection. the shoulder joint was thoroughly irrigated.,5. the edges of the cuff tissue were prepared, prior to the fixation, using the motorized resector.,6. the supraspinatus tendon was reattached and sutured using the arthroscopic knot pusher and mitek knotless anchor system and curved pointed suture passer and large bore cannula (to pass the sutures). the repair was accomplished in a side-to-side and a tendon-to-bone fashion using three double loaded mitek g iv suture anchors with 1 pds suture.,7. the repair was stable to palpation with the probe and watertight.,8. the arthroscope and instruments were removed from the shoulder.,pathology specimen: , no pathology specimens.,wound closure:, the joint was thoroughly irrigated with 7 l of sterile saline. the portal sites were infiltrated with 1% xylocaine. the skin was closed with 4-0 vicryl using interrupted subcuticular technique.,drains / dressing:, applied sterile dressing including gauze, iodoform gauze and elastoplast.,sponge / instrument / needle counts:, final counts were correct.

exam: , two views of the pelvis.,history:, this is a patient post-surgery, 2-1/2 months. the patient has a history of slipped capital femoral epiphysis (scfe) bilaterally.,technique: , frontal and lateral views of the hip and pelvis were evaluated and correlated with the prior film dated mm/dd/yyyy. lateral view of the right hip was evaluated.,findings:, frontal view of the pelvis and a lateral view of the right hip were evaluated and correlated with the patient's most recent priors dated mm/dd/yyyy. current films reveal stable appearing post-surgical changes. again demonstrated is a single intramedullary screw across the left femoral neck and head. there are 2 intramedullary screws through the greater trochanter of the right femur. there is a lucency along the previous screw track extending into the right femoral head and neck. there has been interval removal of cutaneous staples and/or surgical clips. these were previously seen along the lateral aspect of the right hip joint.,deformity related to the previously described slipped capital femoral epiphysis is again seen.,impression:,1. stable-appearing right hip joint status-post pinning.,2. interval removal of skin staples as described above.

procedures performed: , esophagogastroduodenoscopy.,preprocedure diagnosis: , dysphagia.,postprocedure diagnosis: , active reflux esophagitis, distal esophageal stricture, ring due to reflux esophagitis, dilated with balloon to 18 mm.,procedure: , informed consent was obtained prior to the procedure with special attention to benefits, risks, alternatives. risks explained as bleeding, infection, bowel perforation, aspiration pneumonia, or reaction to the medications. vital signs were monitored by blood pressure, heart rate, and oxygen saturation. supplemental o2 given. specifics of the procedure discussed. the procedure was discussed with father and mother as the patient is mentally challenged. he has no complaints of dysphagia usually for solids, better with liquids, worsening over the last 6 months, although there is an emergency department report from last year. he went to the emergency department yesterday with beef jerky.,all of this reviewed. the patient is currently on cortef, synthroid, tegretol, norvasc, lisinopril, ddavp. he is being managed for extensive past history due to an astrocytoma, brain surgery, hypothyroidism, endocrine insufficiency. he has not yet undergone significant workup. he has not yet had an endoscopy or barium study performed. he is developmentally delayed due to the surgery, panhypopituitarism.,his family history is significant for his father being of mine, also having reflux issues, without true heartburn, but distal esophageal stricture. the patient does not smoke, does not drink. he is living with his parents. since his emergency department visitation yesterday, no significant complaints.,large male, no acute distress. vital signs monitored in the endoscopy suite. lungs clear. cardiac exam showed regular rhythm. abdomen obese but soft. extremity exam showed large hands. he was a mallampati score a, asa classification type 2.,the procedure discussed with the patient, the patient's mother. risks, benefits, and alternatives discussed. potential alternatives for dysphagia, such as motility disorder, given his brain surgery, given the possibility of achalasia and similar discussed. the potential need for a barium swallow, modified barium swallow, and similar discussed. all questions answered. at this point, the patient will undergo endoscopy for evaluation of dysphagia, with potential benefit of the possibility to dilate him should there be a stricture. he may have reflux symptoms, without complaining of heartburn. he may benefit from a trial of ppi. all of this reviewed. all questions answered.,

preoperative diagnosis: , low back pain.,postoperative diagnosis: , low back pain.,procedure performed:,1. lumbar discogram l2-3.,2. lumbar discogram l3-4.,3. lumbar discogram l4-5.,4. lumbar discogram l5-s1.,anesthesia: ,iv sedation.,procedure in detail: ,the patient was brought to the radiology suite and placed prone onto a radiolucent table. the c-arm was brought into the operative field and ap, left right oblique and lateral fluoroscopic images of the l1-2 through l5-s1 levels were obtained. we then proceeded to prepare the low back with a betadine solution and draped sterile. using an oblique approach to the spine, the l5-s1 level was addressed using an oblique projection angled c-arm in order to allow for perpendicular penetration of the disc space. a metallic marker was then placed laterally and a needle entrance point was determined. a skin wheal was raised with 1% xylocaine and an #18-gauge needle was advanced up to the level of the disc space using ap, oblique and lateral fluoroscopic projections. a second needle, #22-gauge 6-inch needle was then introduced into the disc space and with ap and lateral fluoroscopic projections, was placed into the center of the nucleus. we then proceeded to perform a similar placement of needles at the l4-5, l3-4 and l2-3 levels.,a solution of isovue 300 with 1 gm of ancef was then drawn into a 10 cc syringe and without informing the patient of our injecting, we then proceeded to inject the disc spaces sequentially.

preoperative diagnosis:, open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36.,postoperative diagnosis:, open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36.,procedure:, open reduction, internal fixation (orif) of bilateral mandible fractures with multiple approaches, cpt code 21470, and surgical extraction of teeth #17, cpt code 41899.,anesthesia: , general anesthesia via nasal endotracheal intubation.,fluids: , 1800 ml of lr.,estimated blood loss: , 150 ml.,hardware: ,a 2.3 titanium locking reconstruction plate from leibinger on the symphysis and a 2.0 reconstruction plate on the left angle.,specimen: , none.,complications: , none.,condition: , the patient was extubated to the pacu, breathing spontaneously in excellent good condition.,indications for the procedure: , the patient is a 55-year-old male that he is 12 hour status post interpersonal violence in which he sustained bilateral mandible fractures and positive loss of consciousness. he reported to the hospital the day after his altercation complaining of mall occlusion and sore left shoulder. he was worked up by the emergency department. his head ct was cleared and his left shoulder was clear of any fractures or soft tissue damage. oral maxillary facial surgery was consulted to manage the mandible fracture. after review of the ct and examination it was determined that the patient would benefit from open reduction, internal fixation of bilateral mandible fractures. risks, benefits, and alternative to treatment were thoroughly discussed with the patient and consent was obtained.,description of procedure:, the patient was brought to the operating room #2 at hospital. he was laid in supine position on the operating room table. asa monitors were attached and stated general anesthesia was induced with iv anesthetic and maintained with nasal endotracheal intubation and inflation anesthetics.,the patient was prepped and draped in the usual oral maxillofacial surgery fashion. the surgeon approached the operating room table in a sterile fashion. approximately 10 ml of 1% lidocaine with 1:100,000 epinephrine was injected into oral vestibule in a nerve block fashion. erich arch bars were adapted to the maxilla and mandible, secured in the posterior teeth with 24-gauge surgical steel wire and 26-gauge surgical steel wire in the anterior. this was done from second molar to second molar on both the maxilla and the mandible secondary to the patient missing multiple teeth. the patient was manipulated up into maximum intercuspation. he has a malocclusion with severe bruxism and so wear facets were lined up. this was secured with 26-gauge surgical steel wire. attention was then directed to the symphysis extraorally. approximately 5 ml of 1% lidocaine with epinephrine was injected into the area of incision which paralleled the inferior border of the mandible 2 cm below the inferior border of the mandible.,after waiting appropriate time for local anesthesia using a 15 blade, a skin and platysma incision was made. then using a series of blunt and sharp dissections, the dissection was carried to the inferior border of the mandible. the periosteum was incised and reflected with the periosteal elevator. the fracture was noted and it was displaced. manipulation of the segments and checking with the occlusion intraorally, the fracture was aligned. this was secured with 7-hole 2.3 titanium locking reconstruction plate with bicortical screws. the wound was then packed with moist ray-tec and attention was directed intraorally to the left angle fracture. approximately 5 ml of 1% lidocaine with 1:100,000 epinephrine was injected into the left vestibule. after waiting appropriate time for local anesthesia to take effect, using bovie electrocautery, a sagittal split incision was made and the fracture was identified. it was noted that the fracture went through tooth #17 and this needed to be extracted. taking a round bur, a buckle trough was made and the tooth was elevated and removed both distal and mesial roots. the fracture was then reduced and lateral superior border plate 2-0 4 whole with monocortical screws was placed. the fracture was noted to be well reduced. the wound was then irrigated with copious amount of sterile water. the patient was released for excellent intercuspation. he was then manipulated up into the occlusion easily. wound was then closed with running 3-0 chromic gut suture. attention was then directed extraorally. this was irrigated with copious amount of sterile water and closed in a layer fashion with 3-0 vicryl, 4-0 vicryl, and 5-0 prolene on skin. attention was then again directed into the mouth. the throat pack was removed and orogastric tube was placed and stomach content was evacuated. the patient was then manipulated back up to maximum intercuspation and secured with interdental elastics and a pressure dressing was applied to the extraoral incisions. at this point, the procedure was then determined to be over.,the patient was extubated and breathing spontaneously, transported to the pacu in excellent condition.

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

preoperative diagnosis: , bilateral knee degenerative arthritis.,postoperative diagnosis: , bilateral knee degenerative arthritis.,procedure performed: , bilateral knee arthroplasty.,please note this procedure was done by dr. x for the left total knee and dr. y for the right total knee. this operative note will discuss the right total knee arthroplasty.,anesthesia: ,general.,complications: , none.,blood loss: , approximately 150 cc.,history:, this is a 79-year-old female who has disabling bilateral knee degenerative arthritis. she has been unresponsive to conservative measures. all risks, complications, anticipated benefits, and postoperative course were discussed. the patient has agreed to proceed with surgery as described below.,gross findings: , there was noted to be eburnation and wear along the patellofemoral joint and femoral tibial articulation medially and laterally with osteophyte formation and sclerosis.,specifications: , the zimmer nexgen total knee system was utilized.,procedure: , the patient was taken to the operating room #2 and placed in supine position on the operating room table. she was administered spinal anesthetic by dr. z.,the tourniquet was placed about the proximal aspect of the right lower extremity. the right lower extremity was then sterilely prepped and draped in the usual fashion. an esmarch bandage was used to exsanguinate the right lower extremity and the tourniquet was inflated to 325 mmhg. longitudinal incision was made over the anterior aspect of the right knee. subcutaneous tissue was carefully dissected. a medial parapatellar retinacular incision was made. the patella was then everted and the above noted gross findings were appreciated. a drill hole was placed in the distal aspect of the femur and the distal femoral cutting guides were positioned in place. the appropriate cuts were made at the distal femur as well as with use of the chamfer guide. the trial femoral component was then positioned in place and noted to have good fit. attention was then directed to proximal tibia, the external tibial alignment guide was positioned in place and the proximal tibial cut was made demonstrating satisfactory cut. the medial and lateral collateral ligaments remained intact throughout the procedure as well as the posterior cruciate ligaments. the remnants of the anterior cruciate ligament and menisci were resected. the tibial trial was positioned in place. intraoperative radiographs were taken, demonstrating satisfactory alignment of the tibial cut. the tibial holes were then drilled. the patella was then addressed with the bovie used to remove the soft tissue around the perimeter of the patella. the patellar cutting guide was positioned in place and the posterior aspect of the patella was resected to the appropriate thickness. three drill holes were made within the patella after it was determined that 35 mm patella would be most appropriate. the knee was placed through range of motion with the trial components marked and then the appropriate components obtained. the tibial tray was inserted with cement, backed it into place, excess methylmethacrylate was removed. the femoral component was inserted with methylmethacrylate. any excessive methylmethacrylate and bony debris were removed from the joint. trial poly was positioned in place and the knee was held in full extension while the methylmethacrylate became firm. the methylmethacrylate was also used at the patella. the prosthesis was positioned in place. the patellar clamp held securely till the methylmethacrylate was firm. after all three components were in place, the knee was then again in placed range of motion and there appeared to be some torsion to the proximal tibial component and concerned regarding the alignment. this component was removed and revised to a stemmed component with better alignment and position. the previous component removed, the methylmethacrylate was removed. further irrigation was performed and then a stemmed template was positioned in place with the intramedullary alignment guide positioned and the tibia drilled and broached. the trial tibial stemmed component was positioned in place. knee was placed through range of motion and the tracking was better. actual component was then obtained, methyl methacrylate was placed within the tibia. the stemmed tibial component was impacted into place with good fit. the poly was then positioned in place. knee held in full extension with compression longitudinally after methylmethacrylate was solidified. the trial poly was removed. wound was irrigated and the joint was inspected. there was no debris. collateral ligaments and posterior cruciate ligaments remained intact. soft tissue balancing was done and a 17 mm poly was then inserted with the knee and tibial and femoral components with good tracking as well as the patellar component. the tourniquet was deflated. hemostasis was satisfactory. a drain was placed into the depths of the wound. the medial retinacular incision was closed with one ethibond suture in interrupted fashion. the knee was placed through range of motion and there was no undue tissue tension, good patellar tracking, no excessive soft tissue laxity or constrain. the subcutaneous tissue was closed with #2-0 undyed vicryl in interrupted fashion. the skin was closed with surgical clips. the exterior of the wound was cleansed as well padded dressing abds and ace wrap over the right lower extremity. at the completion of the procedure, distal pulses were intact. toes were pink, warm, with good capillary refill. distal neurovascular status was intact. postoperative x-ray demonstrated satisfactory alignment of the prosthesis. prognosis is good in this 79-year-old female with a significant degenerative arthritis.

preoperative diagnosis: , bladder tumor.,postoperative diagnosis: , bladder tumor.,procedure performed: , transurethral resection of a medium bladder tumor (turbt), left lateral wall.,anesthesia: , spinal.,specimen to pathology: , bladder tumor and specimen from base of bladder tumor.,drains: , a 22-french 3-way foley catheter, 30 ml balloon.,estimated blood loss:, minimal.,indications for procedure: , this is a 74-year-old male who presented with microscopic and an episode of gross hematuria. he underwent an ivp, which demonstrated enlarged prostate and normal upper tracts. cystoscopy in the office demonstrated a 2.5- to 3-cm left lateral wall bladder tumor. he is brought to the operating room for transurethral resection of that bladder tumor.,description of operation: , after preoperative counseling of the patient and his wife, the patient was taken to the operating room and administered a spinal anesthetic. he was placed in lithotomy position and prepped and draped in the usual fashion. using the visual obturator, the resectoscope was then inserted per urethra into the bladder. the bladder was inspected confirming previous cystoscopic findings of a 2.5- to 3-cm left lateral wall bladder tumor away from the ureteral orifice. using the resectoscope loop, the tumor was then resected down to its base in a stepwise fashion. following completion of resection down to the base, the bladder was _______ free of tumor specimen. the resectoscope was then reinserted and the base of the bladder tumor was then resected to get the base of the bladder tumor specimen, this was sent as a separate pathological specimen. hemostasis was assured with electrocautery. the base of the tumor was then fulgurated again and into the periphery out in the normal mucosa surrounding the base of the bladder tumor. following completion of the fulguration, there was good hemostasis. the remainder of the bladder was without evidence of significant abnormality. both ureteral orifices were visualized and noted to drain freely of clear urine. the bladder was filled and the resectoscope was removed. a 22-french 3-way foley catheter was inserted per urethra into the bladder. the balloon was inflated to 30 ml. the catheter with sterile continuous irrigation and was noted to drain clear irrigant. the patient was then removed from lithotomy position. he was in stable condition.

chief complaint:, well-child check sports physical.,history of present illness:, this is a 14-1/2-year-old white male known to have asthma and allergic rhinitis. he is here with his mother for a well-child check. mother states he has been doing well with regard to his asthma and allergies. he is currently on immunotherapy and also takes advair 500/50 mg, flonase, claritin and albuterol inhaler as needed. his last exacerbation was 04/04. he has been very competitive in his sports this spring and summer and has had no issues since that time. he eats well from all food groups. he has very good calcium intake. he will be attending maize high school in the ninth grade. he has same-sex and opposite-sex friends. he has had a girlfriend in the past. he denies any sexual activity. no use of alcohol, cigarettes or other drugs. his bowel movements are without problems. his immunizations are up to date. his last tetanus booster was in 07/03.,current medications:, as above.,allergies: , he has no known medication allergies.,review of systems:,constitutional: he has had no fever.,heent: no vision problems. no eye redness, itching or drainage. no earache. no sore throat or congestion.,cardiovascular: no chest pain.,respiratory: no cough, shortness of breath or wheezing.,gi: no stomachache, vomiting or diarrhea.,gu: no dysuria, urgency or frequency.,hematological: no excessive bruising or bleeding. he did have a minor concussion in 06/04 while playing baseball.,physical examination:,general: he is alert and in no distress.,vital signs: he is afebrile. his weight is at the 75th percentile. his height is about the 80th percentile.,heent: normocephalic. atraumatic. pupils are equal, round and reactive to light. tms are clear bilaterally. nares patent. nasal mucosa is mildly edematous and pink. no secretions. oropharynx is clear.,neck: supple.,lungs: good air exchange bilaterally.,heart: regular. no murmur.,abdomen: soft. positive bowel sounds. no masses. no hepatosplenomegaly.,gu: male. testes descended bilaterally. tanner iv. no hernia appreciated.,extremities: symmetrical. femoral pulses 2+ bilaterally. full range of motion of all extremities.,back: no scoliosis.,neurological: grossly intact.,skin: normal turgor. minor sunburn on upper back.,neurological: grossly intact.,assessment:,1. well child.,2. asthma with good control.,3. allergic rhinitis, stable.,plan:, hearing and vision assessment today are both within normal limits. will check an h&h today. continue all medications as directed. prescription written for albuterol inhaler, #2, one for home and one for school to be used for rescue. anticipatory guidance for age. he is to return to the office in one year or sooner if needed.

presentation: , patient, 13 years old, comes to your office with his mother complaining about severe ear pain. he awoke during the night with severe ear pain, and mom states that this is the third time this year he has had earaches.,history of present illness: ,patient reports that he felt good after taking antibiotics with each earache episode and has recently started on the wrestling team. mom reports that patient has been afebrile with each of the earache episodes, and he has not had upper respiratory symptoms. patient denies any head trauma associated with wrestling practice.,birth and developmental history:, patient's mother reports a normal pregnancy with no complications, having received prenatal care from 12 weeks. vaginal delivery was uneventful with a normal perinatal course. patient sat alone at 6 months, crawled at 9 months, and walked at 13 months. his verbal and motor developmental milestones were as expected.,family/social history: , patient lives with both parents and two siblings (brother - age 11 years, sister - age 15 years). he reports enjoying school, remains active in scouts, and is very excited about being on the wresting team. mom reports that he has several friends, but she is concerned about the time required for the wrestling team. patient is in 8th grade this year and an a/b student. both siblings are healthy. his dad has hypertension and has frequent heartburn symptoms that he treats with over-the-counter (otc) medications. mom is healthy and has asthma.,past medical history: ,patient has been seen in the clinic yearly for well child exams. he has had no major illnesses or hospitalizations. he had one emergency room visit 2 years ago for a knee laceration. patient has been healthy except for the past year when he had two episodes of otitis media not associated with respiratory infections. he received antibiotic therapy (amoxicillin) for the otitis media and both episodes resolved without problems. patient's mom states that he takes no prescribed medications or otc medications, but he admits that he has been taking his dad's otc pepcid ae sometimes when he gets heartburn. upon further examination, he reports taking pepcid when he eats pizza or mexican food. he does complain of sore throats sometimes and often feels burning in his throat when he goes to sleep at night after a late evening snack.,nutritional history: , patient eats cereal bars or pop tarts with milk for breakfast most days. he takes his lunch (usually a sandwich and chips or yogurt and fruit) for lunch. mom or his sister cooks supper in the evening. the family goes out to eat once or twice a week and he only gets "fast food" once or twice a week according to his mom. he says he eats "a lot" especially after a wrestling meet.,physical exam:,height/weight: patient weighs 109 pounds (60th percentile) and is 69 inches tall (93rd percentile). he is following the growth pattern he established in infancy.,vital signs: bp 110/60, t 99.2, hr 70, r 16.,general: alert, cooperative but a bit shy.,neuro: dtrs symmetric, 2+, negative romberg, able to perform simple calculations without difficulty, short-term memory intact. he responds appropriately to verbal and visual cues, and movements are smooth and coordinated.,heent: normocephalic, peerla, red reflex present, optic disk and ocular vessels normal. tms deep red, dull, landmarks obscured, full bilaterally. post auricular and submandibular nodes on left are palpable and slightly tender.,lungs: cta, breath sounds equal bilaterally, excursion and chest configuration normal.,cardiac: s1, s2 split, no murmurs, pulses equal bilaterally.,abdomen: soft, rounded, reports no epigastric tenderness but states that heartburn begins in epigastric area and rises to throat. bowel sounds active in all quadrants. no hepatosplenomegaly or tenderness. no cva tenderness.,musculoskeletal: full range of motion, all extremities. spine straight, able to perform jumping jacks and duck walk without difficulty.,genital: normal male, tanner stage 4. rectal exam - small amount of soft stool, no fissures or masses.,labs: ,stool negative for blood and h. pylori antigen. normal cbc and urinalysis. a barium swallow and upper gi was scheduled for the following week. it showed marked ge reflux.,assessment: , the differential diagnoses for patient included (a) chronic otitis media/treatment failure, (b) peptic ulcer disease/gastritis, (c) gastro esophageal reflux disease (gerd) or carbonated beverage syndrome, (d) trauma.,chronic otitis media. , chronic otitis media due to a penicillin resistant organism would be the obvious diagnosis in this case. it is rare for an adolescent to have otitis media with no precipitating factor (such as being on a swim team or otherwise exposed to unusual organisms or in an unusual environment). it is certainly unusual for him to have three episodes in 1 year.,peptic ulcer disease., there were no symptoms of peptic ulcer disease, a negative h. pylori screen and lack of pain made this diagnosis less likely. trauma. trauma was a possibility, particularly since adolescent males frequently minimize symptoms especially if they might limit participation in a sport but patient maintained that he had not had an event where he struck his head or neck and that he always wore his helmet with ear padding.,gerd., the history of "heartburn" relieved by his father's medication was striking. the positive study supported the diagnosis of gerd, which was severe and chronic enough to cause irritation of the mucosal surfaces exposed to the gastric juices and edema, inflammation in the inner ears.,plan:, patient and his mom agreed to a trial of omeprazole 20 mg at bedtime for 2 weeks. patient was to keep a diary of any episodes of heartburn, including what foods seemed to aggravate it. the clinician asked him to avoid using any antacid products in the meantime to gage the effectiveness of the medication. he was also given a prescription for 10 days of augmentin99 and a follow-up appointment for 2 weeks. at his follow-up appointment he reported one episode after he ate a whole large pizza after wrestling practice but said it went away pretty quickly after he took his medication. a 6-month follow up appointment was scheduled.

preoperative diagnoses,1. abnormal uterine bleeding.,2. uterine fibroids.,postoperative diagnoses,1. abnormal uterine bleeding.,2. uterine fibroids.,operation performed: , laparoscopic-assisted vaginal hysterectomy.,anesthesia: , general endotracheal anesthesia.,description of procedure: ,after adequate general endotracheal anesthesia, the patient was placed in dorsal lithotomy position, prepped and draped in the usual manner for a laparoscopic procedure. a speculum was placed into the vagina. a single tooth tenaculum was utilized to grasp the anterior lip of the uterine cervix. the uterus was sounded to 10.5 cm. a #10 rumi cannula was utilized and attached for uterine manipulation. the single-tooth tenaculum and speculum were removed from the vagina. at this time, the infraumbilical area was injected with 0.25% marcaine with epinephrine and infraumbilical vertical skin incision was made through which a veress needle was inserted into the abdominal cavity. aspiration was negative; therefore the abdomen was insufflated with carbon dioxide. after adequate insufflation, veress needle was removed and an 11-mm separator trocar was introduced through the infraumbilical incision into the abdominal cavity. through the trocar sheath, the laparoscope was inserted and adequate visualization of the pelvic structures was noted. at this time, the suprapubic area was injected with 0.25% marcaine with epinephrine. a 5-mm skin incision was made and a 5-mm trocar was introduced into the abdominal cavity for instrumentation. evaluation of the pelvis revealed the uterus to be slightly enlarged and irregular. the fallopian tubes have been previously interrupted surgically. the ovaries appeared normal bilaterally. the cul-de-sac was clean without evidence of endometriosis, scarring or adhesions. the ureters were noted to be deep in the pelvis. at this time, the right cornu was grasped and the right fallopian tube, uteroovarian ligament, and round ligaments were doubly coagulated with bipolar electrocautery and transected without difficulty. the remainder of the uterine vessels and anterior and posterior leaves of the broad ligament, as well as the cardinal ligament was coagulated and transected in a serial fashion down to level of the uterine artery. the uterine artery was identified. it was doubly coagulated with bipolar electrocautery and transected. a similar procedure was carried out on the left with the left uterine cornu identified. the left fallopian tube, uteroovarian ligament, and round ligaments were doubly coagulated with bipolar electrocautery and transected. the remainder of the cardinal ligament, uterine vessels, anterior, and posterior sheaths of the broad ligament were coagulated and transected in a serial manner to the level of the uterine artery. the uterine artery was identified. it was doubly coagulated with bipolar electrocautery and transected. the anterior leaf of the broad ligament was then dissected to the midline bilaterally, establishing a bladder flap with a combination of blunt and sharp dissection. at this time, attention was made to the vaginal hysterectomy. the laparoscope was removed and attention was made to the vaginal hysterectomy. the rumi cannula was removed and the anterior and posterior leafs of the cervix were grasped with lahey tenaculum. a circumferential injection with 0.25% marcaine with epinephrine was made at the cervicovaginal portio. a circumferential incision was then made at the cervicovaginal portio. the anterior and posterior colpotomies were accomplished with a combination of blunt and sharp dissection without difficulty. the right uterosacral ligament was clamped, transected, and ligated with #0 vicryl sutures. the left uterosacral ligament was clamped, transected, and ligated with #0 vicryl suture. the parametrial tissue was then clamped bilaterally, transected, and ligated with #0 vicryl suture bilaterally. the uterus was then removed and passed off the operative field. laparotomy pack was placed into the pelvis. the pedicles were evaluated. there was no bleeding noted; therefore, the laparotomy pack was removed. the uterosacral ligaments were suture fixated into the vaginal cuff angles with #0 vicryl sutures. the vaginal cuff was then closed in a running fashion with #0 vicryl suture. hemostasis was noted throughout. at this time, the laparoscope was reinserted into the abdomen. the abdomen was reinsufflated. evaluation revealed no further bleeding. irrigation with sterile water was performed and again no bleeding was noted. the suprapubic trocar sheath was then removed under laparoscopic visualization. the laparoscope was removed. the carbon dioxide was allowed to escape from the abdomen and the infraumbilical trocar sheath was then removed. the skin incisions were closed with #4-0 vicryl in subcuticular fashion. neosporin and band-aid were applied for dressing and the patient was taken to the recovery room in satisfactory condition. estimated blood loss was approximately 100 ml. there were no complications. the instrument, sponge, and needle counts were correct.

pap smear in november 2006 showed atypical squamous cells of undetermined significance. she has a history of an abnormal pap smear. at that time, she was diagnosed with cin 3 as well as vulvar intraepithelial neoplasia. she underwent a cone biopsy that per her report was negative for any pathology. she had no vulvar treatment at that time. since that time, she has had normal pap smears. she denies abnormal vaginal bleeding, discharge, or pain. she uses yaz for birth control. she reports one sexual partner since 1994 and she is a nonsmoker.,she states that she has a tendency to have yeast infections and bacterial vaginosis. she is also being evaluated for a possible interstitial cystitis because she gets frequent urinary tract infections. she had a normal mammogram done in august 2006 and a history of perirectal condyloma that have been treated by dr. b. she also has a history of chlamydia when she was in college.,past medical hx: , depression.,past surgical hx: , none.,medications: , lexapro 10 mg a day and yaz.,allergies: , no known drug allergies.,ob hx: , normal spontaneous vaginal delivery at term in 2001 and 2004, abc weighed 8 pounds 7 ounces and xyz weighed 10 pounds 5 ounces.,family hx: ,maternal grandfather who had a mi which she reports is secondary to tobacco and alcohol use. he currently has metastatic melanoma, mother with hypertension and depression, father with alcoholism.,social hx:, she is a public relations consultant. she is a nonsmoker, drinks infrequent alcohol and does not use drugs. she enjoys horseback riding and teaches jumping.,pe: , vitals: height: 5 feet 6 inches. weight: 139 lb. bmi: 22.4. blood pressure: 102/58. general: she is well-developed and well-nourished with normal habitus and no deformities. she is alert and oriented to time, place, and person and her mood and affect is normal. neck: without thyromegaly or lymphadenopathy. lungs: clear to auscultation bilaterally. heart: regular rate and rhythm without murmurs. breasts: deferred. abdomen: soft, nontender, and nondistended. there is no organomegaly or lymphadenopathy. pelvic: normal external female genitalia. vulva, vagina, and urethra, within normal limits. cervix is status post cone biopsy; however, the transformation zone grossly appears normal and cervical discharge is clear and normal in appearance. gc and chlamydia cultures as well as a repeat pap smear were done.,colposcopy is then performed without and with acetic acid. this shows an entirely normal transformation zone, so no biopsies are taken. an endocervical curettage is then performed with cytobrush and curette and sent to pathology. colposcopy of the vulva is then performed again with acetic acid. there is a thin strip of acetowhite epithelium located transversely on the clitoral hood that is less than a centimeter in diameter. there are absolutely no abnormal vessels within this area. the vulvar colposcopy is completely within normal limits.,a/p: , ascus pap smear with history of a cone biopsy in 1993 and normal followup.,we will check the results of the pap smear, in addition we have ordered dna testing for high-risk hpv. we will check the results of the ecc. she will return in two weeks for test results. if these are normal, she will need two normal pap smears six months apart, and i think followup colposcopy for the vulvar changes.

history of present illness:, this is a 55-year-old female with a history of i-131-induced hypothyroidism years ago who presents with increased weight and edema over the last few weeks with a 25-pound weight gain. she also has a history of fibromyalgia, inflammatory bowel disease, crohn disease, copd, and disc disease as well as thyroid disorder. she has noticed increasing abdominal girth as well as increasing edema in her legs. she has been on norvasc and lisinopril for years for hypertension. she has occasional sweats with no significant change in her bowel status. she takes her thyroid hormone apart from her synthroid. she had been on generic for the last few months and has had difficulty with this in the past.,medications: , include levothyroxine 300 mcg daily, albuterol, asacol, and prilosec. her amlodipine and lisinopril are on hold.,allergies:, include iv dye, sulfa, nsaids, compazine, and demerol.,past medical history:, as above includes i-131-induced hypothyroidism, inflammatory bowel disease with crohn, hypertension, fibromyalgia, copd, and disc disease.,past surgical history: , includes a hysterectomy and a cholecystectomy.,social history: , she does not smoke or drink alcohol.,family history: , positive for thyroid disease but the sister has graves disease, as well a sister with hashimoto thyroiditis.,review of systems: , positive for fatigue, sweats, and weight gain of 20 pounds. denies chest pain or palpitations. she has some loosening stools, but denies abdominal pain. complains of increasing girth and increasing leg swelling.,physical examination:,general: she is an obese female.,vital signs: blood pressure 140/70 and heart rate 84. she is afebrile.,heent: she has no periorbital edema. extraocular movements were intact. there was moist oral mucosa.,neck: supple. her thyroid gland is atrophic and nontender.,chest: good air entry.,cardiovascular: regular rate and rhythm.,abdomen: benign.,extremities: showed 1+ edema.,neurologic: she was awake and alert.,laboratory data:, tsh 0.28, free t4 1.34, total t4 12.4 and glucose 105.,impression/plan:, this is a 55-year-old female with weight gain and edema, as well as history of hypothyroidism. hypothyroidism is secondary to radioactive iodine for graves disease many years ago. she is clinically and biochemically euthyroid. her tsh is mildly suppressed, but her free t4 is normal and with her weight gain i will not decrease her dose of levothyroxine. i will continue on 300 mcg daily of synthroid. if she wanted to lose significant weight, i shall repeat thyroid function test in six weeks' time to ensure that she is not hyperthyroid.

reason for consultation: , management of end-stage renal disease (esrd), the patient on chronic hemodialysis, being admitted for chest pain.,history of present illness:, this is a 66-year-old native american gentleman, a patient of dr. x, my associate, who has a past medical history of coronary artery disease, status post stent placement, admitted with chest pressure around 4 o'clock last night. he took some nitroglycerin tablets at home with no relief. he came to the er. he is going to have a coronary angiogram done today by dr. y. i have seen this patient first time in the morning, approximately around the 4 o'clock. this is a late entry dictation. presently lying in bed, but he feels fine. denies any chest pain, shortness of breath, nausea, vomiting, abdominal pain, diarrhea. denies hematuria, dysuria, or bright red blood per rectum.,past medical history:,1. coronary artery disease, status post stent placement two years ago.,2. diabetes mellitus for the last 12 years.,3. hypertension.,4. end-stage renal disease.,5. history of tia in the past.,past surgical history:,1. as mentioned above.,2. cholecystectomy.,3. appendectomy.,4. right ij permacath placement.,5. av fistula graft in the right wrist.,personal and social history:, he smoked 2 to 3 packets per day for at least last 10 years. he quit smoking roughly about 20 years ago. occasional alcohol use.,family history: , noncontributory.,allergies: ,no known drug allergies.,medications at home: , metoprolol, plavix, rocaltrol, lasix, norvasc, zocor, hydralazine, calcium carbonate, and loratadine.,physical examination,general: he is alert, seems to be in no apparent distress.,vital signs: temperature 98.2, pulse 61, respiratory 20, and blood pressure 139/63.,heent: atraumatic and normocephalic.,neck: no jvd, no thyromegaly, supra and infraclavicular lymphadenopathy.,lungs: clear to auscultation. air entry bilateral equal.,heart: s1 and s2. no pericardial rub.,abdomen: soft and nontender. normal bowel sounds.,extremities: no edema.,neurologic: the patient is alert without focal deficit.,laboratory data:, laboratory data shows hemoglobin 13, hematocrit 38.4, sodium 130, potassium 4.2, chloride 96.5, carbonate 30, bun 26, creatinine 6.03, and glucose 162.,impression:,1. end-stage renal disease, plan for dialysis today.,2. diabetes mellitus.,3. chest pain for coronary angiogram today.,4. hypertension, blood pressure stable.,plan: , currently follow the patient. dr. z is going to assume the care.

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.

preoperative diagnosis:, metopic synostosis with trigonocephaly.,postoperative diagnosis:, metopic synostosis with trigonocephaly.,procedures: ,1. bilateral orbital frontal zygomatic craniotomy (skull base approach).,2. bilateral orbital advancement with (c-shaped osteotomies down to the inferior orbital rim) with bilateral orbital advancement with bone grafts.,3. bilateral forehead reconstruction with autologous graft.,4. advancement of the temporalis muscle bilaterally.,5. barrel-stave osteotomies of the parietal bones.,anesthesia: , general.,procedure: , after induction of general anesthesia, the patient was placed supine on the operating room table with a roll under his shoulders and his head resting on a foam doughnut. scalp was clipped. he was prepped with chloraprep. incision was infiltrated with 0.5% xylocaine with epinephrine 1:200,000 and he received antibiotics and he was then reprepped and draped in a sterile manner.,a bicoronal zigzag incision was made and raney clips used for hemostasis. subcutaneous flaps were developed and reflected anteriorly and slightly posteriorly. these were subgaleal flaps. bipolar and bovie cautery were used for hemostasis. the craniectomy was outlined with methylene blue. the pericranium was incised exposing the bone along the outline of the craniotomy.,paired bur holes were drilled anteriorly and posteriorly straddling the metopic suture. one was just above the nasion and the other was near the bregma. also bilateral pterional bur holes were drilled. there was a little bit of bleeding from a tributary of the sagittal sinus anteriorly and so bone wax was used for hemostasis in all the bur holes.,the dura was separated with a #4 penfield dissector and then the craniotomies were fashioned or cut. i should say with the midas rex drill using the v5 bit and the footplate attachment, the bilateral craniotomies were cut and then the midline piece was elevated separately. great care was taken when removing the bone from the midline. bipolar cautery was used for bleeding points on the dura and especially over the sagittal sinus and the bleeding was controlled.,the wound was irrigated with bacitracin irrigation.,the next step was to perform the orbital osteotomies with careful protection of the orbital contents. osteotomies were made with the midas rex drill using the v5 bit in the orbital roof bilaterally. this was a very thick and vertically oriented orbital roof on each side. midas rex drill and osteotomes and mallet were used to cut these osteotomies using retractors to protect the orbital contents and the dura. the osteotomies were carried down through the tripod of the orbit and down through the lateral orbital rim and all the way down to the inferior orbital rim using the osteotome and mallet. bone wax was used for hemostasis. it was necessary to score the undersurface of the bone at the midline because it was so thick and pointed. so we were not going to be able to effect the orbital advancement without scoring the bone and thinning it out a bit. this was done with the midas rex drill using b5 bit. also, the marked ridge just above the nasion was burred down with the midas rex drill. the osteotomies were also carried down through the zygoma. at this point, with a gentle rocking motion and sustained pressure using the osteotomes, it was then possible to carefully advance the orbital rims bilaterally, first on the right and then on the left again using just a careful rocking motion against the remaining bone to gently bend the orbital rims outward bilaterally.,dr. x cut the bone grafts from the bone flaps and i fashioned a shelf to secure the bone graft by burring a ledge on the internal surface of the superior orbital rim. this created a shelf for the notched bone graft to lean against basically anteriorly. the posterior notch of the bone graft was able to be braced by the ledge of orbital roof posteriorly.,the left medial orbital rim greenstick fractured a bit, but the bone graft appeared to stay in place.,holes were then cut in the supraorbital rim for advancement of the temporalis muscle and then a synthes mesh was placed anteriorly using absorbable screw hardware and attached the mesh where the forehead bone flaps turned around and recontoured to make a nice bilateral forehead for isaac.,at this point the undersurface of the temporalis muscle was scored using the bovie cautery to allow advancement of the muscle anteriorly and we sutured it to the supraorbital rims bilaterally with #3-0 vicryl suture. this helped fill-in the indentation left by the orbital advancement at the temporal region.,also, i separated the undersurface of the dura from the bone bilaterally and cut multiple barrel-stave osteotomies in the parietal bones and then greenstick fractured these barrel-staves outward to create a more normal contour of the bone slightly posteriorly.,at this point, gelfoam had been used to protect the dura over the sagittal sinus during this part of the procedure.,the wound was then irrigated with bacitracin irrigation. bleeding had been controlled during the procedure with bovie and bipolar electrocautery, even so the blood loss was fairly significant adding up to about 300 or 400 ml and he received that much in packed cells and he also received a unit of fresh frozen plasma.,at this point, the reconstruction looked good. the advancement was about 1 cm and we were pleased with the results. the wound was irrigated and then the gelfoam over the midline dura was left in place and the galea was then closed with #4-0 and some #3-0 vicryl interrupted suture and #5-0 mild chromic on the skin. the patient tolerated procedure well. no complications. sponge and needle counts were correct. again, blood loss was bout 300 to 400 ml and he received 2 units of blood and some fresh frozen plasma.

consult for prostate cancer,the patient returned for consultation for his newly diagnosed prostate cancer. the options including radical prostatectomy with or without nerve sparing were discussed with him with the risks of bleeding, infection, rectal injury, impotence, and incontinence. these were discussed at length. alternative therapies including radiation therapy; either radioactive seed placement, conformal radiation therapy, or the hdr radiation treatments were discussed with the risks of bladder, bowel, and rectal injury and possible impotence were discussed also. there is a risk of rectal fistula. hormonal therapy is usually added to the radiation therapy options and this has the risk of osteoporosis, gynecomastia, hot flashes and impotency. potency may not recover after the hormone therapy has been completed. cryosurgery was discussed with the risks of urinary retention, stricture formation, incontinence and impotency. there is a risk of rectal fistula. he would need to have a suprapubic catheter for about two weeks and may need to learn self-intermittent catheterization if he cannot void adequately. prostate surgery to relieve obstruction and retention after radioactive seeds or cryosurgery has a higher risk of urinary incontinence. observation therapy was discussed with him in addition. i answered all questions that were put to me and i think he understands the options that are available. i spoke with the patient for over 60 minutes concerning these options.

xyz street,city, state,dear dr. cd:,thank you for seeing mr. xyz, a pleasant 19-year-old male who has seen you in 2005 for suspected seizure activity. he comes to my office today continuing on dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years. he is requesting to come off the dilantin at this point. upon reviewing your 2005 note there was some discrepancy as to the true nature of his episodes to the emergency room and there was consideration to reconsider medication use. his physical exam, neurologically, is normal at this time. his dilantin level is slightly low at 12.5.,i will appreciate your evaluation and recommendation as to whether we need to continue the dilantin at this time. i understand this will probably entail repeating his eeg and so please coordinate this through health center. i await your response and whether we should continue this medication. if you require any laboratory, we use abc diagnostic and any further testing that is needed should be coordinated at health center prior to scheduling.

preoperative diagnosis: , left carpal tunnel syndrome.,postoperative diagnosis: , left carpal tunnel syndrome.,operative procedure:,1. left endoscopic carpal tunnel release.,2. endotracheal fasciotomy.,anesthesia:, general.,complications: , none.,indication: , the patient is a 62-year-old lady with the aforementioned diagnosis refractory to nonoperative management. all risks and benefits were explained. questions answered. options discussed. no guarantees were made. she wished to proceed with surgery.,procedure: , after administering appropriate antibiotics and mac anesthesia, the upper extremity was prepped and draped in the usual standard fashion, the arm was exsanguinated with esmarch, and the tourniquet inflated to 250 mmhg.,i made a transverse incision one fingerbreadth proximal to the distal volar wrist crease. dissection was carried down to the antebrachial fascia, which was cut in a distally based fashion. bipolar electrocautery was used to maintain meticulous hemostasis. i then performed an antebrachial fasciotomy proximally. i entered the extra bursal space deep into the transverse carpal ligament and used the spatula probe and then the dilators and then the square probe to enlarge the area. great care was taken to feel the washboard undersurface of the transverse carpal ligament and the hamate on the ulnar side. great care was taken with placement. a good plane was positively identified. i then placed the endoscope in and definitely saw the transverse striations of the deep surface of the transverse carpal ligament.,again, i felt the hook of the hamate ulnar to me. i had my thumb on the distal aspect of the transverse carpal ligament. i then partially deployed the blade, and starting 1 mm from the distal edge, the transverse carpal ligament was positively identified. i pulled back and cut and partially tightened the transverse carpal ligament. i then feathered through the distal ligament and performed a full-thickness incision through the distal half of the ligament. i then checked to make sure this was properly performed and then cut the proximal aspect. i then entered the carpal tunnel again and saw that the release was complete, meaning that the cut surfaces of the transverse carpal ligament were separated; and with the scope rotated, i could see only one in the field at a time. great care was taken and at no point was there any longitudinal structure cut. under direct vision through the incision, i made sure that the distal antebrachial fascia was cut. following this, i irrigated and closed the skin. the patient was dressed and sent to the recovery room in good condition.

preoperative diagnosis: , penile skin bridges after circumcision.,postoperative diagnosis: , penile skin bridges after circumcision.,procedure: ,excision of penile skin bridges about 2 cm in size.,abnormal findings: ,same as above.,anesthesia: ,general inhalation anesthetic with caudal block.,fluids received: , 300 ml of crystalloids.,estimated blood loss: , less than 5 ml.,specimens: , no tissue sent to pathology.,tubes and drains:, no tubes or drains were used.,count: , sponge and needle counts were correct x2.,indications for operation: ,the patient is a 2-1/2-year-old boy with a history of newborn circumcision who developed multiple skin bridges after circumcision causing curvature with erection. plan is for repair.,description of procedure: , the patient is taken to the operating room, where surgical consent, operative site, and the patient's identification was verified. once he was anesthetized, the caudal block was placed and iv antibiotics were given. he was then placed in a supine position and sterilely prepped and draped. once he was prepped and draped, we used a straight mosquito clamp and went under the bridges and crushed them, and then excised them with a curved iris and curved tenotomy scissors. we removed the excessive skin on the shaft skin and on the glans itself. we then on the ventrum excised the bridge and did a heinecke-mikulicz closure with interrupted figure-of-eight and interrupted suture of 5-0 chromic. electrocautery was used for hemostasis. once this was done, we then used dermabond tissue adhesive and surgicel to prevent the bridges from returning again. iv toradol was given at the end of procedure. the patient tolerated the procedure well, was in stable condition upon transfer to the recovery room.

history: , the patient is scheduled for laparoscopic gastric bypass. the patient has been earlier seen by dr. x, her physician. she has been referred to us from family practice. in short, she is a 33-year-old lady with a bmi of 43, otherwise healthy with unsuccessful nonsurgical methods of weight loss. ,she was on laparoscopic gastric bypass for weight loss. ,she meets the national institute of health criteria. she is very well educated and motivated and has no major medical contraindications for the procedure.,physical examination:, on physical examination today, she weighs 216 pounds with a bmi of 43.5, pulse is 96, temperature is 97.6, blood pressure is 122/80. lungs are clear. abdomen is soft, nontender. there is stigmata for morbid obesity. she has cesarean section scars in the lower abdomen with no herniation. ,discussion: , i had a long talk with the patient about laparoscopic gastric bypass, possible open including risks, benefits, alternatives, need for long-term followup, need to adhere to dietary and exercise guidelines. i also explained to her complications including rare cases of death secondary to dvt, pe, leak , peritonitis, sepsis, shock, multisystem organ failure, need for re-operation including for leak or bleeding, gastrostomy or jejunostomy for feeding, rare case of respiratory failure requiring mechanical ventilation, etc., with myocardial infarction, pneumonia, atelectasis in the postoperative period were also discussed. ,short-term complications of gastric bypass including gastrojejunal stricture requiring endoscopic dilatation, marginal ulcer secondary to smoking or anti-inflammatory drug intake which can progress on to perforation or bleeding, small bowel obstruction secondary to internal hernia or adhesions, signs and symptoms of which were discussed. the patient would alert us for earlier intervention. symptomatic gallstone formation secondary to rapid weight loss were also discussed. how to avoid it by taking ursodiol were also discussed. long-term complications of gastric bypass including hair loss, excess skin, multivitamin and mineral deficiencies, protein-calorie malnutrition, weight regain, weight plateauing, need for major lifestyle and exercise and habit changes, avoiding pregnancy in the first two years, etc., were all stressed. the patient understands. she wants to go to surgery. ,in preparation of surgery, she will undergo very low-calorie diet through medifast to decrease the size of the liver to make laparoscopic approach more successful and also to optimize her cardiopulmonary and metabolic comorbidities. she will also see a psychologist, nutritionist, and exercise physiologist for a multidisciplinary effort for short and long-term success for weight loss surgery. i will see her two weeks before the plan of surgery for further discussion and any other questions at that point of time.

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.

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

on review of systems, the patient admits to hypertension and occasional heartburn. she undergoes mammograms every six months, which have been negative for malignancy. she denies fevers, chills, weight loss, fatigue, diabetes mellitus, thyroid disease, upper extremity trauma, night sweats, dvt, pulmonary embolism, anorexia, bone pain, headaches, seizures, angina, peripheral edema, claudication, orthopnea, pnd, coronary artery disease, rheumatoid arthritis, rashes, upper extremity edema, cat scratches, cough, hemoptysis, shortness of breath, dyspnea at two flights of stairs, hoarseness, gi bleeding, change in bowel habits, dysphagia, ulcers, hematuria, or history of tb exposure. she has had negative ppd.,past medical history:, hypertension.,past surgical history:, right breast biopsy - benign.,social history: , she was born and raised in baltimore. she has not performed farming or kept birds or cats.,tobacco: none.,ethanol: ,drug use: ,occupation: she is a registered nurse at spring grove hospital.,exposure: negative to asbestos.,family history:, mother with breast cancer.,allergies: , percocet and morphine causing temporary hypotension.,medications: , caduet 10 mg p.o. q.d., coreg cr 40 mg p.o. q.d., and micardis hct 80 mg/12.5 mg p.o. q.d.,physical examination: ,bp: 133/72

preoperative diagnosis: , squamous cell carcinoma on the right hand, incompletely excised.,postoperative diagnosis: , squamous cell carcinoma on the right hand, incompletely excised.,name of operation: , re-excision of squamous cell carcinoma site, right hand.,anesthesia:, local with monitored anesthesia care.,indications:, patient, 72, status post excision of squamous cell carcinoma on the dorsum of the right hand at the base of the thumb. the deep margin was positive. other margins were clear. he was brought back for re-excision.,procedure:, the patient was brought to the operating room and placed in the supine position. he was given intravenous sedation. the right hand was prepped and draped in the usual sterile fashion. three cubic centimeters of 1% xylocaine mixed 50/50 with 0.5% marcaine with epinephrine was instilled with local anesthetic around the site of the excision, and the site of the cancer was re-excised with an elliptical incision down to the extensor tendon sheath. the tissue was passed off the field as a specimen.,the wound was irrigated with warm normal saline. hemostasis was assured with the electrocautery. the wound was closed with running 3-0 nylon without complication. the patient tolerated the procedure well and was taken to the recovery room in stable condition after a sterile dressing was applied.

subjective:, the patient is an 89-year-old lady. she actually turns 90 later this month, seen today for a short-term followup. actually, the main reasons we are seeing her back so soon which are elevated blood pressure and her right arm symptoms are basically resolved. blood pressure is better even though she is not currently on the higher dose mavik likely recommended. she apparently did not feel well with the higher dose, so she just went back to her previous dose of 1 mg daily. she thinks, she also has an element of office hypertension. also, since she is on mavik plus verapamil, she could switch over to the combined drug tarka. however, when we gave her samples of that she thought they were too big for her to swallow. basically, she is just back on her previous blood pressure regimen. however, her blood pressure seems to be better today. her daughter says that they do check it periodically and it is similar to today’s reading. her right arm symptoms are basically resolved and she attributed that to her muscle problem back in the right shoulder blade. we did do a c-spine and right shoulder x-ray and those just mainly showed some degenerative changes and possibly some rotator cuff injury with the humeral head quite high up in the glenoid in the right shoulder, but this does not seem to cause her any problems. she has some vague “stomach problems”, although apparently it is improved when she stopped aleve and she does not have any more aches or pains off aleve. she takes tylenol p.r.n., which seems to be enough for her. she does not think she has any acid reflux symptoms or heartburn. she does take tums t.i.d. and also mylanta at night. she has had dentures for many, many years and just recently i guess in the last few months, although she was somewhat vague on this, she has had some sores in her mouth. they do heal up, but then she will get another one. she also thinks since she has been on the lexapro, she has somewhat of a tremor of her basically whole body at least upper body including the torso and arms and had all of the daughters who i not noticed to speak of and it is certainly difficult to tell her today that she has much tremor. they do think the lexapro has helped to some extent.,allergies: , none.,medication: , verapamil 240 mg a day, mavik 1 mg a day, lipitor 10 mg one and half daily, vitamins daily, ocuvite daily, tums t.i.d., tylenol 2-3 daily p.r.n., and mylanta at night.,review of systems:, mostly otherwise as above.,objective:,general: she is a pleasant elderly lady. she is in no acute distress, accompanied by daughter.,vital signs: blood pressure: 128/82. pulse: 68. weight: 143 pounds.,heent: no acute changes. atraumatic, normocephalic. on mouth exam, she does have dentures. she removed her upper denture. i really do not see any sores at all. her mouth exam was unremarkable.,neck: no adenopathy, tenderness, jvd, bruits, or mass.,lungs: clear.,heart: regular rate and rhythm.,extremities: no significant edema. reasonable pulses. no clubbing or cyanosis, may be just a minimal tremor in head and hands, but it is very subtle and hardly noticeable. no other focal or neurological deficits grossly.,impression:,1. hypertension, better reading today.,2. right arm symptoms, resolved.,3. depression probably somewhat improved with lexapro and she will just continue that. she only got up to the full dose 10 mg pill about a week ago and apparently some days does not need to take it.,4. perhaps a very subtle tremor. i will just watch that.,5. osteoporosis.,6. osteoarthritis.,plan:, i think i will just watch everything for now. i would continue the lexapro, we gave her more samples plus a prescription for the 20 mg that she can cut in half. i offered to see her for again short-term followup. however, they both preferred just to wait until the annual check up already set up for next april and they know they can call sooner. she might get a flu shot here in the next few weeks. daughter mentioned here today that she thinks her mom is doing pretty well, especially given that she is turning 90 here later this month and i would tend to agree with that.

family history:, her father died from leukemia. her mother died from kidney and heart failure. she has two brothers; five sisters, one with breast cancer; two sons; and a daughter. she describes cancer, hypertension, nervous condition, kidney disease, high cholesterol, and depression in her family.,social history:, she is divorced. she does not have support at home. she denies tobacco, alcohol, and illicit drug use.,allergies: , hypaque dye when she had x-rays for her kidneys.,medications: , prempro q.d., levoxyl 75 mcg q.d., lexapro 20 mg q.d., fiorinal as needed, currently she is taking it three times a day, and aspirin as needed. she also takes various supplements including multivitamin q.d., calcium with vitamin d b.i.d., magnesium b.i.d., ester-c b.i.d., vitamin e b.i.d., flax oil and fish oil b.i.d., evening primrose 1000 mg b.i.d., quercetin 500 mg b.i.d., policosanol 20 mg two a day, glucosamine chondroitin three a day, coenzyme-q 10 30 mg two a day, holy basil two a day, sea vegetables two a day, and very green vegetables.,past medical history:, anemia, high cholesterol, and hypothyroidism.,past surgical history:, in 1979, tubal ligation and three milk ducts removed. in 1989 she had a breast biopsy and in 2007 a colonoscopy. she is g4, p3, with no cesarean section.,review of systems: ,heent: for headaches and sore throat. musculoskeletal: she is right handed with joint pain, stiffness, and decreased range of motion. cardiac: for heart murmur. gi: negative and noncontributory. respiratory: negative and noncontributory. urinary: negative and noncontributory. hem-onc: negative and noncontributory. vascular: negative and noncontributory. psychiatric: negative and noncontributory. genital: negative and noncontributory. she denies any bowel or bladder dysfunction or loss of sensation in her genital area.,physical examination: , she is 5 feet 2 inches tall. current weight is 132 pounds, weight one year ago was 126 pounds. bp is 122/68. on physical exam, patient is alert and oriented with normal mentation and appropriate speech, in no acute distress. general, a well-developed and well-nourished female in no acute distress. heent exam, head is atraumatic and normocephalic. eyes, sclerae are anicteric. teeth good dentition. cranial nerves ii, iii, iv, and vi, vision is intact, visual fields are full to confrontation, eoms full bilaterally, and pupils are equal, round, and reactive to light. cranial nerves v and vii, normal facial sensation and symmetrical facial movement. cranial nerve viii, hearing intact. cranial nerves ix, x, and xii, tongue protrudes midline and palate elevates symmetrically.,cranial nerve xi, strong and symmetrical shoulder shrugs against resistance. cardiac, regular rate and rhythm. chest and lungs are clear bilaterally. skin is warm and dry, normal turgor and texture. no rashes or lesions are noted. general musculoskeletal exam reveals no gross deformities, fasciculations, or atrophy. peripheral vascular, no cyanosis, clubbing, or edema. examination of the low back reveals some mild paralumbar spasms. she is nontender to palpation of her spinous processes, si joints, and paralumbar musculature. she does have some poking sensation to deep palpation into the left buttock where she describes some zinging sensation. deep tendon reflexes are 2+ bilateral knees and ankles. no ankle clonus is elicited. babinski, toes are downgoing. straight leg raising is negative bilaterally. strength on manual exam is 5/5 and equal bilateral lower extremity. she is able to ambulate on her toes and her heels without any difficulty. she is able to get up standing on one foot on to the toes. she does have some difficulty getting up on to her heels when standing on one foot. she has trouble with this on the left and right. she complains of increased pain while doing this as well. she also has positive patrick/faber on the right with pain with internal and external rotation, negative on the left. sensation is intact. she has good accuracy to pinprick, dull versus sharp.,findings: , the patient brings in lumbar spine mri dated november 20, 2007, which demonstrates degenerative disc disease throughout. at l4-l5, there is an annular disc bulge with fissuring with facet arthrosis and ligamentum flavum hypertrophy yielding moderate central stenosis and neuroforaminal narrowing but the nerves do not appear to be impinged. at l5-s1, in the right neuroforamina, there appears to be soft tissue density just lateral and posterior to the nerve root, which may cause some displacement, but it is unclear. this could represent a facet synovial cyst. this is lateral to the facet. she does not have x-rays for review. she has had hip and knee x-rays taken but does not bring them in with her.,assessment: , low back pain, lumbar radiculopathy, degenerative disc disease, lumbar spinal stenosis, history of anemia, high cholesterol, and hypothyroidism.,plan: , we discussed treatment options with this patient including:,1 do nothing.,2. conservative therapies.,3. surgery.,she seems to have some issues with her right hip, so i would like for her to fax us over the report of her hip and knee x-rays. we will also order some x-rays of her lumbar spine as well as lower extremity emg.,at this point, the patient has not exhausted conservative measures and would like to start with epidural steroid injections, so we will go ahead and send her out for that. after she has gotten her second epidural injection, she will return to the office for a followup visit to see how she is doing. all questions and concerns were addressed. if she should have any further questions, concerns, or complications, she will contact our office immediately. otherwise, we will see her as scheduled. case was reviewed and discussed with dr. l.

preoperative diagnosis: , voluntary sterility.,postoperative diagnosis: , voluntary sterility.,operative procedure:, bilateral vasectomy.,anesthesia:, local.,indications for procedure: ,a gentleman who is here today requesting voluntary sterility. options were discussed for voluntary sterility and he has elected to proceed with a bilateral vasectomy.,description of procedure: ,the patient was brought to the operating room, and after appropriately identifying the patient, the patient was prepped and draped in the standard surgical fashion and placed in a supine position on the or table. then, 0.25% marcaine without epinephrine was used to anesthetize the scrotal skin. a small incision was made in the right hemiscrotum. the vas deferens was grasped with a vas clamp. next, the vas deferens was skeletonized. it was clipped proximally and distally twice. the cut edges were fulgurated. meticulous hemostasis was maintained. then, 4-0 chromic was used to close the scrotal skin on the right hemiscrotum. next, the attention was turned to the left hemiscrotum, and after the left hemiscrotum was anesthetized appropriately, a small incision was made in the left hemiscrotum. the vas deferens was isolated. it was skeletonized. it was clipped proximally and distally twice. the cut edges were fulgurated. meticulous hemostasis was maintained. then, 4-0 chromic was used to close the scrotal skin. a jockstrap and sterile dressing were applied at the end of the case. sponge, needle, and instruments counts were correct.

primary discharge diagnoses:,1. urinary tract infection.,2. gastroenteritis with nausea and vomiting.,3. upper gastrointestinal bleed likely secondary to gastritis.,4. right hip osteoarthritic pain.,secondary discharge diagnoses:,1. hypertension.,2. gastroesophageal reflux disease.,3. chronic atrial fibrillation.,4. osteoporosis.,5. valvular heart disease.,hospital course summary: , the patient is 93-year-old caucasian female with a past medical history of hypertension, chronic atrial fibrillation, gastroesophageal reflux disease, osteoporosis and chronic right hip pain after total hip arthroplasty was admitted to our hospital for complaints of nausea and vomiting and urinary tract infection. over the course of her hospitalization, the patient was started on antibiotic regimen and proton pump inhibitors for an episode of coffee-ground emesis. the patient was managed conservatively and was also provided with physical therapy for chronic right hip pain.,at the time of discharge, the patient continues to complain of right hip pain impairing ability to walk. the patient denies any chest pain, nausea, vomiting, fever, chills, shortness of breath, abdominal pain or any urine or bowel problems.,past medical history: , can be referred to the h&p dictated in the chart.,past surgical history: , can be referred to the h&p dictated in the chart.,physical examination: ,vital signs: at the time of discharge temperature 36.6 degree celsius, pulse rate of 77 per minute, respiratory rate 20 per minute, blood pressure 115/63, and oxygen saturation of 94% on room air.,general: the patient is a thin built caucasian female with no pallor, cyanosis or icterus. she is alert and oriented x3.,heent: no carotid bruits, jvd, lymphadenopathy or thyromegaly. pupils are equally reactive to light and accommodation.,back and extremity: bilateral pitting edema and peripheral pulses are palpable. the patient has right hip brace/immobilizer.,heart: irregularly irregular heart rhythm, grade 2-3/6 systolic ejection murmur best heard over the aortic area and normal s1 and s2.,chest: auscultation revealed bibasilar crackles.,abdomen: soft, nontender, no organomegaly and bowel sounds are present.,cns: nonfocal.,laboratory studies: , wbc 6.5, hemoglobin 12.5, hematocrit 38.9, platelet count 177,000, inr 1.2, sodium 141, potassium 3.6 and serum creatinine of 0.8. liver function tests were normal. the patient's troponin was elevated at 0.05 at the time or presentation, but it trended down to 0.04 on the third set. urinalysis revealed trace protein, trace blood, and 10-20 wbcs. blood culture showed no growth till date. urine culture grew 50-100,000 colonies of enterococcus susceptible to ampicillin and nitrofurantoin.,chest x-ray showed enlarged heart with large intrathoracic hiatal hernia. lung parenchyma was otherwise clear.,right hip x-ray showed that the prosthesis was in satisfactory position. there was small gap between the cancellous bone and the long stem femoral component of the prosthesis, which is within normal limits.,discharge medications:,1. aspirin 81 mg orally once daily.,2. calcium with vitamin d two tablets orally once daily.,3. nexium 40 mg orally once daily.,4. multivitamins with minerals one capsule once daily.,5. zoloft 25 mg orally once daily.,6. norco 325/10 mg every 6-8 hours as needed for pain.,7. systane ophthalmic solution two drops in both eyes every two hours as needed.,8. herbal __________ by mouth everyday.,9. macrodantin 100 mg orally every six hours for seven days.,allergies:, penicillin.,prognosis: , improved.,assessment and discharge plan: ,the patient is a 93-year-old caucasian female with a past medical history of chronic right hip pain, osteoporosis, hypertension, depression, and chronic atrial fibrillation admitted for evaluation and management of severe nausea and vomiting and urinary tract infection.,problem #1:

preoperative diagnosis:, right common, internal and external carotid artery stenosis.,postoperative diagnosis:, right common, internal and external carotid artery stenosis.,operations,1. right common carotid endarterectomy.,2. right internal carotid endarterectomy.,3. right external carotid endarterectomy.,4. hemashield patch angioplasty of the right common, internal and external carotid arteries.,anesthesia:, general endotracheal anesthesia.,urine output: , not recorded,operation in detail: , after obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered. next the right neck was prepped and draped in the standard surgical fashion. a #10-blade scalpel was used to make an incision at the anterior tip of the sternocleidomastoid muscle. dissection was carried down to the level of the carotid artery using bovie electrocautery and sharp dissection with metzenbaum scissors. the common, internal and external carotid arteries were identified. the facial vein was ligated with #3-0 silk. the hypoglossal nerve was identified and preserved as it coursed across the carotid artery. after dissecting out an adequate length of common, internal and external carotid artery, heparin was given. next, an umbilical tape was passed around the common carotid artery. a #0 silk suture was passed around the internal and external carotid arteries. the hypoglossal nerve was identified and preserved. an appropriate sized argyle shunt was chosen. a hemashield patch was cut to the appropriate size. next, vascular clamps were placed on the external carotid artery. debakey pickups were used to control the internal carotid artery and common carotid artery. a #11-blade scalpel was used to make an incision on the common carotid artery. the arteriotomy was lengthened onto the internal carotid artery. next, the argyle shunt was placed. it was secured in place. next, an endarterectomy was performed; and this was done on the common, internal carotid and external carotid arteries. an inversion technique was used on the external carotid artery. the artery was irrigated and free debris was removed. next, we sewed the hemashield patch onto the artery using #6-0 prolene in a running fashion. prior to completion of our anastomosis, we removed our shunt. we completed the anastomosis. next, we removed our clamp from the external carotid artery, followed by the common carotid artery, and lastly by the internal carotid artery. there was no evidence of bleeding. full-dose protamine was given. the incision was closed with #0 vicryl, followed by #2-0 vicryl, followed by #4-0 pds in a running subcuticular fashion. a sterile dressing was applied.

preoperative diagnosis:, penoscrotal hypospadias with chordee.,postoperative diagnosis: , penoscrotal hypospadias with chordee.,procedure:, hypospadias repair (tit and tissue flap relocation) and nesbit tuck chordee release.,anesthesia: , general inhalation anesthetic with a caudal block.,fluids received: , 300 ml of crystalloids.,estimated blood loss: , 15 ml.,specimens: , no tissue sent to pathology.,tubes and drains: , an 8-french zaontz catheter.,indications for operation: , the patient is a 1-1/2-year-old boy with penoscrotal hypospadias; plan is for repair.,description of procedure: ,the patient was taken to the operating room, where surgical consent, operative site and the patient's identification was verified. once he was anesthetized, a caudal block was placed. iv antibiotic was given. the dorsal hood was retracted and the patient was then sterilely prepped and draped. a stay stitch of 4-0 prolene was then placed in the glans for traction. his urethra was calibrated, it was quite thin, to a 10-french with the straight sounds. we then marked the coronal cuff and the urethral plate as well as the penile shaft skin with marking pen and incised the coronal cuff circumferentially and then around the urethral plate with the 15 blade knife and then degloved the penis with a curved tenotomy scissors. electrocautery was used for hemostasis. the ventral chordee tissue was removed. we then placed a vessel loop tourniquet around the base of the penis and using iv grade saline did an artificial erection test, which showed that he had a persistent chordee. in the midline a 15 blade knife was used to incise buck fascia after marking the area of chordee with the marking pen. we then used a heinecke-mikulicz nesbit tuck with 5-0 prolene to straighten the penis. artificial erection again performed showed the penis was straight. the knot was buried with figure-of-eight suture of 7-0 vicryl in buck fascia above it. we then left the tourniquet in place and then after marking the urethral plate incised it and enlarged it with beaver blade and a 15 blade. we then elevated the glanular wings as well in the similar fashion. an 8-french zaontz catheter was then placed and the urethral plate was then closed over this with a distal interrupted sutures of 7-0 vicryl and then a running subcuticular closure of 7-0 vicryl to close the defect. we then put the stay sutures in the inter-preputial skin with 7-0 vicryl and then rotated a flap using the subcutaneous tissue after dissecting it down to the pubis at the base of the penile shaft on the dorsum using the curved iris scissors. we buttonholed the flap and then placed it through the penis as a sleeve. interrupted sutures of 7-0 vicryl then used to reapproximate and to tack this flap and place over the urethroplasty. once this was done, a two 5-0 vicryl deep sutures were placed in the glans to rotate the glans and allow for hemostasis. interrupted sutures of 7-0 vicryl were then used to create the neomeatus and horizontal mattress sutures of 7-0 vicryl used to reconstitute the glans. we then removed the excessive preputial skin and using tacking sutures of 6-0 chromic tacked the penile shaft skin to the coronal cuff and on the ventrum we dropped a portion of the skin down on the left side of the penis to reconstitute the penoscrotal junction using horizontal mattress sutures. we then closed the ventral defect. once this was done, the stay suture in the glans was used to keep the zaontz catheter to tack it into place. we then used surgicel, dermabond, and telfa dressing with mastisol and an eye tape to keep the dressing in place. iv toradol was given at the end of the procedure. the patient was in stable condition upon transfer to the recovery room.

history of present illness:, i was kindly asked to see ms. abc who is a 74-year-old woman for cardiology consultation regarding atrial fibrillation and anticoagulation after a fall.,the patient is somnolent at this time, but does arouse, but is unable to provide much history. by review of the chart, it appears that she fell, which is what she states when she got up out of a rocking chair and could not get herself off the floor. she states that 1-1/2 hours later she was able to get herself off the floor.,the patient denies any chest pain nor clear shortness of breath.,past medical history: , includes, end-stage renal disease from hypertension. she follows up with dr. x in her office and has been known to have a small-to-moderate sized pericardial effusion since 11/07 that has apparently been followed and it appears that the patient was not interested in having diagnostic pericardiocentesis done. she had an echocardiogram today (please see also that report), which shows stable and small-to-moderate sized pericardial effusion without tamponade, normal left ventricular ejection fraction at 55% with mild concentric left ventricular hypertrophy, mildly dilated right ventricular size, normal right ventricular ejection fraction, moderate mitral regurgitation and severe tricuspid regurgitation with severe pulmonary hypertension, estimated pa systolic pressure of 71 mmhg when compared to the prior echocardiogram done 08/29/07, previously the mitral regurgitation was mild and previously the pa systolic pressure was estimated at 90 mmhg. other findings were not significantly changed including pericardial effusion description. she has a history of longstanding hypertension. she has been on hemodialysis since 1997 for renal failure, history of mini-strokes documented several years ago, history of seizure disorder, she has a history of right upper extremity edema and right breast enlargement from right subclavian vein occlusion. she has a history of hypertension, depression, hyperlipidemia, on sensipar for tertiary hyperparathyroidism.,past surgical history: , includes, cholecystectomy, post fistula in the left arm, which has failed, and right arm, which is being used including number of operative procedures to the fistula. she follows up with dr. y regarding neurovascular surgery.,medications: , on admission:,1. norvasc 10 mg once a day.,2. aspirin 81 mg once a day.,3. colace 200 mg two at bedtime.,4. labetalol 100 mg p.o. b.i.d.,5. nephro-vite one tablet p.o. q.a.m.,6. dilantin 100 mg p.o. t.i.d.,7. renagel 1600 mg p.o. t.i.d.,8. sensipar 120 mg p.o. every day.,9. sertraline 100 mg p.o. nightly.,10. zocor 20 mg p.o. nightly.,allergies: , to medications per chart are none.,family history: ,unable to obtain as the patient becomes quite sleepy when i am talking.,social history: ,unable to obtain as the patient becomes quite sleepy when i am talking.,review of systems: , unable to obtain as the patient becomes quite sleepy when i am talking.,physical exam: ,temperature 99.2, blood pressure ranges from 88/41 to 108/60, pulse 70, respiratory rate, 20, o2 saturation 98%. height is 5 feet 1 inch, weight 147 pounds. on general exam, she is a pleasant elderly woman who does arouse to voice, but then becomes quite sleepy and apparently that is an improvement from when she was admitted. heent shows the cranium is normocephalic and atraumatic. she has moist mucosal membranes. neck veins are difficult to assess, but do not appear clinically distended. no carotid bruits. lungs are clear to auscultation anteriorly. no wheezes. cardiac exam: s1, s2 regular rate, 3/6 holosystolic murmur heard with radiation from the left apex towards the left axilla. no rub, no gallop. pmi is nondisplaced. abdomen: soft, nondistended. cva is benign. extremities with no significant edema. pulses appear grossly intact. she has evidence of right upper extremity edema, which is apparently chronic.,diagnostic data/lab data: , ekgs are reviewed including from 07/07/09 at 08:31 a.m., which shows atrial fibrillation with left anterior fascicular block, poor r-wave progression when compared to one done on 07/06/09 at 18:25, there is really no significant change. the atrial fibrillation appears present since at least on ekg done on 11/02/07 and this ekg is not significantly changed from the most recent one. echocardiogram results as above. chest x-ray shows mild pulmonary vascular congestion. bnp shows 3788. sodium 136, potassium 4.5, chloride 94, bicarbonate 23, bun 49, creatinine 5.90. troponin was 0.40 followed by 0.34. inr 1.03 on 05/18/07. white blood cell count 9.4, hematocrit 42, platelet count 139.,impression: , ms. abc is a 74-year-old woman admitted to the hospital with a fall and she has a history of vascular dementia, so her history is somewhat unreliable it seems and she is somnolent at that time. she does have chronic atrial fibrillation again documented at least present since 2007 and i found an ekg report by dr. x, which shows atrial fibrillation on 08/29/07 per her report. one of the questions we were asked was whether the patient would be a candidate for coumadin. clearly given her history of small mini-strokes, i think coumadin would be appropriate given this chronic atrial fibrillation, but the main issue is the fall risk. if not felt to be significant fall risk then i would strongly recommend coumadin as the patient herself states that she has only fallen twice in the past year. i would defer that decision to dr. z and dr. xy who know the patient well and it may be that physical therapy consult is appropriate to help adjudicate.,recommendations:,1. fall assessment as per dr. z and dr. xy with possible pt consult if felt appropriate and if the patient is not felt to be at significant fall risk, would put her on coumadin. given her history of small strokes as documented in the chart and her chronic atrial fibrillation, she does have reasonable heart rate control on current labetalol.,2. the patient has elevated bnp and i suspect that is due to her severe pulmonary hypertension and renal failure and in the light of normal lv function, i would not make any further evaluation of that other than aggressive diuresis.,3. regarding this minimal troponin elevation, i do not feel this is a diagnosis especially in the setting of pulmonary hypertension and her small-to-moderate sized stable pericardial effusion again that has been longstanding since 2007 from what i can tell and there is no evidence of tamponade. i would defer to her usual cardiologist dr. x whether an outpatient stress evaluation is appropriate for risk stratification. i did find that the patient had a prior cardiac stress test in 08/07 where they felt that there was some subtle reversibility of the anterior wall, but it was felt that it may be artifact rather than true ischemia with normal lv function seen on that study as well.,4. continue norvasc for history of hypertension as well as labetalol.,5. the patient is felt to be a significant fall risk and will at least continue her aspirin 81 mg once a day for secondary cva, thromboprophylaxis (albeit understanding that it is inferior to coumadin).,6. continue dilantin for history of seizures.

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

preoperative diagnosis:, stress urinary incontinence, intrinsic sphincter deficiency.,postoperative diagnoses: , stress urinary incontinence, intrinsic sphincter deficiency.,operations: , cystoscopy, cystocele repair, bioarc midurethral sling.,anesthesia:, spinal.,ebl: , minimal.,fluids: , crystalloid.,brief history: ,the patient is a 69-year-old female with a history of hysterectomy, complained of urgency, frequency, and stress urinary incontinence. the patient had urodynamics done and a cystoscopy, which revealed intrinsic sphincter deficiency. options such as watchful waiting, kegel exercises, broad-based sling to help with isd versus coaptite bulking agents were discussed. risks and benefits of all the procedures were discussed. the patient understood and wanted to proceed with bioarc. risk of failure of the procedure, recurrence of incontinence due to urgency, mesh erosion, exposure, etc., were discussed. risk of mi, dvt, pe, and bleeding etc., were discussed. the patient understood the risk of infection and wanted to proceed with the procedure. the patient was told that due to the intrinsic sphincter deficiency, we will try to make the sling little bit tighter to allow better urethral closure, which may put her a high risk of retention versus if we make it too loose, then she may leak afterwards.,the patient understood and wanted to proceed with the procedure.,details of the operation: , the patient was brought to the or and anesthesia was applied. the patient was placed in dorsal lithotomy position. the patient was prepped and draped in usual sterile fashion. a foley catheter was placed. bladder was emptied. two allis clamps were placed on the anterior vaginal mucosa. lidocaine 1% with epinephrine was applied, and hydrodissection was done. incision was made. a bladder was lifted off of the vaginal mucosa. the bladder cystocele was reduced. two stab incisions were placed on the lateral thigh over the medial aspect of the obturator canal. using bioarc needle, the needles were passed through under direct palpation through the vaginal incision from the lateral thigh to the vaginal incision. the mesh arms were attached and arms were pulled back the outer plastic sheath and the excess mesh was removed. the mesh was right at the bladder neck to the mid-urethra, completely covering over the entire urethra.,the sling was kept little tight, even though the right angle was easily placed between the urethra and the bioarc material. the urethra was coapted very nicely. at the end of the procedure, cystoscopy was done and there was no injury to the bladder. there was good efflux of urine with indigo carmine coming through from both the ureteral openings. the urethra was normal, seemed to have closed up very nicely with the repair. the vaginal mucosa was closed using 0 vicryl in interrupted fashion. the lateral thigh incisions were closed using dermabond. please note that the irrigation with antibiotic solution was done prior to the bioarc mesh placement. the mesh was placed in antibiotic solution prior to the placement in the body. the patient tolerated the procedure well. after closure, premarin cream was applied. the patient was told to use premarin cream postop. the patient was brought to recovery in stable condition.,the patient was told not to do any heavy lifting, pushing, pulling, and no tub bath, etc., for at least 2 months. the patient understood. the patient was to follow up as an outpatient.

preoperative diagnoses: , chronic otitis media and tonsillar adenoid hypertrophy.,postoperative diagnoses:, chronic otitis media and tonsillar adenoid hypertrophy.,procedures:, bilateral myringotomy and tube placement, tonsillectomy and adenoidectomy.,indications for procedure: , the patient is a 3-1/2-year-old child with history of recurrent otitis media as well as snoring and chronic mouth breathing. risks and benefits of surgery including risk of bleeding, general anesthesia, tympanic membrane perforation as well as persistent recurrent otitis media were discussed with the patient and parents and informed consent was signed by the parents.,findings: ,the patient was brought to the operating room, placed in supine position, given general endotracheal anesthesia. the left ear was then draped in a clean fashion. under microscopic visualization, the ear canal was cleaned of the wax. myringotomy incision was made in the anterior inferior quadrant. there was no fluid in the middle ear space. a micron bobbin tube was easily placed. floxin drops were placed in the ear. the same was performed on the right side with similar findings. the patient was then turned to be placed in rose position. the patient draped in clean fashion. a small mcivor mouth gag was used to hold open the oral cavity. the soft palate was palpated. there was no submucous cleft felt. using a 1:1 mixture of 1% xylocaine with 1:100,000 epinephrine and 0.25% marcaine, both tonsillar pillars and the fossae injected with approximately 7 ml total. using a curved allis the right tonsil was grasped and pulled medially. tonsil was dissected off the tonsillar fossa using a coblator. the left tonsil was removed in the similar fashion. hemostasis then achieved in tonsillar fossa using the coblator on coagulation setting. the soft palate was then retracted using red rubber catheter. under mirror visualization, the patient was found to have enlarged adenoids. the adenoids were removed using the coblator. hemostasis was also achieved using the coblator on coagulation setting. the rubber catheter was then removed. reexamining the oropharynx, small bleeding points were cauterized with the coblator. stomach contents were then aspirated with saline sump. the patient was woken up from anesthesia, extubated and brought to recovery room in stable condition. there were no intraoperative complications. needle and sponge correct. estimated blood loss minimal.

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

procedure:,: after informed consent was obtained, the patient was brought to the operating room and placed supine on the operating room table. general endotracheal anesthesia was induced. the patient was then prepped and draped in the usual sterile fashion. an #11 blade scalpel was used to make a small infraumbilical skin incision in the midline. the fascia was elevated between two ochsner clamps and then incised. a figure-of-eight stitch of 2-0 vicryl was placed through the fascial edges. the 11-mm port without the trocar engaged was then placed into the abdomen. a pneumoperitoneum was established. after an adequate pneumoperitoneum had been established, the laparoscope was inserted. three additional ports were placed all under direct vision. an 11-mm port was placed in the epigastric area. two 5-mm ports were placed in the right upper quadrant. the patient was placed in reverse trendelenburg position and slightly rotated to the left. the fundus of the gallbladder was retracted superiorly and laterally. the infundibulum was retracted inferiorly and laterally. electrocautery was used to carefully begin dissection of the peritoneum down around the base of the gallbladder. the triangle of calot was carefully opened up. the cystic duct was identified heading up into the base of the gallbladder. the cystic artery was also identified within the triangle of calot. after the triangle of calot had been carefully dissected, a clip was then placed high up on the cystic duct near its junction with the gallbladder. the cystic artery was clipped twice proximally and once distally. scissors were then introduced and used to make a small ductotomy in the cystic duct, and the cystic artery was divided. an intraoperative cholangiogram was obtained. this revealed good flow through the cystic duct and into the common bile duct. there was good flow into the duodenum without any filling defects. the hepatic radicals were clearly visualized. the cholangiocatheter was removed, and two clips were then placed distal to the ductotomy on the cystic duct. the cystic duct was then divided using scissors. the gallbladder was then removed up away from the liver bed using electrocautery. the gallbladder was easily removed through the epigastric port site. the liver bed was then irrigated and suctioned. all dissection areas were inspected. they were hemostatic. there was not any bile leakage. all clips were in place. the right gutter up over the edge of the liver was likewise irrigated and suctioned until dry. all ports were then removed under direct vision. the abdominal cavity was allowed to deflate. the fascia at the epigastric port site was closed with a stitch of 2-0 vicryl. the fascia at the umbilical port was closed by tying the previously placed stitch. all skin incisions were then closed with subcuticular sutures of 4-0 monocryl and 0.25% marcaine with epinephrine was infiltrated into all port sites. the patient tolerated the procedure well. the patient is currently being aroused from general endotracheal anesthesia. i was present during the entire case.

cc:, confusion.,hx: , a 71 y/o rhm ,with a history of two strokes ( one in 11/90 and one in 11/91), had been in a stable state of health until 12/31/92 when he became confused, and displayed left-sided weakness and difficulty speaking. the symptoms resolved within hours and recurred the following day. he was then evaluated locally and hct revealed an old right parietal stroke. carotid duplex scan revealed a "high grade stenosis" of the rica. cerebral angiogram revealed 90%rica and 50%lica stenosis. he was then transferred to uihc vascular surgery for carotid endarterectomy. his confusion persisted and he was evaluated by neurology on 1/8/93 and transferred to neurology on 1/11/93.,pmh:, 1)cholecystectomy. 2)inguinal herniorrhaphies, bilaterally. 3)etoh abuse: 3-10 beers/day. 4)right parietal stroke 10/87 with residual left hemiparesis (leg worse than arm). 5) 2nd stoke in distant past of unspecified type.,meds:, none on admission.,fhx:, alzheimer's disease and stroke on paternal side of family.,shx:, 50+pack-yr cigarette use.,ros:, no weight loss. poor appetite/selective eater.,exam:, bp137/70 hr81 rr13 o2sat 95% afebrile.,ms: oriented to city and month, but did not know date or hospital. naming and verbal comprehension were intact. he could tell which direction iowa city and des moines were from clinton and remembered 2-3 objects in two minutes, but both with assistance only. incorrectly spelled "world" backward, as "dlow.",cn: unremarkable except neglects left visual field to double simultaneous stimulation.,motor: deltoids 4+/4-, biceps 5-/4, triceps 5/4+, grip 4+/4+, hf4+/4-, he 4+/4+, hamstrings 5-/5-, ae 5-/5-, af 5-/5-.,sensory: intact pp/lt/vib.,coord: dysdiadochokinesis on ram, bilaterally.,station: dyssynergic rue on fnf movement.,gait: nd,reflexes: 2+/2+ throughout bue and at patellae. absent at ankles. right plantar was flexor; and left plantar was equivocal.,course:, cbc revealed normal hgb, hct, plt and wbc, but mean corpuscular volume was large at 103fl (normal 82-98). urinalysis revealed 20+wbc. gs, tsh, ft4, vdrl, ana and rf were unremarkable. he was treated for a uti with amoxacillin. vitamin b12 level was reduced at 139pg/ml (normal 232-1137). schillings test was inconclusive dure to inability to complete a 24-hour urine collection. he was placed on empiric vitamin b12 1000mcg im qd x 7 days; then qmonth. he was also placed on thiamine 100mg qd, folate 1mg qd, and asa 325mg qd. his esr and crp were elevated on admission, but fell as his uti was treated.,eeg showed diffuse slowing and focal slowing in the theta-delta range in the right temporal area. hct with contrast on 1/19/93 revealed a gyriform enhancing lesion in the left parietal lobe consistent with a new infarct; and an old right parietal hypodensity (infarct). his confusion was ascribed to the uti in the face of old and new strokes and vitamin b12 deficiency. he was lost to follow-up and did not undergo carotid endarterectomy.

discharge summary,summary of treatment planning:, this discharge is at the family's request.,identified problems/outcomes:,1.

subjective:, i am asked to see the patient today with ongoing issues around her diabetic control. we have been fairly aggressively, downwardly adjusting her insulins, both the lantus insulin, which we had been giving at night as well as her sliding scale humalog insulin prior to meals. despite frequent decreases in her insulin regimen, she continues to have somewhat low blood glucoses, most notably in the morning when the glucoses have been in the 70s despite decreasing her lantus insulin from around 84 units down to 60 units, which is a considerable change. what i cannot explain is why her glucoses have not really climbed at all despite the decrease in insulin. the staff reports to me that her appetite is good and that she is eating as well as ever. i talked to anna today. she feels a little fatigued. otherwise, she is doing well.,physical examination: ,vitals as in the chart. the patient is a pleasant and cooperative. she is in no apparent distress.,assessment and plan: , diabetes, still with some problematic low blood glucoses, most notably in the morning. to address this situation, i am going to hold her lantus insulin tonight and decrease and then change the administration time to in the morning. she will get 55 units in the morning. i am also decreasing once again her humalog sliding scale insulin prior to meals. i will review the blood glucoses again next week.,

cc:, fluctuating level of consciousness.,hx:, 59y/o male experienced a "pop" in his head on 10/10/92 while showering in cheyenne, wyoming. he was visiting his son at the time. he was found unconscious on the shower floor 1.5 hours later. his son then drove him back to iowa. since then he has had recurrent headaches and fluctuating level of consciousness, according to his wife. he presented at local hospital this am, 10/13/92. a hct there demonstrated a subarachnoid hemorrhage. he was then transferred to uihc.,meds:, none.,pmh:, 1) right hip and clavicle fractures many years ago. 2) all of his teeth have been removed., ,fhx:, not noted.,shx:, cigar smoker. truck driver.,exam: , bp 193/73. hr 71. rr 21. temp 37.2c.,ms: a&o to person, place and time. no note regarding speech or thought process.,cn: subhyaloid hemorrhages, ou. pupils 4/4 decreasing to 2/2 on exposure to light. face symmetric. tongue midline. gag response difficult to elicit. corneal responses not noted.,motor: 5/5 strength throughout.,sensory: intact pp/vib.,reflexes: 2+/2+ throughout. plantars were flexor, bilaterally.,gen exam: unremarkable.,course:, the patient underwent cerebral angiography on 10/13/92. this revealed a lobulated aneurysm off the supraclinoid portion of the left internal carotid artery close to the origin of the posterior communication artery. the patient subsequently underwent clipping of this aneurysm. he recovery was complicated severe vasospasm and bacterial meningitis. hct on 10/19/92 revealed multiple low density areas in the left hemisphere in the laca-lpca watershed, left fronto-parietal area and left thalamic region. he was left with residual right hemiparesis, urinary incontinence, some (unspecified) degree of mental dysfunction. he was last seen 2/26/93 in neurosurgery clinic and had stable deficits.

procedure: , laparoscopy with ablation of endometriosis.,diagnosis: , endometriosis.,anesthesia:, general.,estimated blood loss: , none.,findings: , allen-masters window in the upper left portion of the cul-de-sac, bronze lesions of endometriosis in the central portion of the cul-de-sac as well as both the left uterosacral ligament, flame lesions of the right uterosacral ligament approximately 5 ml of blood tinged fluid in the cul-de-sac. normal tubes and ovaries, normal gallbladder, smooth liver edge.,procedure: ,the patient was taken to the operating room and placed under general anesthesia. she was put in the dorsal lithotomy position, and the perineum and abdomen were prepped and draped in a sterile manner. subumbilical area was injected with marcaine, and a veress needle was placed subumbilically through which approximately 2 l of co2 were inflated. scalpel was used to make a subumbilical incision through which a 5-mm trocar was placed. laparoscope was inserted through the cannula and the pelvis was visualized. under direct visualization, two 5-mm trocars were placed in the right and left suprapubic midline. incision sites were transilluminated and injected with marcaine prior to cutting. hulka manipulator was placed on the cervix. pelvis was inspected and blood tinged fluid was aspirated from the cul-de-sac. the beginnings of an allen-masters window in the left side of the cul-de-sac were visualized along with bronze lesions of endometriosis. some more lesions were noted above the left uterosacral ligament. flame lesions were noted above the right uterosacral ligament. tubes and ovaries were normal bilaterally with the presence of a few small paratubal cysts on the left tube. there was a somewhat leathery appearance to the ovaries. the lesions of endometriosis were ablated with the argon beam coagulator, as was a region of the allen-masters window. pelvis was irrigated and all operative sites were hemostatic. no other abnormalities were visualized and all instruments were moved under direct visualization. approximately 200 ml of fluid remained in the abdominal cavity. all counts were correct and the skin incisions were closed with 2-0 vicryl after all co2 was allowed to escape. the patient was taken to the recovery in stable condition.

multisystem exam,constitutional: ,the vital signs showed that the patient was afebrile; blood pressure and heart rate were within normal limits. the patient appeared alert.,eyes: ,the conjunctiva was clear. the pupil was equal and reactive. there was no ptosis. the irides appeared normal.,ears, nose and throat: ,the ears and the nose appeared normal in appearance. hearing was grossly intact. the oropharynx showed that the mucosa was moist. there was no lesion that i could see in the palate, tongue. tonsil or posterior pharynx.,neck: ,the neck was supple. the thyroid gland was not enlarged by palpation.,respiratory: ,the patient's respiratory effort was normal. auscultation of the lung showed it to be clear with good air movement.,cardiovascular: ,auscultation of the heart revealed s1 and s2 with regular rate with no murmur noted. the extremities showed no edema.,gastrointestinal: , the abdomen was soft, nontender with no rebound, no guarding, no enlarged liver or spleen. bowel sounds were present.,gu: , the scrotal elements were normal. the testes were without discrete mass. the penis showed no lesion, no discharge.,lymphatic: ,there was no appreciated node that i could feel in the groin or neck area.,musculoskeletal: ,the head and neck by inspection showed no obvious deformity. again, the extremities showed no obvious deformity. range of motion appeared to be normal for the upper and lower extremities.,skin: , inspection of the skin and subcutaneous tissues appeared to be normal. the skin was pink, warm and dry to touch.,neurologic: ,deep tendon reflexes were symmetrical at the patellar area. sensation was grossly intact by touch.,psychiatric: , the patient was oriented to time, place and person. the patient's judgment and insight appeared to be normal.

procedure: ,caudal epidural steroid injection without fluoroscopy.,anesthesia:, local sedation.,vital signs: , see nurse's records.,procedure details: , int was placed. the patient was in the prone position. the back was prepped with betadine. lidocaine 1.5% was used to make a skin wheal over the sacral hiatus. a 18-gauge tuohy needle was then placed into the epidural space. there were no complications from this (no blood or csf). after negative aspiration was performed, a mixture of 10 cc preservative free normal saline plus 160 mg preservative free depo-medrol was injected. neosporin and band-aid were applied over the puncture site. the patient was then placed in supine position. the patient was discharged to outpatient recovery in stable condition.

preoperative diagnoses: , dysphagia and esophageal spasm.,postoperative diagnoses: , esophagitis and esophageal stricture.,procedure:, gastroscopy.,medications:, mac.,description of procedure: , the olympus gastroscope was introduced into the oropharynx and passed carefully through the esophagus, stomach, and duodenum, to the third portion of the duodenum. the hypopharynx was normal and the upper esophageal sphincter was unremarkable. the esophageal contour was normal, with the gastroesophageal junction located at 38 cm from the incisors. at this point, there were several linear erosions and a sense of stricturing at 38 cm. below this, there was a small hiatal hernia with the hiatus noted at 42 cm from the incisors. the mucosa within the hernia was normal. the gastric lumen was normal with normal mucosa throughout. the pylorus was patent permitting passage of the scope into the duodenum, which was normal through the third portion. during withdrawal of the scope, additional views were obtained of the cardia, confirming the presence of a small hiatal hernia. it was decided to attempt dilation of the strictured area, so an 18-mm tts balloon was placed across the stricture and inflated to the recommended diameter. when the balloon was fully inflated, the lumen appeared to be larger than 18 mm diameter, suggesting that the stricture was in fact not a significant one. no stretching of the mucosa took place. the balloon was deflated and the scope was withdrawn. the patient tolerated the procedure well and was sent to the recovery room.,final diagnoses:,1. esophagitis.,2. minor stricture at the gastroesophageal junction.,3. hiatal hernia.,4. otherwise normal upper endoscopy to the transverse duodenum.,recommendations: ,continue proton pump inhibitor therapy.

procedure: , keller bunionectomy.,for informed consent, the more common risks, benefits, and alternatives to the procedure were thoroughly discussed with the patient. an appropriate consent form was signed, indicating that the patient understands the procedure and its possible complications.,this 59 year-old female was brought to the operating room and placed on the surgical table in a supine position. following anesthesia, the surgical site was prepped and draped in the normal sterile fashion.,attention was then directed to the right foot where, utilizing a # 15 blade, a 6 cm. linear incision was made over the 1st metatarsal head, taking care to identify and retract all vital structures. the incision was medial to and parallel to the extensor hallucis longus tendon. the incision was deepened through subcutaneous underscored, retracted medially and laterally - thus exposing the capsular structures below, which were incised in a linear longitudinal manner, approximately the length of the skin incision. the capsular structures were sharply underscored off the underlying osseous attachments, retracted medially and laterally.,utilizing an osteotome and mallet, the exostosis was removed, and the head was remodeled with the liston bone forceps and the bell rasp. the surgical site was then flushed with saline. the base of the proximal phalanx of the great toe was osteotomized approximately 1 cm. distal to the base and excised to toto from the surgical site.,superficial closure was accomplished using vicryl 5-0 in a running subcuticular fashion. site was dressed with a light compressive dressing. the tourniquet was released. excellent capillary refill to all the digits was observed without excessive bleeding noted.,anesthesia: , local.,hemostasis: , accomplished with pinpoint electrocoagulation.,estimated blood loss: , 10 cc.,materials:, none.,injectables:, agent used for local anesthesia was lidocaine 2% without epi.,pathology:, sent no specimen.,dressings: , site was dressed with a light compressive dressing.,condition: , patient tolerated procedure and anesthesia well. vital signs stable. vascular status intact to all digits. patient recovered in the operating room.,scheduling: , return to clinic in 2 week (s).

preoperative diagnosis:, macular edema, right eye.,postoperative diagnosis: ,macular edema, right eye.,title of operation: , insertion of radioactive plaque, right eye with lateral canthotomy.,operative procedure in detail: ,the patient was prepped and draped in the usual manner for a local eye procedure. initially, a 5 cc retrobulbar injection of 2% xylocaine was done. then, a lid speculum was inserted and the conjunctiva was incised 4 mm posterior to the limbus. a 2-0 silk traction suture was placed around the insertion of the lateral rectus muscle and, with gentle traction, the temporal one-half of the globe was exposed. the plaque was positioned on the scleral surface immediately behind the macula and secured with two sutures of 5-0 dacron. the placement was confirmed with indirect ophthalmoscopy. next, the eye was irrigated with neosporin and the conjunctiva was closed with 6-0 plain catgut. the intraocular pressure was found to be within normal limits. an eye patch was applied and the patient was sent to the recovery room in good condition. a lateral canthotomy had been done.

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

preoperative diagnosis: , incidental right adnexal mass on ultrasound.,postoperative diagnoses:,1. complex left ovarian cyst.,2. bilateral complex adnexae.,3. bilateral hydrosalpinx.,4. chronic pelvic inflammatory disease.,5. massive pelvic adhesions.,procedure performed:,1. dilation and curettage (d&c).,2. laparoscopy.,3. enterolysis.,4. lysis of the pelvic adhesions.,5. left salpingo-oophorectomy.,anesthesia: ,general.,complications: , none.,specimens: , endometrial curettings and left ovarian mass.,estimated blood loss: , less than 100 cc.,drains:, none.,findings: , on bimanual exam, the patient has a slightly enlarged, anteverted, freely mobile uterus with an enlarged left adnexa. laparoscopically, the patient has massive pelvic adhesions with completely obliterated posterior cul-de-sac and adnexa.,no adnexal structures were initially able to be visualized until after the lysis of adhesions. eventually we found a normal appearing right ovary, severely scarred right and left fallopian tubes, and a enlarged complex cystic left ovary. there was a normal-appearing appendix and liver, and the vesicouterine junction appeared within normal limits. there were significant adhesions from the small bowel to the bilateral adnexa in the posterior surface of the uterus.,procedure: ,the patient was taken to the operating room where a general anesthetic was administered. she was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion. once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic. next, a weighted speculum was placed in the vagina and anterior wall of the vagina was elevated with the uterine sound and the anterior lip of the cervix was grasped with a vulsellum tenaculum. the uterus was then sounded to 12 cm. the cervix was then serially dilated with hank dilators to a size #20 hank. next a telfa pad was placed on the weighted speculum and a short curettage was performed obtaining a large amount of endometrial tissue. next, the uterine manipulator was placed in the cervix and attached to the anterior lip of the cervix. at this point, the vulsellum tenaculum and weighted speculum were removed. next, attention was turned to the abdomen where an approximately 2 cm incision was made immediately inferior to the umbilicus. the superior aspect of the umbilicus was grasped with a towel clamp and veress needle was inserted through this incision. small amount of normal saline was injected into veress needle and seemed to drop freely. so, the veress needle was connected to he co2 gas, which was started at the lower setting. it was seen to flow freely with a normal resistance so the gas was advanced to the higher setting. the abdomen was then insufflated to an adequate distention. next, the veress needle was removed and a size #11 step trocar was inserted. next, the introducer was removed from the trocar and the laparoscope was inserted through this port and the port was also connected to the co2 gas. at this point, the initial operative findings were seen. next, a size #5 step trocar was inserted approximately two fingerbreadths above the pubic symphysis in the midline. this was done by making a 1 cm incision with the skin knife, introducing a veress needle with ethicon sheet, and the veress needle was then removed and the #5 port was introduced under direct visualization. a size #5 port was also placed approximately six fingerbreadths to the right of the umbilicus in a similar manner also under direct visualization. a blunt probe was inserted suprapubically along with a grasper in the right upper quadrant. these were used to see the above operative findings. next, a size #12 mm port was introduced approximately seven fingerbreadths to the left of the umbilicus under direct visualization. through this, a harmonic scalpel was inserted.,the harmonic scalpel along with the grasper was used to meticulously address the adhesions along the right adnexa in the posterior cul-de-sac. care was taken at all times to avoid the bowel and the ureters. the fallopian tubes appeared massively scarred and completely obliterated from disease. after the right adnexa had been freed to the point where we could visualize the ovary and the posterior cul-de-sac was clearing off then we could visualize the uterosacral ligaments. attention was turned to the left adnexa, which appeared to contain a cystic structure, but it was unclear at the beginning of the procedure what the structure was. adhesions were carefully taken down from the bowel to the left fallopian tube and ovary, and sidewall. the adhesions were then carefully removed from the inferior aspect of the ovary also with the harmonic scalpel. at intermittent points throughout the procedure, the suction irrigator was used to irrigate and suck blood and irrigation out of the pelvis to watch for any bleeding. at this point, the harmonic scalpel was removed and another laparoscopic needle with a 60 cc syringe was inserted and this was used to aspirate approximately 30 cc of serosanguineous fluid from the cystic structure. next, the needle was removed and the ligature device was inserted. this was used to clamp across the fallopian tube initially and then after the fallopian tube was ligated, the uterovarian ligament was clamped and ligated with the ligature device. next, the fallopian tube was removed from the ovary with the ligature device in approximately 3 clamping and ligations. then, the attention was turned to the inferior aspect of the ovary. first the infundibulopelvic ligament was identified, clamped with a ligature device, and ligated. next, the ovary was bluntly dissected from the ovarian fossa with attention to the left ureter. next, the ligature device was used to clamp and ligate the broad ligament immediately inferior to the ovary across. then the ovary was completely bluntly dissected out of the ovarian fossa and completely separated from the pelvis. this was grasped with a clamp. the ligature device was removed from the #12 and a endocatch bag was inserted to the size #12 port. the left ovary was placed in this endocatch bag, which was then removed along with the whole port from the left upper quadrant. next, the pelvis was copiously irrigated and suctioned of all blood and extra fluid. at this point, the remaining two size #5 ports were removed under direct visualization. the camera was removed and the abdomen was desufflated. next, an introducer was replaced on a #11 port. the #11 port was removed. next, the fascia in the left upper quadrant port was identified and grasped with ochsner clamps, tented up, and closed with a single interrupted suture of #0 vicryl on a ur-6 needle. next, all skin incisions were closed with #4-0 undyed vicryl in a subcuticular interrupted fashion. the incisions were cleaned, injected with 0.25% marcaine, and then adjusted with steri-strips and bandage appropriately.,the patient was taken from the operating room in stable condition and should be observed overnight in the hospital.

procedure: , bilateral l5, s1, s2, and s3 radiofrequency ablation.,indication: , sacroiliac joint pain.,informed consent: , the risks, benefits and alternatives of the procedure were discussed with the patient. the patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,the risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and cns side effects with possible of vascular entry of medications. i also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,the patient was informed both verbally and in writing. the patient understood the informed consent and desired to have the procedure performed.,procedure: , oxygen saturation and vital signs were monitored continuously throughout the procedure. the patient remained awake throughout the procedure in order to interact and give feedback. the x-ray technician was supervised and instructed to operate the fluoroscopy machine.,the patient was placed in a prone position on the treatment table with a pillow under the chest and head rotated. the skin over and surrounding the treatment area was cleaned with betadine. the area was covered with sterile drapes, leaving a small window opening for needle placement. fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach. the skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% lidocaine.,with fluoroscopy, a 20 gauge 10-mm bent teflon coated needle was gently guided into the groove between the sap and the sacrum for the dorsal ramus of l5 and the lateral border of the posterior sacral foramen, for the lateral branches of s1, s2, and s3. also, fluoroscopic views were used to ensure proper needle placement.,the following technique was used to confirm correct placement. motor stimulation was applied at 2 hz with 1 millisecond duration. no extremity movement was noted at less than 2 volts. following this, the needle trocar was removed and a syringe containing 1% lidocaine was attached. at each level, after syringe aspiration with no blood return, 0.5 ml of 1% lidocaine was injected to anesthetize the lateral branch and the surrounding tissue. after completion, a lesion was created at that level with a temperature of 80 degrees for 90 seconds.,all injected medications were preservative free. sterile technique was used throughout the procedure.,additional details: ,none.,complications: , none.,discussion: , post-procedure vital signs and oximetry were stable. the patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day. the patient was told to resume all medications. the patient was told to be in relative rest for 1 day but then could resume all normal activities.,the patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.,follow up appointment was made at pm&r spine clinic in approximately one to two weeks.

preoperative diagnoses,1. cervical radiculopathy, c5-c6 and c6-c7.,2. symptomatic cervical spondylosis, c5-c6 and c6-c7.,3. symptomatic cervical stenosis, c5-c6 and c6-c7.,4. symptomatic cervical disc herniations, c5-c6 and c6-c7.,postoperative diagnoses,1. cervical radiculopathy, c5-c6 and c6-c7.,2. symptomatic cervical spondylosis, c5-c6 and c6-c7.,3. symptomatic cervical stenosis, c5-c6 and c6-c7.,4. symptomatic cervical disc herniations, c5-c6 and c6-c7.,operative procedure,1. cpt code 63075: anterior cervical discectomy and osteophytectomy, c5-c6.,2. cpt code 63076: anterior cervical discectomy and osteophytectomy, c6-c7, additional level.,3. cpt code 22851: application of prosthetic interbody fusion device, c5-c6.,4. cpt code 22851-59: application of prosthetic interbody fusion device, c6-c7, additional level.,5. cpt code 22554-51: anterior cervical interbody arthrodesis, c5-c6.,6. cpt code 22585: anterior cervical interbody arthrodesis, c6-c7, additional level.,7. cpt code 22845: anterior cervical instrumentation, c5-c7.,anesthesia:, general endotracheal.,estimated blood loss: ,negligible.,drains: , small suction drain in the cervical wound.,complications:, none.,procedure in detail:, the patient was given intravenous antibiotic prophylaxis and thigh-high ted hoses were placed on the lower extremities while in the preanesthesia holding area. the patient was transported to the operative suite and on to the operative table in the supine position. general endotracheal anesthesia was induced. the head was placed on a well-padded head holder. the eyes and face were protected from pressure. a well-padded roll was placed beneath the neck and shoulders to help preserve the cervical lordosis. the arms were tucked and draped to the sides. all bony prominences were well padded. an x-ray was taken to confirm the correct level of the skin incision. the anterior neck was then prepped and draped in the usual sterile fashion.,a straight transverse skin incision over the left side of the anterior neck was made and carried down sharply through the skin and subcutaneous tissues to the level of the platysma muscle, which was divided transversely using the electrocautery. the superficial and deep layers of the deep cervical fascia were divided. the midline structures were reflected to the right side. care was taken during the dissection to avoid injury to the recurrent laryngeal nerve and the usual anatomical location of that nerve was protected. the carotid sheath was palpated and protected laterally. an x-ray was taken to confirm the level of c5-c6 and c6-c7.,the longus colli muscle was dissected free bilaterally from c5 to c7 using blunt dissection. hemostasis was obtained using the electrocautery. the blades of the cervical retractor were placed deep to the longus colli muscles bilaterally. at c5-c6, the anterior longitudinal ligament was divided transversely. straight pituitary rongeurs and a curette were used to remove the contents of the disc space. all cartilages were scraped off the inferior endplate of c5 and from the superior endplate of c6. the disc resection was carried posteriorly to the posterior longitudinal ligament and laterally to the uncovertebral joints. the posterior longitudinal ligament was resected using a 1 mm kerrison rongeur. beginning in the midline and extending into both neural foramen, posterior osteophytes were removed using a 1 m and a 2 mm kerrison rongeurs. the patient was noted to have significant bony spondylosis causing canal and foraminal stenosis as well as a degenerative and protruding disc in agreement with preoperative diagnostic imaging studies. following completion of the discectomy and osteophytectomy, a blunt nerve hook was passed into the canal superiorly and inferiorly as well as in the both neural foramen to make sure that there were no extruded disc fragments and to make sure the bony decompression was complete. a portion of the uncovertebral joint was resected bilaterally for additional nerve root decompression. both nerve roots were visualized and noted to be free of encroachment. the same procedure was then carried out at c6-c7 with similar findings. the only difference in the findings was that at c6-c7 on the left side, the patient was found to have an extruded disc fragment in the canal and extending into the left side neural foramen causing significant cord and nerve root encroachment.,in preparation for the arthrodesis, the endplates of c5, c6, and c7 were burred in a parallel fashion down to the level of bleeding bone using a high-speed cutting bur with irrigant solution for cooling. the disc spaces were then measured to the nearest millimeter. attention was then turned toward preparation of the structural allograft, which consisted of two pieces of pre-machined corticocancellous bone. the grafts were further shaped to fit the disc spaces exactly in a press-fit manner with approximately 1.5 mm of distraction at each disc space. the grafts were shaped to be slightly lordotic to help preserve the cervical lordosis. the grafts were impacted into the disc spaces. there was complete bony apposition between the ends of the bone grafts and the vertebral bodies of c5, c6, and c7. a blunt nerve hook was passed posterior to each bone graft to make sure that the bone grafts were in good position. anterior osteophytes were removed using a high-speed cutting bur with irrigant solution for cooling. an appropriate length synthes cervical plate was selected and bent slightly to conform to the patient's cervical lordosis. the plate was held in the midline with provided instrumentation while a temporary fixation screw was applied at c6. screw holes were then drilled using the provided drill and drill guide taking care to avoid injury to neurovascular structures. the plate was then rigidly fixed to the anterior spine using 14-mm cancellous screws followed by locking setscrews added to the head of each screw to prevent postoperative loosening of the plate and/or screws.,an x-ray was taken, which confirmed satisfactory postioning of the plate, screws, and bone grafts.,blood loss was minimal. the wound was irrigated with irrigant solution containing antibiotics. the wound was inspected and judged to be dry. the wound was closed over a suction drain placed in the deepest portion of the wound by reapproximating the platysma muscle with #4-0 vicryl running suture, the subdermal and subcuticular layers with #4-0 monocryl interrupted sutures, and the skin with steri-strips. the sponge and needle count were correct. a sterile dressing was applied to the wound. the neck was placed in a cervical orthosis. the patient tolerated the procedure and was transferred to the recovery room in stable condition.

preoperative diagnosis:, bilateral upper lobe cavitary lung masses.,postoperative diagnoses:,1. bilateral upper lobe cavitary lung masses.,2. final pending pathology.,3. airway changes including narrowing of upper lobe segmental bronchi, apical and posterior on the right, and anterior on the left. there are also changes of inflammation throughout.,procedure performed: , diagnostic fiberoptic bronchoscopy with biopsies and bronchoalveolar lavage.,anesthesia: , conscious sedation was with demerol 150 mg and versed 4 mg iv.,operative report: , the patient is residing in the endoscopy suite. after appropriate anesthesia and sedation, the bronchoscope was advanced transorally due to the patient's recent history of epistaxis. topical lidocaine was utilized for anesthesia. epiglottis and vocal cords demonstrated some mild asymmetry of the true cords with right true and false vocal cord appearing slightly more prominent. this may be normal anatomic variant. the scope was advanced into the trachea. the main carina was sharp in appearance. right upper, middle, and lower segmental bronchi as well as left upper lobe and lower lobe segmental bronchi were serially visualized. immediately noted were some abnormalities including circumferential narrowing and probable edema involving the posterior and apical segmental bronchi on the right and to a lesser degree the anterior segmental bronchus on the left. no specific intrinsic masses were noted. under direct visualization, the scope was utilized to lavage the posterior segmental bronchus in the right upper lobe. also cytologic brushings and protected bacteriologic brushing specimens were obtained. three biopsies were attempted within the cavitary lesion in the posterior segment of the right upper lobe. during lavage, some caseous appearing debris appeared intermittently. the specimens were collected and sent to the lab. procedure was terminated with hemostasis having been verified. the patient tolerated the procedure well.,throughout the procedure, the patient's vital signs and oximetry were monitored and remained within satisfactory limits.,the patient will be returned to her room with orders as per usual.

preoperative diagnosis: , bilateral degenerative arthritis of the knees.,postoperative diagnosis: , bilateral degenerative arthritis of the knees.,procedure performed: , right total knee arthroplasty done in conjunction with a left total knee arthroplasty, which will be dictated separately.,anesthesia: , general.,complications: ,none.,estimated blood loss: , bilateral procedure was 400 cc.,total tourniquet time: ,75 minutes.,components: , include the zimmer nexgen complete knee solution system, which include a size f right cruciate retaining femoral component, a size #8 peg tibial component precoat, a all-poly standard size 38, 9.5 mm thickness patellar component, and a prolonged highly cross-linked polyethylene nexgen cruciate retaining tibial articular surface size blue 12 mm height.,history of present illness: , the patient is a 69-year-old male who presented to the office complaining of bilateral knee pain for a couple of years. the patient complained of clicking noises and stiffness, which affected his daily activities of living.,procedure: , after all potential complications, risks as well as anticipated benefits of the above-named procedure was discussed at length, the patient's informed consent was obtained.,operative extremities were then confirmed with the operating surgeons as well as the nursing staff, department of anesthesia, and the patient. the patient was then transferred to preoperative area to operative suite #2 and placed on the operating room table in supine position. all bony prominences were well padded at this time. at this time, department of anesthesia administered general anesthetic to the patient. the patient was allowed in dvt study and the right extremity was in the esmarch study as well as the left. the nonsterile tourniquet was then applied to the right upper thigh of the patient, but not inflated at this time. the right lower extremity was sterilely prepped and draped in the usual sterile fashion. the right upper extremity was then elevated and exsanguinated using an esmarch and the tourniquet was inflated using 325 mmhg. the patient was a consideration for a unicompartmental knee replacement. so, after all bony and soft tissue landmarks were identified, a limited midline longitudinal incision was made directly over the patella. a sharp dissection was then taken down to the level of the fascia in line with the patella as well as the quadriceps tendon. next, a medial parapatellar arthrotomy was performed using the #10 blade scalpel. upon viewing of the articular surfaces, there was significant ware in the trochlear groove as well as the medial femoral condyle and it was elected to proceed with total knee replacement. at this time, the skin incisions as well as the deep incisions were extended proximally and distally in a midline fashion. total incision now measured approximately 25 cm. retractors were placed. next, attention was directed to establishing medial and lateral flaps of the proximal tibia. reciprocating osteal elevator was used to establish soft tissue plane and then an electrocautery was then used to subperiosteal strip medially and laterally on the proximal tibia. at this time, the patella was then everted. the knee was flexed up to 90 degrees. next, using the large drill bit, the femoral canal was then opened in appropriate position. the intramedullary sizing guide was then placed and the knee was sized to a size f. at this time, the three degrees external rotation holes were then drilled after carefully assessing the epicondylar access as well as the white sideline. the guide was then removed. the intramedullary guide was then placed with nails holding the guide in three degrees of external rotation. next, the anterior femoral resection guide was then placed and clamped into place using a pointed _________________ was then used to confirm that there would no notching performed. next, soft tissue retractors were placed and an oscillating saw was used to make the anterior femoral cut. upon checking, it was noted to be flat with no oscillations. the anterior guide was then removed and the distal femoral resection guide was placed in five degrees of valgus. it was secured in place using nails. the intramedullary guide was then removed and the standard distal femoral cut was then made using oscillating saw.,this was then removed and the size f distal finishing femoral guide was then placed on the femur in proper position. bony and soft tissue landmarks were confirmed and the resection guide was then held in place using nail as well as spring screws. again, the collateral ligament retractors were then placed and the oscillating saw was used to make each of the anterior and posterior as well as each chamfer cut. a reciprocating saw was then used to cut the trochlear cut and the peg holes were drilled as well. the distal finishing guide was then removed and osteotome was then used to remove all resected bone. the oscillating saw was then used to complete the femoral notch cut. upon viewing, there appeared to be proper amount of bony resection and all bone was removed completely. there was no posterior osteophytes noted and no fragments to the posterior aspect. next, attention was directed towards the tibia. the external tibial guide was reflected. this was placed on the anterior tibia and held in place using nails after confirming the proper varus and valgus position. the resection guide was then checked and appeared to be sufficient amount of resection in both medial and lateral condyles of the tibia. next, collateral ligament retractors were placed as well as mcgill retractors for the pcl. oscillating saw was then used to make the proximal tibial cut. osteotome was used to remove this excess resected bone. the laminar spreader was then used to check the flexion and extension. the gaps appeared to be equal. the external guide was then removed and trial components were placed to a size f femoral component and a 12 mm tibial component on a size 8 tray. the knee was taken through range of motion and had very good flexion as well as full extension. there appeared to be good varus and valgus stability as well. next, attention was directed towards the patella. there noted to be a sufficient ware and it was selected to replace the patella. it was sized with caliper, pre-cut and noted to be 26 mm depth. the sizing guide was then used and a size 51 resection guide selected. a 51 mm reamer was then placed and sufficient amount of patella was then removed. the calcar was then used to check again and there was noted to be 15 mm remaining. the 38 mm patella guide was then placed on the patella. it was noted to be in proper size and the three drill holes for the pegs were used. a trial component was then placed. the knee was taken through range of motion. there was noted to be some subluxation lateral to the patellar component and a lateral release was performed. after this, the component appeared to be tracking very well. there remained a good range of motion in the knee and extension as well as flexion. at this time, an ap x-ray of the knee was taken with the trial components in place. upon viewing this x-ray, it appeared that the tibial cut was in neutral, all components in proper positioning. the knee was then copiously irrigated and dried. the knee was then flexed ___________ placed, and the peg drill guide was placed on the tibia in proper position, held in place with nails.,the four peg holes were then drilled. the knee again was copiously irrigated and suction dried. the final components were then selected again consisting of size f femoral components. a peg size 8 tibial component, a 12 mm height articular surface, size blue, and a 38 mm 9.5 mm thickness all-poly patella. polymethyl methacrylate was then prepared at this time. the proximal tibia was dried and the cement was then pressed into place. the cement was then placed on the backside of the tibial component and the tibial component was then impacted into proper positioning. next, the proximal femur was cleaned and dried. polymethyl methacrylate was placed on the resected portions of the femur as well as the backside of the femoral components. this was then impacted in place as well. at this time, all excess cement was removed from both the tibial and femoral components. a size 12 mm trial tibial articular surface was then put in place. the knee was reduced and held in loading position throughout the remaining drying position of the cement. next, the resected patella was cleaned and dried. the cement was placed on the patella as well as the backside of the patellar component. the component was then put in proper positioning and held in place with a clamp. all excess polymethyl methacrylate was removed from this area as well. this was held until the cement had hardened sufficiently. next, the knee was examined. all excess cement was then removed. the knee was taken through range of motion with sufficient range of motion as well as stability. the final 12 mm height polyethylene tibial component was then put into place and snapped down in proper position. again range of motion was noted to be sufficient. the knee was copiously irrigated and suction dried once again. a drain was then placed within the knee. the wound was then closed first using #1 ethibond to close the arthrotomy oversewn with a #1 vicryl. the knee was again copiously irrigated and dried. the skin was closed using #2-0 vicryl in subcuticular fashion followed by staples on the skin. the constavac was then _______ to the drain. sterile dressing was applied consisting of adaptic, 4x4, abds, kerlix, and a 6-inch dupre roll from foot to thigh. department of anesthesia then reversed the anesthetic. the patient was transferred back to the hospital gurney to postanesthesia care unit. the patient tolerated the procedure well and there were no complications.

reason for visit:, lap band adjustment.,history of present illness:, ms. a is status post lap band placement back in 01/09 and she is here on a band adjustment. apparently, she had some problems previously with her adjustments and apparently she has been under a lot of stress. she was in a car accident a couple of weeks ago and she has problems, she does not feel full. she states that she is not really hungry but she does not feel full and she states that she is finding when she is hungry at night, having difficulty waiting until the morning and that she did mention that she had a candy bar and that seemed to make her feel better.,physical examination: , on exam, her temperature is 98, pulse 76, weight 197.7 pounds, blood pressure 102/72, bmi is 38.5, she has lost 3.8 pounds since her last visit. she was alert and oriented in no apparent distress. ,procedure: ,i was able to access her port. she does have an ap standard low profile. i aspirated 6 ml, i did add 1 ml, so she has got approximately 7 ml in her band, she did tolerate water postprocedure.,assessment:, the patient is status post lap band adjustments, doing well, has a total of 7 ml within her band, tolerated water postprocedure. she will come back in two weeks for another adjustment as needed.,

history of present illness:, this is a 41-year-old registered nurse (r.n.). she was admitted following an overdose of citalopram and warfarin. the patient has had increasing depression and has been under stress as a result of dissolution of her second marriage. she notes starting in january, her husband of five years seemed to be quite withdrawn. it turned out, he was having an affair with one of her best friends and he subsequently moved in with this woman. the patient is distressed, as over the five years of their marriage, she has gotten herself into considerable debt supporting him and trying to find a career that would work for him. they had moved to abcd where he had recently been employed as a restaurant manager. she also moved her mother and son out there and is feeling understandably upset that he was being dishonest and deceitful with her. she has history of seasonal affective disorder, winter depressions, characterized by increased sleep, increased irritability, impatience, and fatigue. some suggestion on her part that her father may have had some mild bipolar disorder and including the patient has a cyclical and recurrent mood disorder. in january, she went on citalopram. she reports since that time, she has lost 40 pounds of weight, has trouble sleeping at night, thinks perhaps her mood got worse on the citalopram, which is possible, though it is also possible that the progressive nature of getting divorce than financial problems has contributed to her worsening mood.,past and developmental history: , she was born in xyz. she describes the family as being somewhat dysfunctional. father was a truckdriver. she is an only child. she reports that she had a history of anorexia and bulimia as a teenager. in her 20s, she served six years in naval reserve. she was previously married for four years. she described that as an abusive relationship. she had a history of being in counseling with abc, but does not think this therapist, who is now by her estimate 80 years old, is still in practice.,physical examination: ,general: this is an alert and cooperative woman.,vital signs: temperature 98.1, pulse 60, respirations 18, blood pressure 95/54, oxygen saturation 95%, and weight is 132.,psychiatric: she makes good eye contact. speech is normal in rate, volume, grammar, and vocabulary. there is no thought disorder. she denies being suicidal. her affect is appropriate for material being discussed. she has a sense of future, wants to get back to work, has plans to return to counseling. she appeared to have normal orientation, concentration, memory, and judgment.,medical history is notable for factor v leiden deficiency, history of pulmonary embolus, restless legs syndrome. she has been off her mirapex. i did encourage her to go back on the mirapex, which would likely lead to some improvement in mood by facilitating better sleep.,the patient at this time can contract for safety. she has made plans for outpatient counseling this saturday and we will get a referral to a psychiatrist for which she is agreeable to following up with.,laboratory data: , inr, which is still 8.8. in 1998, she had a normal mri. electrolytes, bun, creatinine, and cbc were all normal.,diagnoses: ,1. seasonal depressive disorder.,2. restless legs syndrome.,3. overdose of citalopram and warfarin.,recommendations: , the patient reports she has been feeling better since discontinuing antidepressants. i, therefore, recommend she stay off antidepressants at present. if needed, she can take prozac, which has been effective for her in the past and she plans to see a psychiatrist for consultation. she does give a fairly good history of seasonal depression and given that her mood has improved in the past with prozac, this will be an appropriate agent to try as needed in the future, but given the situational nature of the depression, she primarily appears to need counseling.,please feel free to contact me at digital pager if there is additional information i can provide.

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

procedure:, belly button piercing for insertion of belly button ring.,description of procedure:, the patient was prepped after informed consent was given of risk of infection and foreign body reaction. the area was marked by the patient and then prepped. the area was injected with 2% xylocaine 1:100,000 epinephrine.,then a #14-gauge needle was inserted above the belly button and inserted up to the skin just above the actual umbilical area and the ring was inserted into the #14-gauge needle and pulled through. a small ball was placed over the end of the ring. this terminated the procedure.,the patient tolerated the procedure well. postop instructions were given regarding maintenance. patient left the office in satisfactory condition.

we discovered new t-wave abnormalities on her ekg. there was of course a four-vessel bypass surgery in 2001. we did a coronary angiogram. this demonstrated patent vein grafts and patent internal mammary vessel and so there was no obvious new disease.,she may continue in the future to have angina and she will have nitroglycerin available for that if needed.,her blood pressure has been elevated and so instead of metoprolol, we have started her on coreg 6.25 mg b.i.d. this should be increased up to 25 mg b.i.d. as preferred antihypertensive in this lady's case. she also is on an ace inhibitor.,so her discharge meds are as follows:,1. coreg 6.25 mg b.i.d.,2. simvastatin 40 mg nightly.,3. lisinopril 5 mg b.i.d.,4. protonix 40 mg a.m.,5. aspirin 160 mg a day.,6. lasix 20 mg b.i.d.,7. spiriva puff daily.,8. albuterol p.r.n. q.i.d.,9. advair 500/50 puff b.i.d.,10. xopenex q.i.d. and p.r.n.,i will see her in a month to six weeks. she is to follow up with dr. x before that.

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

chief complaint: , swelling of lips causing difficulty swallowing.,history of present illness:, this patient is a 57-year old white cuban woman with a long history of rheumatoid arthritis. she has received methotrexate on a weekly basis as an outpatient for many years. approximately two weeks ago, she developed a respiratory infection for which she received antibiotics. she developed some ulcerations of the mouth and was instructed to discontinue the methotrexate approximately ten days ago. she showed some initial improvement, but over the last 3-5 days has had malaise, a low-grade fever, and severe oral ulcerations with difficulty in swallowing although she can drink liquids with less difficulty. ,the patient denies any other problems at this point except for a flare of arthritis since discontinuing the methotrexate. she has rather diffuse pain involving both large and small joints. ,medications:, prednisone 7.5 mg p.o. q.d., premarin 0.125 mg p.o. q.d., and dolobid 1000 mg p.o. q.d., recently discontinued because of questionable allergic reaction. hctz 25 mg p.o. q.o.d., oral calcium supplements. in the past she has been on penicillin, azathioprine, and hydroxychloroquine, but she has not had azulfidine, cyclophosphamide, or chlorambucil. ,allergies: ,none by history. ,family/social history:, noncontributory.,physical examination:, this is a chronically ill appearing female, alert, oriented, and cooperative. she moves with great difficulty because of fatigue and malaise. vital signs: blood pressure 107/80, heart rate: 100 and regular, respirations 22. heent: normocephalic. no scalp lesions. dry eyes with conjuctival injections. mild exophthalmos. dry nasal mucosa. marked cracking and bleeding of her lips with erosion of the mucosa. she has a large ulceration of the mucosa at the bite margin on the left. she has some scattered ulcerations on her hard and soft palette. tonsils not enlarged. no visible exudate. she has difficulty opening her mouth because of pain. skin: she has some mild ecchymoses on her skin and some erythema; she has patches but no obvious skin breakdown. she has some fissuring in the buttocks crease. pulmonary: clear to percussion in auscultation. cardiovascular: no murmurs or gallops noted. abdomen: protuberant no organomegaly and positive bowel sounds. neurologic exam: cranial nerves ii through xii are grossly intact. diffuse hyporeflexia. musculoskelatal: erosive, destructive changes in the elbows, wrist and hands consistent with rheumatoid arthritis. she also has bilateral total knee replacements with stovepipe legs and parimalleolar pitting adema 1+. i feel no pulse distally in either leg. ,problems: ,1. swelling of lips and dysphagia with questionable early stevens-johnson syndrome.,2. rheumatoid arthritis class 3, stage 4.,3. flare of arthritis after discontinuing methotrexate.,4. osteoporosis with compression fracture.,5. mild dehydration.,6. nephrolithiasis.,plan:, patient is admitted for iv hydration and treatment of oral ulcerations. we will obtain a dermatology consult. iv leucovorin will be started, and the patient will be put on high-dose corticosteroids.

procedure: , fiberoptic bronchoscopy.,preoperative diagnosis:, right lung atelectasis.,postoperative diagnosis:, extensive mucus plugging in right main stem bronchus.,procedure in detail:, fiberoptic bronchoscopy was carried out at the bedside in the medical icu after versed 0.5 mg intravenously given in 2 aliquots. the patient was breathing supplemental nasal and mask oxygen throughout the procedure. saturations and vital signs remained stable throughout. a flexible fiberoptic bronchoscope was passed through the right naris. the vocal cords were visualized. secretions in the larynx were as aspirated. as before, he had a mucocele at the right anterior commissure that did not obstruct the glottic opening. the ports were anesthetized and the trachea entered. there was no cough reflex helping explain the propensity to aspiration and mucus plugging. tracheal secretions were aspirated. the main carinae were sharp. however, there were thick, sticky, grey secretions filling the right mainstem bronchus up to the level of the carina. this was gradually lavaged clear. saline and mucomyst solution were used to help dislodge remaining plugs. the airways appeared slightly friable, but were patent after the airways were suctioned. o2 saturations remained in the mid-to-high 90s. the patient tolerated the procedure well. specimens were submitted for microbiologic examination. despite his frail status, he tolerated bronchoscopy quite well.

subjective:, the patient is a 78-year-old female who returns for recheck. she has hypertension. she denies difficulty with chest pain, palpations, orthopnea, nocturnal dyspnea, or edema.,past medical history / surgery / hospitalizations:, reviewed and unchanged from the dictation on 12/03/2003.,medications: ,atenolol 50 mg daily, premarin 0.625 mg daily, calcium with vitamin d two to three pills daily, multivitamin daily, aspirin as needed, and triviflor 25 mg two pills daily. she also has elocon cream 0.1% and synalar cream 0.01% that she uses as needed for rash.,allergies: ,benadryl, phenobarbitone, morphine, lasix, and latex.,family history / personal history: , reviewed. mother died from congestive heart failure. father died from myocardial infarction at the age of 56. family history is positive for ischemic cardiac disease. brother died from lymphoma. she has one brother living who has had angioplasties x 2. she has one brother with asthma.,personal history:, negative for use of alcohol or tobacco.,review of systems:,bones and joints: she has had continued difficulty with lower back pain particularly with standing which usually radiates down her right leg. she had been followed by dr. mills, but decided to see dr. xyz who referred to her dr isaac. she underwent several tests. she did have magnetic resonance angiography of the lower extremities and the aorta which were normal. she had nerve conduction study that showed several peripheral polyneuropathy. she reports that she has myelogram last week but has not got results of this. she reports that the rest of her tests have been normal, but it seems that vertebrae shift when she stands and then pinches the nerve. she is now seeing dr. xyz who comes to hutchison from ku medical center, and she thinks that she probably will have surgery in the near future.,genitourinary: she has occasional nocturia.,physical examination:,vital signs: weight: 227.2 pounds. blood pressure: 144/72. pulse: 80. temperature: 97.5 degrees.,general appearance: she is an elderly female patient who is not in acute distress.,mouth: posterior pharynx is clear.,neck: without adenopathy or thyromegaly.,chest: lungs are resonant to percussion. auscultation reveals normal breath sounds.,heart: normal s1 and s2 without gallops or rubs.,abdomen: without masses or tenderness to palpation.,extremities: without edema.,impression/plan:,1. hypertension. she is advised to continue with the same medication.,2. syncope. she previously had an episode of syncope around thanksgiving. she has not had a recurrence of this and her prior cardiac studies did not show arrhythmias.,3. spinal stenosis. she still is being evaluated for this and possibly will have surgery in the near future.

indication:, acute coronary syndrome.,consent form: , the procedure of cardiac catheterization/pci risks included but not restricted to death, myocardial infarction, cerebrovascular accident, emergent open heart surgery, bleeding, hematoma, limb loss, renal failure requiring dialysis, blood loss, infection had been explained to him. he understands. all questions answered and is willing to sign consent.,procedure performed:, selective coronary angiography of the right coronary artery, left main lad, left circumflex artery, left ventricular catheterization, left ventricular angiography, angioplasty of totally occluded mid rca, arthrectomy using 6-french catheter, stenting of the mid rca, stenting of the proximal rca, femoral angiography and perclose hemostasis.,narrative: , the patient was brought to the cardiac catheterization laboratory in a fasting state. both groins were draped and sterilized in the usual fashion. local anesthesia was achieved with 2% lidocaine to the right groin area and a #6-french femoral sheath was inserted via modified seldinger technique in the right common femoral artery. selective coronary angiography was performed with #6 french jl4 catheter for the left coronary system and a #6 french jr4 catheter of the right coronary artery. left ventricular catheterization and angiography was performed at the end of the procedure with a #6-french angle pigtail catheter.,findings,1. hemodynamics systemic blood pressure 140/70 mmhg. lvedp at the end of the procedure was 13 mmhg.,2. the left main coronary artery is a large with mild diffuse disease in the distal third resulting in less than 20% angiographic stenosis at the take off of the left circumflex artery. the left circumflex artery is a large caliber vessel with diffuse disease in the ostium of the proximal segment resulting in less than 30% angiographic stenosis. the left circumflex artery gives rise to a high small obtuse marginal branch that has high moderate-to-severe ostium. the rest of the left circumflex artery has mild diffuse disease and it gives rise to a second large obtuse marginal branch that bifurcates into an upper and lower trunk.,the lad is calcified and diffusely disease in the proximal and mid portion. there is mild nonobstructive disease in the proximal lad resulting in less than 20% angiographic stenosis.,3. the right coronary artery is dominant. it is septal to be occluded in the mid portion.,the findings were discussed with the patient and she opted for pci. angiomax bolus was started. the act was checked. it was higher in 300. i have given the patient 600 mg of oral plavix.,the right coronary artery was engaged using a #6-french jr4 guide catheter. i was unable to cross through this lesion using a bmw wire and a 3.0x8 mm balloon support. i was unable to cross with this lesion using a whisper wire. i was unable to cross with this lesion using cross-it 100 wire. i have also used second #6-french amplatz right i guide catheter. at one time, i have lost flow in the distal vessel. the patient experienced severe chest pain, st-segment elevation, bradycardia, and hypotension, which responded to intravenous fluids and atropine along with intravenous dopamine.,dr. x was notified.,eventually, an asahi grand slam wire using the same 3.0 x 8 mm voyager balloon support, i was able to cross into the distal vessel. i have performed careful balloon angioplasty of the mid rca. i have given nitroglycerin under the nursing several times during the procedure.,i then performed arthrectomy using #5-french export catheter.,i performed more balloon predilation using a 3.0 x16 mm voyager balloon. i then deployed 4.0 x15 mm, excised, and across the mid rca at 18 atmospheres with good angiographic result. proximal to the proximal edge of the stent, there was still some persistent haziness most likely just diseased artery/diffuse plaquing. i decided to cover this segment using a second 4.0 x 15 mm, excised, and two stents were overlapped, the overlap was postdilated using the same stent delivery balloon at high pressure with excellent angiographic result.,left ventricular catheterization was performed with #6-french angle pigtail catheter. the left ventricle is rather smaller in size. the mid inferior wall is minimally hypokinetic, ejection fraction is 70%. there is no evidence of aortic wall stenosis or mitral regurgitation.,femoral angiography revealed that the entry point was above the bifurcation of the right common femoral artery and i have performed this as perclose hemostasis.,conclusions,1. normal left ventricular size and function. ejection fraction is 65% to 70%. no mr.,2. successful angioplasty and stenting of the subtotally closed mid rca. this was hard, organized thrombus, very difficult to penetrate. i have deployed two overlapping 4.0 x15 mm excised and with excellent angiographic result. the rca is dominant.,3. no moderate disease in the distal left main. moderate disease in the ostium of the left circumflex artery. mild disease in the proximal lad.,plan: , recommend smoking cessation. continue aspirin lifelong and continue plavix for at least 12 months.

chief complaint:, followup on hypertension and hypercholesterolemia.,subjective:, this is a 78-year-old male who recently had his right knee replaced and also back surgery about a year and a half ago. he has done well with that. he does most of the things that he wants to do. he travels at every chance he has, and he just got back from a cruise. he denies any type of chest pain, heaviness, tightness, pressure, shortness of breath with stairs only, cough or palpitations. he sees dr. ferguson. he is known to have crohn's and he takes care of that for him. he sees dr. roszhart for his prostate check. he is a nonsmoker and denies swelling in his ankles.,medications:, refer to chart.,allergies:, refer to chart.,physical examination:, ,vitals: wt; 172 lbs, up 2 lbs, b/p; 150/60, t; 96.4, p; 72 and regular. ,general: a 78-year-old male who does not appear to be in any acute distress. glasses. good dentition.,cv: distant s1, s2 without murmur or gallop. no carotid bruits. p: 2+ all around.,lungs: diminished with increased ap diameter. ,abdomen: soft, bowel sounds active x 4 quadrants. no tenderness, no distention, no masses or organomegaly noted.,extremities: well-healed surgical scar on the right knee. no edema. hand grasps are strong and equal.,back: surgical scar on the lower back.,neuro: intact. a&o. moves all four with no focal motor or sensory deficits.,impression:,1. hypertension.,2. hypercholesterolemia.,3. osteoarthritis.,4. fatigue.,plan:, we will check a bmp, lipid, liver profile, cpk, and cbc. refill his medications x 3 months. i gave him a copy of partners in prevention. increase his altace to 5 mg day for better blood pressure control. diet, exercise, and weight loss, and we will see him back in three months and p.r.n.

past medical history:, he has difficulty climbing stairs, difficulty with airline seats, tying shoes, used to public seating, and lifting objects off the floor. he exercises three times a week at home and does cardio. he has difficulty walking two blocks or five flights of stairs. difficulty with snoring. he has muscle and joint pains including knee pain, back pain, foot and ankle pain, and swelling. he has gastroesophageal reflux disease.,past surgical history:, includes reconstructive surgery on his right hand 13 years ago. ,social history:, he is currently single. he has about ten drinks a year. he had smoked significantly up until several months ago. he now smokes less than three cigarettes a day.,family history:, heart disease in both grandfathers, grandmother with stroke, and a grandmother with diabetes. denies obesity and hypertension in other family members.,current medications:, none.,allergies:, he is allergic to penicillin.,miscellaneous/eating history:, he has been going to support groups for seven months with lynn holmberg in greenwich and he is from eastchester, new york and he feels that we are the appropriate program. he had a poor experience with the greenwich program. eating history, he is not an emotional eater. does not like sweets. he likes big portions and carbohydrates. he likes chicken and not steak. he currently weighs 312 pounds. ideal body weight would be 170 pounds. he is 142 pounds overweight. if ,he lost 60% of his excess body weight that would be 84 pounds and he should weigh about 228.,review of systems: ,negative for head, neck, heart, lungs, gi, gu, orthopedic, and skin. specifically denies chest pain, heart attack, coronary artery disease, congestive heart failure, arrhythmia, atrial fibrillation, pacemaker, high cholesterol, pulmonary embolism, high blood pressure, cva, venous insufficiency, thrombophlebitis, asthma, shortness of breath, copd, emphysema, sleep apnea, diabetes, leg and foot swelling, osteoarthritis, rheumatoid arthritis, hiatal hernia, peptic ulcer disease, gallstones, infected gallbladder, pancreatitis, fatty liver, hepatitis, hemorrhoids, rectal bleeding, polyps, incontinence of stool, urinary stress incontinence, or cancer. denies cellulitis, pseudotumor cerebri, meningitis, or encephalitis.,physical examination:, he is alert and oriented x 3. cranial nerves ii-xii are intact. afebrile. vital signs are stable.

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

findings:,there are post biopsy changes seen in the retroareolar region, middle third aspect of the left breast at the post biopsy site.,there is abnormal enhancement seen in this location compatible with patient’s history of malignancy.,there is increased enhancement seen in the inferior aspect of the left breast at the 6:00 o’clock, n+5.5 cm position measuring 1.2 cm. further work-up with ultrasound is indicated.,there are other multiple benign appearing enhancing masses seen in both the right and left breasts.,none of the remaining masses appear worrisome for malignancy based upon mri criteria.,impression:, birads category m/5,there is a malignant appearing area of enhancement in the left breast which does correspond to the patient’s history of recent diagnosis of malignancy.,she has been scheduled to see a surgeon, as well as medical oncologist.,dedicated ultrasonography of the inferior aspect of the left breast should be performed at the 6:00 o’clock, n+5.5 cm position for further evaluation of the mass. at that same time, ultrasonography of the remaining masses should also be performed.,please note, however that the remaining masses have primarily benign features based upon mri criteria. however, further evaluation with ultrasound should be performed.

subjective:, patient presents with mom and dad for her 5-year 3-month well-child check. family has not concerns stating patient has been doing well overall since last visit. taking in a well-balanced diet consisting of milk and dairy products, fruits, vegetables, proteins and grains with minimal junk food and snack food. no behavioral concerns. gets along well with peers as well as adults. is excited to start kindergarten this upcoming school year. does attend daycare. normal voiding and stooling pattern. no concerns with hearing or vision. sees the dentist regularly. growth and development: denver ii normal passing all developmental milestones per age in areas of fine motor, gross motor, personal and social interaction and speech and language development. see denver ii form in the chart.,allergies:, none.,medications: , none.,family social history:, unchanged since last checkup. lives at home with mother, father and sibling. no smoking in the home.,review of systems:, as per hpi; otherwise negative.,objective:,vital signs: weight 43 pounds. height 42-1/4 inches. temperature 97.7. blood pressure 90/64.,general: well-developed, well-nourished, cooperative, alert and interactive 5-year -3month-old white female in no acute distress.,heent: atraumatic, normocephalic. pupils equal, round and reactive. sclerae clear. red reflex present bilaterally. extraocular muscles intact. tms clear bilaterally. oropharynx: mucous membranes moist and pink. good dentition.,neck: supple, no lymphadenopathy.,chest: clear to auscultation bilaterally. no wheeze or crackles. good air exchange.,cardiovascular: regular rate and rhythm. no murmur. good pulses bilaterally.,abdomen: soft, nontender. nondistended. positive bowel sounds. no masses or organomegaly.,gu: tanner i female genitalia. femoral pulses equal bilaterally. no rash.,extremities: full range of motion. no cyanosis, clubbing or edema.,back: straight. no scoliosis.,integument: warm, dry and pink without lesions.,neurological: alert. good muscle tone and strength. cranial nerves ii-xii grossly intact. dtrs 2+/4+ bilaterally.,assessment/plan:,1. well 5-year 3-month-old white female.,2. anticipatory guidance for growth and diet development and safety issues as well as immunizations. will receive mmr, dtap and ipv today. discussed risks and benefits as well as possible side effects and symptomatic treatment. gave 5-year well-child check handout to mom. completed school pre-participation physical. copy in the chart. completed vision and hearing screening. reviewed results with family.,3. follow up in one year for next well-child check or as needed for acute care.

history: , the patient is a 48-year-old female who was seen in consultation requested from dr. x on 05/28/2008 regarding chronic headaches and pulsatile tinnitus. the patient reports she has been having daily headaches since 02/25/2008. she has been getting pulsations in the head with heartbeat sounds. headaches are now averaging about three times per week. they are generally on the very top of the head according to the patient. interestingly, she denies any previous significant history of headaches prior to this. there has been no nausea associated with the headaches. the patient does note that when she speaks on the phone, the left ear has "weird sounds." she feels a general fullness in the left ear. she does note pulsation sounds within that left ear only. this began on february 17th according to the patient. the patient reports that the ear pulsations began following an air flight to iowa where she was visiting family. the patient does admit that the pulsations in the ears seem to be somewhat better over the past few weeks. interestingly, there has been no significant drop or change in her hearing. she does report she has had dizzy episodes in the past with nausea, being off balance at times. it is not associated with the pulsations in the ear. she does admit the pulsations will tend to come and go and there had been periods where the pulsations have completely cleared in the ear. she is denying any vision changes. the headaches are listed as moderate to severe in intensity on average about three to four times per week. she has been taking tylenol and excedrin to try to control the headaches and that seems to be helping somewhat. the patient presents today for further workup, evaluation, and treatment of the above-listed symptoms.,review of systems: , ,allergy/immunologic: negative.,cardiovascular: hypercholesterolemia.,pulmonary: negative.,gastrointestinal: pertinent for nausea.,genitourinary: the patient is noted to be a living kidney donor and has only one kidney.,neurologic: history of dizziness and the headaches as listed above.,visual: negative.,dermatologic: history of itching. she has also had a previous history of skin cancer on the arm and back.,endocrine: negative.,musculoskeletal: negative.,constitutional: she has had an increased weight gain and fatigue over the past year.,past surgical history:, she has had a left nephrectomy, c-sections, mastoidectomy, laparoscopy, and t&a.,family history:, father, history of cancer, hypertension, and heart disease.,current medications: , tylenol, excedrin, and she is on multivitamin and probiotic's.,allergies: , she is allergic to codeine and penicillin.,social history: , she is married. she works at eye center as a receptionist. she denies tobacco at this time though she was a previous smoker, stopped four years ago, and she denies alcohol use.,physical examination: , vital signs: blood pressure 120/78, pulse 64 and regular, and the temperature is 97.4.,general: the patient is an alert, cooperative, well-developed 48-year-old female with a normal-sounding voice and good memory.,head & face: inspected with no scars, lesions or masses noted. sinuses palpated and are normal. salivary glands also palpated and are normal with no masses noted. the patient also has full facial function.,cardiovascular: heart regular rate and rhythm without murmur.,respiratory: lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,eyes: extraocular muscles were tested and within normal limits.,ears: there is an old mastoidectomy scar, left ear. the ear canals are clean and dry. drums intact and mobile. weber exam is midline. grossly hearing is intact. please note audiologist not available at today's visit for further audiologic evaluation.,nasal: reveals clear drainage. deviated nasal septum to the left, listed as mild to moderate. ostiomeatal complexes are patent and turbinates are healthy. there was no mass or neoplasm within the nasopharynx noted on fiberoptic nasopharyngoscopy. see fiberoptic nasopharyngoscopy separate exam.,oral: oral cavity is normal with good moisture. lips, teeth and gums are normal. evaluation of the oropharynx reveals normal mucosa, normal palates, and posterior oropharynx. examination of the larynx with a mirror reveals normal epiglottis, false and true vocal cords with good mobility of the cords. the nasopharynx was briefly examined by mirror with normal appearing mucosa, posterior choanae and eustachian tubes.,neck: the neck was examined with normal appearance. trachea in the midline. the thyroid was normal, nontender, with no palpable masses or adenopathy noted.,neurologic: cranial nerves ii through xii evaluated and noted to be normal. patient oriented times 3.,dermatologic: evaluation reveals no masses or lesions. skin turgor is normal.,impression: ,1. pulsatile tinnitus, left ear with eustachian tube disorder as the etiology. consider, also normal pressure hydrocephalus.,2. recurrent headaches.,3. deviated nasal septum.,4. dizziness, again also consider possible meniere disease.,recommendations: , i did recommend the patient begin a 2 g or less sodium diet. i have also ordered a carotid ultrasound study as part of the workup and evaluation. she has had a recent cat scan of the brain though this was without contrast. it did reveal previous mastoidectomy, left temporal bone, but no other mass noted. i have started her on nasacort aq nasal spray one spray each nostril daily as this is eustachian tube related. hearing protection devices should be used at all times as well. i did counsel the patient if she has any upcoming airplane trips to use nasal decongestant or topical nasal decongestant spray prior to boarding the plane, and also using the airplane ear plugs as these can be effective at helping to prevent eustachian tube issues. i am going to recheck her in three weeks. if the pulsatile tinnitus at that time is not clear, we have discussed other treatment options including myringotomy or ear tube placement, which could be done here in the office. she will be scheduled for a audio and tympanogram to be done as well prior to that procedure.

preoperative diagnoses:,1. severe menometrorrhagia unresponsive to medical therapy.,2. anemia.,3. symptomatic fibroid uterus.,postoperative diagnoses:,1. severe menometrorrhagia unresponsive to medical therapy.,2. anemia.,3. symptomatic fibroid uterus.,procedure: , total abdominal hysterectomy.,anesthesia: ,general.,estimated blood loss: , 150 ml.,complications: , none.,finding: ,large fibroid uterus.,procedure in detail: ,the patient was prepped and draped in the usual sterile fashion for an abdominal procedure. a scalpel was used to make a pfannenstiel skin incision, which was carried down sharply through the subcutaneous tissue to the fascia. the fascia was nicked in the midline and incision was carried laterally bilaterally with curved mayo scissors. the fascia was then bluntly and sharply dissected free from the underlying rectus abdominis muscles. the rectus abdominis muscles were then bluntly dissected in the midline and this incision was carried forward inferiorly and superiorly with care taken to avoid bladder and bowel. the peritoneum was then bluntly entered and this incision was carried forward inferiorly and superiorly with care taken to avoid bladder and bowel. the o'connor-o'sullivan instrument was then placed without difficulty. the uterus was grasped with a thyroid clamp and the entire pelvis was then visualized without difficulty. the gia stapling instrument was then used to separate the infundibulopelvic ligament in a ligated fashion from the body of the uterus. this was performed on the left infundibulopelvic ligament and the right infundibulopelvic ligament without difficulty. hemostasis was noted at this point of the procedure. the bladder flap was then developed free from the uterus without difficulty. careful dissection of the uterus from the pedicle with the uterine arteries and cardinal ligaments was then performed using #1 chromic suture ligature in an interrupted fashion on the left and right side. this was done without difficulty. the uterine fundus was then separated from the uterine cervix without difficulty. this specimen was sent to pathology for identification. the cervix was then developed with careful dissection. jorgenson scissors were then used to remove the cervix from the vaginal cuff. this was sent to pathology for identification. hemostasis was noted at this point of the procedure. a #1 chromic suture ligature was then used in running fashion at the angles and along the cuff. hemostasis was again noted. figure-of-eight sutures were then used in an interrupted fashion to close the cuff. hemostasis was again noted. the entire pelvis was washed. hemostasis was noted. the peritoneum was then closed using 2-0 chromic suture ligature in running pursestring fashion. the rectus abdominis muscles were approximated using #1 chromic suture ligature in an interrupted fashion. the fascia was closed using 0 vicryl in interlocking running fashion. foundation sutures were then placed in an interrupted fashion for further closing the fascia. the skin was closed with staple gun. sponge and needle counts were noted to be correct x2 at the end of the procedure. instrument count was noted to be correct x2 at the end of the procedure. hemostasis was noted at each level of closure. the patient tolerated the procedure well and went to recovery room in good condition.

history:, the patient is 14 months old, comes in with a chief complaint of difficulty breathing. difficulty breathing began last night. he was taken to emergency department where he got some xopenex, given a prescription for amoxicillin and discharged home. they were home for about an hour when he began to get worse and they drove here to children's hospital. he has a history of reactive airway disease. he has been seen here twice in the last month on 10/04/2007 and 10/20/2007, both times with some wheezing. he was diagnosed with pneumonia back on 06/12/2007 here in the emergency department but was not admitted at that time. he has been on albuterol off and on over that period. he has had fever overnight. no vomiting, no diarrhea. increased work of breathing with retractions and audible wheezes noted and thus brought to the emergency department. normal urine output. no rashes have been seen.,past medical history: , as noted above. no hospitalizations, surgeries, allergies.,medications: , xopenex.,immunizations:, up-to-date.,birth history:, the child was full term, no complications, home with mom. no surgeries.,family history: , negative.,social history: , no smokers or pets in the home. no ill contacts, no travel, no change in living condition.,review of systems: , ten are asked, all are negative, except as noted above.,physical examination:,vital signs: temp 37.1, pulse 158, respiratory rate 48, 84% on room air indicating hypoxia.,general: the child is awake, alert, in moderate respiratory distress.,heent: pupils equal, round, reactive to light. extraocular movements are intact. the tms are clear. the nares show some dry secretions. audible congestion and wheezing is noted. mucous membranes are dry. throat is clear. no oral lesions noted.,neck: supple without lymphadenopathy or masses. trachea is midline.,lungs: show inspiratory and expiratory wheezes in all fields. audible wheezes are noted. there are intercostal and subcostal retractions and suprasternal muscle use is noted.,heart: shows tachycardia. regular rhythm. normal s1, s2. no murmur.,abdomen: soft, nontender. positive bowel sounds. no guarding. no rebound. no hepatosplenomegaly.,extremities: capillary refill is brisk. good distal pulses.,neurologic: cranial nerves ii through xii intact. moves all 4 extremities equally and normally.,hospital course: , the child has an iv placed. i felt the child was dehydrated on examination. we gave 20 ml/kg bolus of normal saline over one hour. the child was given solu-medrol 2 mg/kg iv. he was initially started on unit dose albuterol and atrovent but high-dose albuterol for continuous nebulization was ordered.,a portable chest x-ray was done showing significant peribronchial thickening bilaterally. normal heart size. no evidence of pneumothorax. no evidence of focal pneumonia. after 3 unit dose of albuterol/atrovent breathing treatments, there was much better air exchange bilaterally but still with inspiratory/expiratory wheezes and high-dose continuous albuterol was started at that time. the child was monitored closely while on high-dose albuterol and slowly showed improvement resulting in only expiratory wheezes after one hour. the child's pulse ox on breathing treatments with 100% oxygen was 100%. respiratory rate remained about 40 to 44 breaths per minute indicating tachypnea. the child's color improved with oxygen therapy, and the capillary refill was always less than 2 seconds.,the child has failed outpatient therapy at this time. after 90 minutes of continuous albuterol treatment, the child still has expiratory wheezes throughout. after i removed the oxygen, the pulse ox was down at 91% indicating hypoxia. the child has a normal level of alertness; however, has not had any vomiting here. i spoke with dr. x, on call for hospitalist service. she has come down and evaluated the patient. we both feel that since this child had two er visits this last month, one previous er visit within the last 5 hours, we should admit the child for continued albuterol treatments, iv steroids, and asthma teaching for the family. the child is admitted in a stable condition.,differential diagnoses: ,ruled out pneumothorax, pneumonia, bronchiolitis, croup.,time spent: ,critical care time outside billable procedures was 45 minutes with this patient.,impression: ,status asthmaticus, hypoxia.,plan: ,admitted to pediatrics.

reason for consultation:, atrial fibrillation.,history of present illness:, the patient is a 78-year-old, hispanic woman with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia. apparently, the patient is a resident of lake harris port square long-term facility after her stroke. she was found to have confusion while in her facility. she then came to the emergency room and found to have a right sided acute stroke. 12-lead ekg performed on august 10, 2009, found to have atrial fibrillation. telemetry also revealed atrial fibrillation with rapid ventricular response. currently, the telemetry is normal sinus rhythm. because of the finding of atrial fibrillation, cardiology was consulted.,the patient is a poor historian. she did not recall why she is in the hospital, she said she had a stroke. she reported no chest discomfort, no shortness of breath, no palpitations.,the following information was obtained from the patient's chart:,past medical history:,1. coronary artery disease status post bypass grafting surgery. unable to obtain the place, location, anatomy, and the year it was performed.,2. carotid artery stenosis status post right carotid artery stenting. again, the time was unknown.,3. diabetes.,4. hypertension.,5. hyperlipidemia.,6. history of stroke with left side hemiplegia.,allergies: , no known drug allergies.,family history: , noncontributory.,social history:, the patient is a resident of lake harris port square. she has no history of alcohol use.,current medications: , please see attached list including hydralazine, celebrex, colace, metformin, aspirin, potassium, lasix, levaquin, norvasc, insulin, plavix, lisinopril, and zocor.,review of systems: , unable to obtain.,physical examination:,vital signs: blood pressure 133/44, pulse 98, o2 saturation is 98% on room air. temperature 99, respiratory rate 16.,general: the patient is sitting in the chair at bedside. appears comfortable. left facial droop. left side hemiplegia.,head and neck: no jvp seen. right side carotid bruit heard.,chest: clear to auscultation bilaterally.,cardiovascular: pmi not displaced, regular rhythm. normal s1 and s2. positive s4. there is a 2/6 systolic murmur best heard at the left lower sternal border.,abdomen: soft.,extremities: not edematous.,data:, a 12-lead ekg performed on august 9, 2009, revealed atrial fibrillation with a ventricular rate of 96 beats per minute, nonspecific st wave abnormality.,review of telemetry done the last few days, currently the patient is in normal sinus rhythm at the rate of 60 beats per minute. atrial fibrillation was noted on admission noted august 8 and august 10; however, there was normal sinus rhythm on august 10.,laboratory data: , wbc 7.2, hemoglobin 11.7. the patient's hemoglobin was 8.2 a few days ago before blood transfusion. chemistry-7 within normal limits. lipid profile: triglycerides 64, total cholesterol 106, hdl 26, ldl 17. liver function tests are within normal limits. inr was 1.1.,a 2d echo was performed on august 11, 2009, and revealed left ventricle normal in size with ef of 50%. mild apical hypokinesis. mild dilated left atrium. mild aortic regurgitation, mitral regurgitation, and tricuspid regurgitation. no intracardiac masses or thrombus were noted. the aortic root was normal in size.,assessment and recommendations:,1. paroxysmal atrial fibrillation. it is unknown if this is a new onset versus a paroxysmal atrial fibrillation. given the patient has a recurrent stroke, anticoagulation with coumadin to prevent further stroke is indicated. however, given the patient's current neurologic status, the safety of falling is unclear. we need to further discuss with the patient's primary care physician, probably rehab physician. if the patient's risk of falling is low, then coumadin is indicated. however, if the patient's risk for falling is high, then a course using aspirin and plavix will be recommended. transesophageal echocardiogram probably will delineate possible intracardiac thrombus better, however will not change our current management. therefore, i will not recommend transesophageal echocardiogram at this point. currently, the patient's heart rate is well controlled, antiarrhythmic agent is not recommended at this point.,2. carotid artery stenosis. the patient underwent a carotid doppler ultrasound on this admission and found to have a high-grade increased velocity of the right internal carotid artery. it is difficult to assess the severity of the stenosis given the history of possible right carotid stenting. if clinically indicated, ct angio of the carotid will be indicated to assess for stent patency. however, given the patient's current acute stroke, revascularization is not indicated at this time.,3. coronary artery disease. clinically stable. no further test is indicated at this time.

preoperative diagnosis:, prior history of polyps.,postoperative diagnosis:, small polyps, no evidence of residual or recurrent polyp in the cecum.,premedications: , versed 5 mg, demerol 100 mg iv.,reported procedure:, the rectal chamber revealed no external lesions. prostate was normal in size and consistency.,the colonoscope was inserted into the rectal ampulla and advanced under direct vision at all times until the tip of the scope was placed in the cecum. the position of the scope within the cecum was verified by identification of the ileocecal valve. navigation was difficult because it seemed that the cecum took an upward turn at its final turn, but the examination was completed.,the cecum was extensively studied and no lesion was seen. there was not even a scar representing the prior polyp. i was able to see the area across from the ileocecal valve exactly where the polyp was two years ago, and i saw no lesion at all. the scope was then slowly withdrawn. in the mid transverse colon, was a small submucosal lesion, which appeared to be a lipoma. it was freely mobile and very small with normal overlying mucosa. there was a similar lesion in the descending colon. both of these appeared to be lipomatous, so no attempt was made to remove them. there were diverticula present in the sigmoid colon. in addition, there were two polyps in the sigmoid colon both of which were resected using electrocautery. there was no bleeding. the scope was then withdrawn. the rectum was normal. when the scope was retroflexed in the rectum, two very small polyps were noted just at the anorectal margin, and so these were obliterated using the electrocautery snare. there was no specimen and there was no bleeding. the scope was then straightened, withdrawn, and the procedure terminated.,endoscopic impression:,1. small polyps, sigmoid colon, resected them.,2. diverticulosis, sigmoid colon.,3. small rectal polyps, obliterated them.,4. submucosal lesions, consistent with lipomata as described.,5. no evidence of residual or recurrent neoplasm in the cecum.

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

subjective:, the patient is a 78-year-old female with the problem of essential hypertension. she has symptoms that suggested intracranial pathology, but so far work-up has been negative.,she is taking hydrochlorothiazide 25-mg once a day and k-dur 10-meq once a day with adequate control of her blood pressure. she denies any chest pain, shortness of breath, pnd, ankle swelling, or dizziness.,objective:, heart rate is 80 and blood pressure is 130/70. head and neck are unremarkable. heart sounds are normal. abdomen is benign. extremities are without edema.,assessment and plan:, the patient reports that she had an echocardiogram done in the office of dr. sample doctor4 and was told that she had a massive heart attack in the past. i have not had the opportunity to review any investigative data like chest x-ray, echocardiogram, ekg, etc. so, i advised her to have a chest x-ray and an ekg done before her next appointment, and we will try to get hold of the echocardiogram on her from the office of dr. sample doctor4. in the meantime, she is doing quite well, and she was advised to continue her current medication and return to the office in three months for followup.

chief complaint:, vomiting and nausea.,hpi: , the patient is a 52-year-old female who said she has had 1 week of nausea and vomiting, which is moderate-to-severe. she states she has it at least once a day. it can be any time, but can also be postprandial. she states she will vomit up some dark brown-to-green fluid. there has been no hematemesis. she states because of the nausea and vomiting, she has not been able to take much in the way of po intake over the past week. she states her appetite is poor. the patient has lost 40 pounds of weight over the past 16 months. she states for the past few days, she has been getting severe heartburn. she used tums over-the-counter and that did not help. she denies having any dysphagia or odynophagia. she is not having any abdominal pain. she has no diarrhea, rectal bleeding, or melena. she has had in the past, which was remote. she did have some small amounts of rectal bleeding on the toilet tissue only if she passed a harder stool. she has a history of chronic constipation for most of her life but she definitely has a bowel movement every 3 to 4 days and this is unchanged. the patient states she has never had any endoscopy or barium studies of the gi tract.,the patient is anemic and her hemoglobin is 5.7 and she is thrombocytopenic with the platelet count of 34. she states she has had these abnormalities since she has been diagnosed with breast cancer. she states that she has metastatic breast cancer and that is in her rib cage and spine and she is getting hormonal chemotherapy for this and she is currently under the care of an oncologist. the patient also has acute renal failure at this point. the patient said she had a pet scan done about a week ago.,past medical history:, metastatic breast cancer to her rib cage and spine, hypothyroidism, anemia, thrombocytopenia, hypertension, bells palsy, depression, uterine fibroids, hysterectomy, cholecystectomy, breast lumpectomy, and thyroidectomy.,allergies: , no known drug allergies.,medicines:, she is on zofran, protonix, fentanyl patch, synthroid, ativan, and ambien.,social history: ,the patient is divorced and is a homemaker. no smoking or alcohol.,family history:, negative for any colon cancer or polyps. her father died of mesothelioma, mother died of hodgkin lymphoma.,systems review: , no fevers, chills or sweats. she has no chest pain, palpitations, coughing or wheezing. she does get shortness of breath, no hematuria, dysuria, arthralgias, myalgias, rashes, jaundice, bleeding or clotting disorders. the rest of the system review is negative as per the hpi.,physical exam: , temperature 98.4, blood pressure 95/63, heart rate 84, respiratory rate of 18, and weight is 108 kg. general appearance: the patient was comfortable in bed. skin exam is negative for any rashes or jaundice. lymphatics: there is no palpable lymphadenopathy of the cervical or the supraclavicular area. heent: she has some mild ptosis of the right eye. there is no icterus. the patient's conjunctivae and sclerae are normal. pupils are equal, round, and reactive to light and accommodation. no lesions of the oral mucosa or mucosa of the pharynx. neck: supple. carotids are 2+. no thyromegaly, masses or adenopathy. heart: has regular rhythm. normal s1 and s2. she has a 2/6 systolic ejection murmur. no rubs or gallops. lungs are clear to percussion and auscultation. abdomen is obese, it may be mildly distended. there is no increased tympany. the patient does have hepatosplenomegaly. there is no obvious evidence of ascites. the abdomen is nontender, bowel sounds are present. the extremities show some swelling and edema of the ankle regions bilaterally. legs are in scds. no cyanosis or clubbing. for the rectal exam, it shows brown stool that is very trace heme positive at most. for the neuro exam, she is awake, alert, and oriented x3. memory intact. no focal deficits. insight and judgment are intact.,x-ray and laboratory data: ,she came in, white count 9.2, hemoglobin 7.2, hematocrit 22.2, mcv of 87, platelet count is 47,000. calcium is 8.1, sodium 134, potassium 5.3, chloride 102, bicarbonate 17, bun of 69, creatinine of 5.2, albumin 2.2, alt 28, bilirubin is 2.2, alkaline phosphatase is 359, ast is 96, and lipase is 30. today, her hemoglobin is 5.7, tsh is 1.1, platelet count is 34,000, alkaline phosphatase is 303, and bilirubin of 1.7.,impression,1. the patient has one week of nausea and vomiting with decreased p.o. intake as well as dehydration. this could be on the basis of her renal failure. she may have a viral gastritis. the patient does have a lot of gastroesophageal reflux disease symptoms recently. she could have peptic mucosal inflammation or peptic ulcer disease.,2. the patient does have hepatosplenomegaly. there is a possibility she could have liver metastasis from the breast cancer.,3. she has anemia as well as thrombocytopenia. the patient states this is chronic.,4. a 40-pound weight loss.,5. metastatic breast cancer.,6. increased liver function tests. given her bone metastasis, the elevated alkaline phosphatase may be from this as opposed to underlying liver disease.,7. chronic constipation.,8. acute renal failure.,plan: ,the patient will be on a clear liquid diet. she will continue on the zofran. she will be on iv protonix. the patient is going to be transfused packed red blood cells and her hemoglobin and hematocrit will be monitored. i obtained the result of the abdominal x-rays she had done through the er. the patient has a consult pending with the oncologist to see what her pet scan show. there is a renal consult pending. i am going to have her get a total abdominal ultrasound to see if there is any evidence of liver metastasis and also to assess her kidneys. her laboratory studies will be followed. based upon the patient's medical condition and including her laboratory studies including a platelet count, we talked about egd versus upper gi workup per upper gi symptoms. i discussed informed consent for egd. i discussed the indications, risks, benefits, and alternatives. the risks reviewed included, but were not limited to an allergic reaction or side effect to medicines, cardiopulmonary complications, bleeding, infection, perforation, and needing to get admitted for antibiotics or blood transfusion or surgery. the patient voices her understanding of the above. she wants to think about what she wants to do. overall, this is a very ill patient with multiorgan involvement.

preoperative diagnoses,1. intrauterine pregnancy at 39 plus weeks gestation.,2. gestational hypertension.,3. thick meconium.,4. failed vacuum attempted delivery.,postoperative diagnoses,1. intrauterine pregnancy at 39 plus weeks gestation.,2. gestational hypertension.,3. thick meconium.,4. failed vacuum attempted delivery.,operation performed: , spontaneous vaginal delivery.,anesthesia: , epidural was placed x2.,estimated blood loss:, 500 ml.,complications: , thick meconium. severe variables, apgars were 2 and 7. respiratory therapy and icn nurse at delivery. baby went to newborn nursery.,findings: , male infant, cephalic presentation, roa. apgars 2 and 7. weight 8 pounds and 1 ounce. intact placenta. three-vessel cord. third degree midline tear.,description of operation: , the patient was admitted this morning for induction of labor secondary to elevated blood pressure, especially for the last three weeks. she was already 3 cm dilated. she had artificial rupture of membranes. pitocin was started and she actually went to complete dilation. while pushing, there was sudden onset of thick meconium, and she was having some severe variables and several late decelerations. when she was complete +2, vacuum attempted delivery, three pop-offs were done. the vacuum was then no longer used after the three pop-offs. the patient pushed for a little bit longer and had a delivery, roa, of a male infant, cephalic, over a third-degree midline tear. secondary to the thick meconium, delee suctioned nose and mouth before the anterior shoulder was delivered and again after delivery. baby was delivered floppy. cord was clamped x2 and cut, and the baby was handed off to awaiting icn nurse and respiratory therapist. delivery of intact placenta and three-vessel cord. third-degree midline tear was repaired with vicryl without any complications. baby initially did well and went to newborn nursery, where they are observing him a little bit longer there. again, mother and baby are both doing well. mother will go to postpartum and baby is already in newborn nursery.

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

admitting diagnosis:, aftercare of multiple trauma from an motor vehicle accident.,discharge diagnoses:,1. aftercare following surgery for injury and trauma.,2. decubitus ulcer, lower back.,3. alcohol induced persisting dementia.,4. anemia.,5. hypokalemia.,6. aftercare healing traumatic fracture of the lower arm.,7. alcohol abuse, not otherwise specified.,8. aftercare healing traumatic lower leg fracture.,9. open wound of the scalp.,10. cervical disk displacement with myelopathy.,11. episodic mood disorder.,12. anxiety disorder.,13. nervousness.,14. psychosis.,15. generalized pain.,16. insomnia.,17. pain in joint pelvic region/thigh.,18. motor vehicle traffic accident, not otherwise specified.,principal procedures:, none.,history of present illness: , as per dr. x without any changes or corrections.,hospital course: ,this is a 50-year-old male, who is initially transferred from medical center after treatment for multiple fractures after a motor vehicle accident. he had a left tibial plateau fracture, right forearm fracture with orif, head laceration, and initially some symptoms of head injury. when he was initially transferred to healthsouth, he was status post orif for his right forearm. he had a brace placed in the left leg for his left tibial plateau fracture. he was confused initially and initially started on rehab. he was diagnosed with some acute psychosis and thought problems likely related to his alcohol abuse history. he did well from orthopedic standpoint. he did have a small sacral decubitus ulcer, which was well controlled with the wound care team and healed quite nicely. he did have some anemia initially and he had dropped down in to the low 9, but he was 9.2 with his lowest on 06/11/2008, which had responded well to iron treatment and by the time of discharge, he was lower at 11.0. he made slow progress from therapy. his confusion gradually cleared. he did have some problems with insomnia and was placed on seroquel to help with both of his moods and other issues and he did quite well with this. he did require some ativan for agitation. he was on chronic pain medications as an outpatient. his medications were adjusted here and he did well with this as well. the patient was followed throughout his entire stay with case management and discussions were made with them and the psychologist concerning the placement upon discharge to an acute alcohol rehab facility; however, the patient refused throughout this entire stay. we did have orthopedic followup. he was taken out of his right leg brace the week of 06/16/2008. he did well with therapy. overall, he was doing much and much better. he had progressed with the therapy to the point where that he was comfortable to go home and receive outpatient therapy and follow up with his primary care physician. on 06/20/2008, with all parties in agreement, the patient was discharged to home in stable condition.,at the time of discharge, the patient's ambulatory status was much better. he was using a wheeled walker. he was able to bear weight on his left leg. his pain level had been well controlled and his moods had improved dramatically. he was no longer having any signs of agitation or confusion and he seemed to be at a stable baseline. his anemia had resolved almost completely and he was doing quite well. ,medications: , on discharge included:,1. calcium with vitamin d 1 tablet twice a day.,2. ferrous sulfate 325 mg t.i.d.,3. multivitamin 1 daily.,4. he was on nicotine patch 21 mg per 24 hour.,5. he was on seroquel 25 mg at bedtime.,6. he was on xenaderm for his sacral pressure ulcer.,7. he was on vicodin p.r.n. for pain.,8. ativan 1 mg b.i.d. for anxiety and otherwise he is doing quite well.,the patient was told to follow up with his orthopedist dr. y and also with his primary care physician upon discharge.

chief complaint:, left knee pain.,subjective: , this is a 36-year-old white female who presents to the office today with a complaint of left knee pain. she is approximately five days after a third synvisc injection. she states that the knee is 35% to 40 % better, but continues to have a constant pinching pain when she full weight bears, cannot handle having her knee in flexion, has decreased range of motion with extension. rates her pain in her knee as a 10/10. she does alternate ice and heat. she is using tylenol no. 3 p.r.n. and ibuprofen otc p.r.n. with minimal relief.,allergies,1. penicillin.,2. keflex.,3. bactrim.,4. sulfa.,5. ace bandages.,medications,1. toprol.,2. xanax.,3. advair.,4. ventolin.,5. tylenol no. 3.,6. advil.,review of systems:, will be starting the medifast diet, has discussed this with her pcp, who encouraged her to have gastric bypass, but the patient would like to try this medifast diet first. other than this, denies any further problems with her eyes, ears, nose, throat, heart, lungs, gi, gu, musculoskeletal, nervous system, except what is noted above and below.,physical examination,vital signs: pulse 72, blood pressure 130/88, respirations 16, height 5 feet 6.5 inches.,general: this is a 36-year-old white female who is a&o x3, in no apparent distress with a pleasant affect. she is well developed, well nourished, appears her stated age.,extremities: orthopedic evaluation of the left knee reveals there to be well-healed portholes. she does have some medial joint line swelling. negative ballottement. she has significant pain to palpation of the medial joint line, none of the lateral joint line. she has no pain to palpation on the popliteal fossa. range of motion is approximately -5 degrees to 95 degrees of flexion. it should be noted that she has extreme hyperextension on the right with 95+ degrees of flexion on the right. she has a click with mcmurray. negative anterior-posterior drawer. no varus or valgus instability noted. positive patellar grind test. calf is soft and nontender. gait is stable and antalgic on the left.,assessment,1. osteochondral defect, torn meniscus, left knee.,2. obesity.,plan: , i have encouraged the patient to work on weight reduction, as this will only benefit her knee. i did discuss treatment options at length with the patient, but i think the best plan for her would be to work on weight reduction. she questions whether she needs a total knee; i don't believe she needs total knee replacement. she may, however, at some point need an arthroscopy. i have encouraged her to start formal physical therapy and a home exercise program. will use ice or heat p.r.n. i have given her refills on tylenol no. 3, flector patch, and relafen not to be taken with any other anti-inflammatory. she does have some abdominal discomfort with the anti-inflammatories, was started on nexium 20 mg one p.o. daily. she will follow up in our office in four weeks. if she has not gotten any relief with formal physical therapy and the above-noted treatments, we will discuss with dr. x whether she would benefit from another knee arthroscopy. the patient shows a good understanding of this treatment plan and agrees.

preoperative diagnosis: , partial rotator cuff tear, left shoulder.,postoperative diagnosis: , partial rotator cuff tear, left shoulder.,procedure performed:, arthroscopy of the left shoulder with arthroscopic rotator cuff debridement, soft tissue decompression of the subacromial space of the left shoulder.,anesthesia: ,scalene block with general anesthesia.,estimated blood loss: , 30 cc.,complications: , none.,disposition: ,the patient went to the pacu stable.,gross operative findings: , there was no overt pathology of the biceps tendon. there was some softening and loss of the articular cartilage over the glenoid. the labrum was ________ attached permanently to the glenoid. the biceps tendon was nonsubluxable. upon ranging of the shoulder in internal and external rotation showed no evidence of rotator cuff tear on the articular side. subacromial space did show excessive soft tissue causing some overstuffing of the subacromial space. there was reconstitution of the bursa noted as well.,history of present illness:, this is a 51-year-old female had left shoulder pain of chronic nature who has had undergone prior rotator cuff debridement in may with partial pain relief and has had continued pain in the left shoulder. mri shows partial rotator cuff tear.,procedure: , the patient was taken to the operating room and placed in a beachchair position. after all bony prominences were adequately padded, the head was placed in the headholder with no excessive extension in the neck on flexion. the left extremity was prepped and draped in usual fashion. the #18 gauge needles were inserted into the left shoulder to locate the ac joint, the lateral aspect of the acromion as well as the pass of the first trocar to enter the shoulder joint from the posterior aspect. we took an #11 blade scalpel and made a small 1-cm skin incision posteriorly approximately 4-cm inferior and medial to the lateral port of the acromion. a blunt trocar was used to bluntly cannulate the joint and we put the camera into the shoulder at that point of the joint and instilled sterile saline to distend the capsule and begin our arthroscopic assessment of the shoulder. a second port was established superior to the biceps tendon anteriorly under direct arthroscopic visualization using #11 blade on the skin and inserted bluntly the trocar and the cannula. the operative findings found intra-articularly were as described previously gross operative findings. we did not see any evidence of acute pathology. we then removed all the arthroscopic instruments as well as the trocars and tunneled subcutaneously into the subacromial space and reestablished the portal and camera and inflow with saline. the subacromial space was examined and found to have excessive soft tissue and bursa that was in the subacromial space that we debrided using arthroscopic shaver after establishing a lateral portal. all this was done and hemostasis was achieved. the rotator cuff was examined from the bursal side and showed no evidence of tears. there was some fraying out laterally near its attachment over the greater tuberosity, which was debrided with the arthroscopic shaver. we removed all of our instruments and suctioned the subacromial space dry. a #4-0 nylon was used on the three arthroscopic portal and on the skin we placed sterile dressing and the arm was placed in an arm sling. she was placed back on the gurney, extubated and taken to the pacu in stable condition.