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reason for consult: , substance abuse.,history of present illness: , the patient is a 42-year-old white male with a history of seizures who was brought to the er in abcd by his sister following cocaine and nitrous oxide use. the patient says he had been sober from any illicit substance for 15 months prior to most recent binge, which occurred approximately 2 days ago. the patient is unable to provide accurate history as to amount use in this most recent binge or time period it was used over. the patient had not used cocaine for 15 years prior to most recent usage but had used alcohol and nitrous oxide up until 15 months ago. the patient says he was depressed and agitated. he says he used cocaine by snorting and nitrous oxide but denies other drug usage. he says he experienced visual hallucinations while intoxicated, but has not had hallucinations since being in the hospital. the patient states he has had cocaine-induced seizures several times in the past but is not able to provide an accurate history as to the time period of the seizure. the patient denies suicidal ideation, homicidal ideation, auditory hallucinations, visual hallucinations, or tactile hallucinations. the patient is a&o x3.,past psychiatric history:, substance abuse as per hpi. the patient went to a well sober for 15 months.,past medical history:, seizures.,past surgical history:, shoulder injury.,social history:, the patient lives alone in an apartment uses prior to sobriety 15 months ago. he was a binge drinker, although unable to provide detail about frequency of binges. the patient does not work since brother became ill 3 months ago when he quit his job to care for him.,family history:, none reported.,medications outpatient:, seroquel 100 mg p.o. daily for insomnia.,medications inpatient:,1. gabapentin 300 mg q.8h.,2. seroquel 100 mg p.o. q.h.s.,3. seroquel 25 mg p.o. q.8h. p.r.n.,4. phenergan 12.5 mg iv q.4h. p.r.n.,5. acetaminophen 650 mg q.4h. p.r.n.,6. esomeprazole 40 mg p.o. daily. ,mental status examination: , the patient is a 42-year-old male who appears stated age, dressed in a hospital gown. the patient shows psychomotor agitation and is somewhat irritable. the patient makes fair eye contact and is cooperative. he had answers my questions with "i do not know." mood "depressed" and "agitated." affect is irritable. thought process logical and goal directed with thought content. he denies suicidal ideation, homicidal ideation, auditory hallucinations, visual hallucinations, or tactile hallucinations. insight and judgment are both fair. the patient seems to understand why he is in the hospital and patient says he will return to alcoholics anonymous and will try to stay sober in all substances following discharge. the patient is a&o x3.,assessment:,axis i: substance withdrawal, substance abuse, and substance dependence.,axis ii: deferred.,axis iii: history of seizures.,axis iv: lives alone and unemployed.,axis v: 55.,impression:, the patient is a 42-year-old white male who recently had a cocaine binge following 15 months of sobriety. the patient is experiencing mild symptoms of cocaine withdrawal.,recommendations:,1. gabapentin 300 mg q.8h. for agitation and history of seizures.,2. reassess this afternoon for reduction in agitation and withdrawal seizures.,thank you for the consult. please call with further questions.

procedure performed,1. placement of a subclavian single-lumen tunneled hickman central venous catheter.,2. surgeon-interpreted fluoroscopy.,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 anesthesia was administered. next, a #18-gauge needle was used to locate the subclavian vein. after aspiration of venous blood, a j wire was inserted through the needle using seldinger technique. the needle was withdrawn. the distal tip location of the j wire was confirmed to be in adequate position with surgeon-interpreted fluoroscopy. next, a separate stab incision was made approximately 3 fingerbreadths below the wire exit site. a subcutaneous tunnel was created, and the distal tip of the hickman catheter was pulled through the tunnel to the level of the cuff. the catheter was cut to the appropriate length. a dilator and sheath were passed over the j wire. the dilator and j wire were removed, and the distal tip of the hickman catheter was threaded through the sheath, which was simultaneously withdrawn. the catheter was flushed and aspirated without difficulty. the distal tip was confirmed to be in good location with surgeon-interpreted fluoroscopy. a 2-0 nylon was used to secure the cuff down to the catheter at the skin level. the skin stab site was closed with a 4-0 monocryl. the instrument and sponge count was correct at the end of the case. the patient tolerated the procedure well and was transferred to the postanesthesia recovery area in good condition.

reason for consultation: , neurologic consultation was requested by dr. x to evaluate her seizure medication and lethargy.,history of present illness: , the patient is well known to me. she has symptomatic partial epilepsy secondary to a static encephalopathy, cerebral palsy, and shunted hydrocephalus related to prematurity. she also has a history of factor v leiden deficiency. she was last seen at neurology clinic on 11/16/2007. at that time, instructions were given to mom to maximize her trileptal dose if seizures continue. she did well on 2 ml twice a day without any sedation. this past friday, she had a 25-minute seizure reportedly. this consisted of eye deviation, unresponsiveness, and posturing. diastat was used and which mom perceived was effective. her trileptal dose was increased to 3 ml b.i.d. yesterday.,according to mom since her shunt revision on 12/18/2007, she has been sleepier than normal. she appeared to be stable until this past monday about six days ago, she became more lethargic and had episodes of vomiting and low-grade fevers. according to mom, she had stopped vomiting since her hospitalization. reportedly, she was given a medication in the emergency room. she still is lethargic, will not wake up spontaneously. when she does awaken however, she is appropriate, and interacts with them. she is able to eat well; however her overall p.o. intake has been diminished. she has also been less feisty as her usual sounds. she has been seizure free since her admission.,laboratory data: , pertinent labs obtained here showed the following: crp is less than 0.3, cmp normal, and cbc within normal limits. csf cultures so far is negative. dr. limon's note refers to a csf, white blood cell count of 2, 1 rbc, glucose of 55, and protein of 64. there are no imaging studies in the computer. i believe that this may have been done at kaweah delta hospital and reviewed by dr. x, who indicated that there was no evidence of shunt malfunction or infection.,current medications: , trileptal 180 mg b.i.d., lorazepam 1 mg p.r.n., acetaminophen, and azithromycin.,physical examination:,general: the patient was asleep, but easily aroused. there was a brief period of drowsiness, which she had some jerky limb movements, but not seizures. she eventually started crying and became agitated. she made attempts to sit by bending her neck forward. fully awake, she sucks her bottle eagerly.,heent: she was obviously visually impaired. pupils were 3 mm, sluggishly reactive to light.,extremities: bilateral lower extremity spasticity was noted. there was increased flexor tone in the right upper extremity. iv was noted on the left hand.,assessment: ,seizure breakthrough due to intercurrent febrile illness. her lethargy could be secondary to a viral illness with some component of medication effect since her trileptal dose was increased yesterday and these are probable explanations if indeed shunt malfunction has been excluded.,i concur with dr. x's recommendations. i do not recommend any changes in trileptal for now. i will be available while she remains hospitalized.,

procedure: , medial branch rhizotomy, lumbosacral.,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.,sedation: , the patient was given conscious sedation and monitored throughout the procedure. oxygenation was given. the patient's oxygenation and vital signs were closely followed to ensure the safety of the administration of the drugs.,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 the prone position on the treatment table with a pillow under the abdomen to reduce the natural lumbar lordosis. 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 boney landmarks of the spine and the planned needle approach. the skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% lidocaine. with fluoroscopy, a teflon coated needle, ***, was gently guided into the region of the medial branch nerves from the dorsal ramus of ***. specifically, each needle tip was inserted to the bone at the groove between the transverse process and superior articular process on lumbar vertebra, or for sacral vertebrae at the lateral-superior border of the posterior sacral foramen. needle localization was confirmed with ap and lateral radiographs.,the following technique was used to confirm placement at the medial branch nerves. sensory stimulation was applied to each level at 50 hz; paresthesias were noted at,*** volts. motor stimulation was applied at 2 hz with 1 millisecond duration; corresponding paraspinal muscle twitching without extremity movement was noted at *** 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, 1cc 1% lidocaine was injected to anesthetize the medial branch nerve and surrounding tissue. after completion of each nerve block a lesion was created at that level with a temperature of 85 degrees celsius for 90 seconds. all injected medications were preservative free. sterile technique was used throughout the procedure.,complications:, none. no complications.,the patient tolerated the procedure well and was sent to the recovery room in good condition.,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 in approximately 1 week.

cc:, left-sided weakness.,hx:, this 28y/o rhm was admitted to a local hospital on 6/30/95 for a 7 day history of fevers, chills, diaphoresis, anorexia, urinary frequency, myalgias and generalized weakness. he denied foreign travel, iv drug abuse, homosexuality, recent dental work, or open wound. blood and urine cultures were positive for staphylococcus aureus, oxacillin sensitive. he was place on appropriate antibiotic therapy according to sensitivity.. a 7/3/95 transthoracic echocardiogram revealed normal left ventricular function and a damaged mitral valve with regurgitation. later that day he developed left-sided weakness and severe dysarthria and aphasia. hct, on 7/3/95 revealed mild attenuated signal in the right hemisphere. on 7/4/95 he developed first degree av block, and was transferred to uihc.,meds: ,nafcillin 2gm iv q4hrs, rifampin 600mg q12hrs, gentamicin 130mg q12hrs.,pmh:, 1) heart murmur dx age 5 years.,fhx:, unremarkable.,shx:, employed cook. denied etoh/tobacco/illicit drug use.,exam:, bp 123/54, hr 117, rr 16, 37.0c,ms: somnolent and arousable only by shaking and repetitive verbal commands. he could follow simple commands only. he nodded appropriately to questioning most of the time. dysarthric speech with sparse verbal output.,cn: pupils 3/3 decreasing to 2/2 on exposure to light. conjugate gaze preference toward the right. right hemianopia by visual threat testing. optic discs flat and no retinal hemorrhages or roth spots were seen. left lower facial weakness. tongue deviated to the left. weak gag response, bilaterally. weak left corneal response.,motor: dense left flaccid hemiplegia.,sensory: less responsive to pp on left.,coord: unable to test.,station and gait: not tested.,reflexes: 2/3 throughout (more brisk on the left side). left ankle clonus and a left babinski sign were present.,gen exam: holosystolic murmur heard throughout the precordium. janeway lesions were present in the feet and hands. no osler's nodes were seen.,course:, 7/6/95, hct showed a large rmca stroke with mass shift. his neurologic exam worsened and he was intubated, hyperventilated, and given iv mannitol. he then underwent emergent left craniectomy and duraplasty. he tolerated the procedure well and his brain was allowed to swell. he then underwent mitral valve replacement on 7/11/95 with a st. judes valve. his post-operative recovery was complicated by pneumonia, pericardial effusion and dysphagia. he required temporary peg placement for feeding. the 7/27/95, 8/6/95 and 10/18/96 hct scans show the chronologic neuroradiologic documentation of a large rmca stroke. his 10/18/96 neurosurgery clinic visit noted that he can ambulate without assistance with the use of a leg brace to prevent left foot drop. his proximal lle strength was rated at a 4. his lue was plegic. he had a seizure 6 days prior to his 10/18/96 evaluation. this began as a jacksonian march of shaking in the lue; then involved the lle. there was no loc or tongue-biting. he did have urinary incontinence. he was placed on dph. his speech was dysarthric but fluent. he appeared bright, alert and oriented in all spheres.

chief complaint:, fever.,history of present illness:, this is an 18-month-old white male here with his mother for complaint of intermittent fever for the past five days. mother states he just completed amoxil several days ago for a sinus infection. patient does have a past history compatible with allergic rhinitis and he has been taking zyrtec serum. mother states that his temperature usually elevates at night. two days his temperature was 102.6. mother has not taken it since, and in fact she states today he seems much better. he is cutting an eye tooth that causes him to be drooling and sometimes fussy. he has had no vomiting or diarrhea. there has been no coughing. nose secretions are usually discolored in the morning, but clear throughout the rest of the day. appetite is fine.,physical examination:,general: he is alert in no distress.,vital signs: afebrile.,heent: normocephalic, atraumatic. pupils equal, round and react to light. tms are clear bilaterally. nares patent. clear secretions present. oropharynx is clear.,neck: supple.,lungs: clear to auscultation.,heart: regular, no murmur.,abdomen: soft. positive bowel sounds. no masses. no hepatosplenomegaly.,skin: normal turgor.,assessment:,1. allergic rhinitis.,2. fever history.,3. sinusitis resolved.,4. teething.,plan:, mother has been advised to continue zyrtec as directed daily. supportive care as needed. reassurance given and he is to return to the office as scheduled.

hpi - workers comp:, the current problem began on or about 2/10/2000. the symptoms were sudden in onset. according to the patient, the current problem is a result of a work injury involving lifting approximately 40 pounds. pain location (lower body): left hip. the patient describes the pain as dull, aching and stabbing. the severity of the pain ranges from mild to severe. the pain is severe occasionally. it is present constantly. the pain is made worse by sitting, riding in a car, twisting and lifting. the pain is made better by rest. the patient's symptoms appear to be soft tissue (spine), myofascial (spine) and musculoskeletal (spine) in origin. sleep alteration because of pain: positive and wakes up after getting to sleep nightly. systemic signs/symptoms relevant or potentially relevant to the spine: none. patient reports the following symptoms: depressed mood, loss of interest or pleasure in all or most activities, insomnia, inability to concentrate, fatigue and loss of energy.,work status:,

preoperative diagnoses:,1. pelvic pain.,2. ectopic pregnancy.,postoperative diagnoses:,1. pelvic pain.,2. ectopic pregnancy.,3. hemoperitoneum.,procedures performed:,1. dilation and curettage (d&c).,2. laparoscopy.,3. right salpingectomy.,4. lysis of adhesions.,5. evacuation of hemoperitoneum.,anesthesia: , general endotracheal.,estimated blood loss: , scant from the operation, however, there was approximately 2 liters of clotted and old blood in the abdomen.,specimens:, endometrial curettings and right fallopian tube.,complications: , none.,findings: , on bimanual exam, the patient has a small anteverted uterus, it is freely mobile. no adnexal masses, however, were appreciated on the bimanual exam. laparoscopically, the patient had numerous omental adhesions to the vesicouterine peritoneum in the fundus of the uterus. there were also adhesions to the left fallopian tube and the right fallopian tube. there was a copious amount of blood in the abdomen approximately 2 liters of clotted and unclotted blood. there was some questionable gestational tissue ________ on the left sacrospinous ligament. there was an apparent rupture and bleeding ectopic pregnancy in the isthmus portion of the right fallopian tube.,procedure:, after an informed consent was obtained, the patient was taken to the operating room and the 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. a weighted speculum was then placed in the vagina. the interior wall of vagina elevated with the uterine sound and the anterior lip of the cervix was grasped with the vulsellum tenaculum. the cervix was then serially dilated with hank dilators to a size #20 hank and then a sharp curettage was performed obtaining a moderate amount of decidual appearing tissue and the tissue was then sent to pathology. at this point, the uterine manipulator was placed in the cervix and attached to the anterior cervix and vulsellum tenaculum and weighted speculum were removed. next, attention was then turned to the abdomen. the surgeons all are removed the dirty gloves in the previous portion of the case. next, a 2 cm incision was made immediately inferior to umbilicus. the superior aspect of the umbilicus was grasped with a towel clamp and a veress needle was inserted through this incision. next, a syringe was used to inject normal saline into the veress needle. the normal saline was seen to drop freely, so a veress needle was connected to the co2 gas which was started at its lowest setting. the gas was seen to flow freely with normal resistance, so the co2 gas was advanced to a higher setting. the abdomen was insufflated to an adequate distension. once an adequate distention was reached, the co2 gas was disconnected. the veress needle was removed and a size #11 step trocar was placed. the introducer was removed and the trocar was connected to the co2 gas and a camera was inserted. next, a 1 cm incision was made in the midline approximately two fingerbreadths below the pubic symphysis after transilluminating with the camera. a veress needle and a step sheath were inserted through this incision. next, the veress needle was removed and a size #5 trocar was inserted under direct visualization. next a size #5 port was placed approximately five fingerbreadths to the left of the umbilicus in a similar fashion. a size #12 port was placed in a similar fashion approximately six fingerbreadths to the right of the umbilicus and also under direct visualization. the laparoscopic dissector was inserted through the suprapubic port and this was used to dissect the omental adhesions bluntly from the vesicouterine peritoneum and the bilateral fallopian tubes. next, the dorsey suction irrigator was used to copiously irrigate the abdomen. approximate total of 3 liters of irrigation was used and the majority of all blood clots and free blood was removed from the abdomen.,once the majority of blood was cleaned from the abdomen, the ectopic pregnancy was easily identified and the end of the fallopian tube was grasped with the grasper from the left upper quadrant and the ligasure device was then inserted through the right upper quadrant with # 12 port. three bites with the ligasure device were used to transect the mesosalpinx inferior to the fallopian tube and then transect the fallopian tube proximal to the ectopic pregnancy. an endocatch bag was then placed to the size #12 port and this was used to remove the right fallopian tube and ectopic pregnancy. this was then sent to the pathology. next, the right mesosalpinx and remains of the fallopian tube were examined again and they were seemed to be hemostatic. the abdomen was further irrigated. the liver was examined and appeared to be within normal limits. at this point, the two size #5 ports and a size #12 port were removed under direct visualization. the camera was then removed. the co2 gas was disconnected and the abdomen was desufflated. the introducer was then replaced in a size #11 port and the whole port and introducer was removed as a single unit. all laparoscopic incisions were closed with a #4-0 undyed vicryl in a subcuticular interrupted fashion. they were then steri-stripped and bandaged appropriately. at the end of the procedure, the uterine manipulator was removed from the cervix and the patient was taken to recovery in stable condition. the patient tolerated the procedure well. sponge, lap, and needle counts were correct x2. she was discharged home with a postoperative hemoglobin of 8.9. she was given iron 325 mg to be taken twice a day for five months and darvocet-n 100 mg to be taken every four to six hours for pain. she will follow up within a week in the ob resident clinic.

preoperative diagnosis: , bilateral open mandible fracture, open left angle and open symphysis fracture.,postoperative diagnosis: , bilateral open mandible fracture, open left angle and open symphysis fracture.,procedure: ,closed reduction of mandible fracture with mmf.,anesthesia: , general anesthesia via nasal endotracheal intubation.,fluids: , 2 l of crystalloid.,estimated blood loss: , minimal.,hardware: , none.,specimens: , none.,complications: , none.,condition: ,the patient was extubated to pacu in good condition.,indications for procedure: , the patient is a 17-year-old female who is 2 days status post an altercation in which she sustained multiple blows to the face. she was worked up on friday night, 2 days earlier at hospital, was given palliative treatment and discharged and instructed to follow up as an outpatient with an oral surgeon and given a phone number to call. the patient was worked up initially. on initial exam, it was noted that the patient had a left v3 paresthesia. she had a gross malocclusion. on the facial ct and panoramic x-ray, it was noted to be a displaced left angle fracture and nondisplaced symphysis fracture. alternatives were discussed with the patient and it was determined she would benefit from being taken to the operating room under general anesthesia to have a closed reduction of her fractures. risks, benefits, and alternatives of treatment were thoroughly discussed with the patient and informed consent was obtained with the patient's mother.,description of procedure:, the patient was taken to the operating room #4 at hospital and laid in a supine position on the operating room table. monitor was attached and general anesthesia was induced with iv anesthetics and maintained with nasal endotracheal intubation and inhalation anesthetics. the patient was prepped and draped in the usual oromaxillofacial surgery fashion.,surgeon approached the operating table in a sterile fashion. approximately 10 ml of 2% lidocaine with 1:100,000 epinephrine was injected into the oral vestibule in a nerve block fashion. a moistened ray-tec sponge was placed in the posterior oropharynx and the mouth was prepped with peridex mouthrinse, scrubbed with a toothbrush. the peridex was evacuated with yankauer suction. erich arch bars were adapted to the maxilla from the first molar to the contralateral first molar and secured with 24-gauge surgical steel wire on the posterior teeth and 26-gauge surgical steel wire on the anterior teeth. same was done on the mandible. the patient was then manipulated up in the maximum intercuspation and noted to be reproducible. the throat pack was then removed.,the patient was remanipulated up to the maximum intercuspation and secured with interdental elastics. at this point in time, the procedure was then determined to be over.,the patient was extubated and transferred to the pacu in good condition.

operation: , left lower lobectomy.,operative procedure in detail: , the patient was brought to the operating room and placed in the supine position. after general endotracheal anesthesia was induced, the appropriate monitoring devices were placed. the patient was placed in the right lateral decubitus position. the left chest and back were prepped and draped in a sterile fashion. a right lateral thoracotomy incision was made. subcutaneous flaps were raised. the anterior border of the latissimus dorsi was freed up, and the muscle was retracted posteriorly. the posterior border of the pectoralis was freed up and it was retracted anteriorly. the 5th intercostal space was entered.,the inferior pulmonary ligament was then taken down with electrocautery. the major fissure was then taken down and arteries identified. the artery was dissected free and it was divided with an endo gia stapler. the vein was then dissected free and divided with an endo gia stapler. the bronchus was then cleaned of all nodal tissue. a ta-30 green loaded stapler was then placed across this, fired, and main bronchus divided distal to the stapler.,then the lobe was removed and sent to pathology where margins were found to be free of tumor. level 9, level 13, level 11, and level 6 nodes were taken for permanent cell specimen. hemostasis noted. posterior 28-french and anterior 24-french chest tubes were placed.,the wounds were closed with #2 vicryl. a subcutaneous drain was placed. subcutaneous tissue was closed with running 3-0 dexon, skin with running 4-0 dexon subcuticular stitch.

preoperative diagnoses:,1. intrauterine pregnancy of 39 weeks.,2. herpes simplex virus, positive by history.,3. hepatitis c, positive by history with low elevation of transaminases.,4. cephalopelvic disproportion.,5. asynclitism.,6. postpartum macrosomia.,postoperative diagnoses:,1. intrauterine pregnancy of 39 weeks.,2. herpes simplex virus, positive by history.,3. hepatitis c, positive by history with low elevation of transaminases.,4. cephalopelvic disproportion.,5. asynclitism.,6. postpartum macrosomia.,7. delivery of viable 9 lb female neonate.,procedure performed: , primary low transverse cervical cesarean section.,complications:, none.,estimated blood loss: , about 600 cc.,baby is doing well. the patient's uterus is intact, bladder is intact.,history: , the patient is an approximately 25-year-old caucasian female with gravida-4, para-1-0-2-1. the patient's last menstrual period was in december of 2002 with a foreseeable due date on 09/16/03 confirmed by ultrasound.,the patient has a history of herpes simplex virus to which there is no active prodromal and no evidence of lesions. the patient has a history of ivda and contracted hepatitis c with slightly elevated liver transaminases. the patient had been seen through our office for prenatal care. the patient is on valtrex. the patient was found to be 3 cm about 40%, 0 to 9 engaged. bag of waters was ruptured. she was on pitocin. she was contracting appropriately for a couple of hours or so with appropriate ________. there was no cervical change noted. most probably because there was a sink vertex and that the head was too large to descend into the pelvis. the patient was advised of this and we recommended cesarean section. she agreed. we discussed the surgery, foreseeable risks and complications, alternative treatment, the procedure itself, and recovery in layman's terms. the patient's questions were answered. i personally made sure that she understood every aspect of the consent and that she was comfortable with the understanding of what would transpire.,procedure: ,the patient was then taken back to operative suite. she was given anesthetic and sterilely prepped and draped. pfannenstiel incision was used. a second knife was used to carry the incision down to the anterior rectus fascia. anterior rectus fascia was incised in the midline and carried bilaterally and the fascia was lifted off the underlying musculature. the rectus muscles were separated. the patient's peritoneum tented up towards the umbilicus and we entered the abdominal cavity. there was a very thin lower uterine segment. there seemed to be quite a large baby. the patient had a small nick in the uterus. following the blunt end of the bladder knife going through the innermost layer of the myometrium and into the endometrial cavity, clear amniotic fluid was obtained. a blunt low transverse cervical incision was made. following this, we placed a ________ on the very large fetal head. the head was delivered following which we were able to deliver a large baby girl, 9 lb, good at tone and cry. the patient then underwent removal of the placenta after the cord blood and abg were taken. the patient's uterus was examined. there appeared to be no retained products. the patient's uterine incision was reapproximated and sutured with #0 vicryl in a running non-interlocking fashion, the second imbricating over the first. the patient's uterus was hemostatic. bladder flap was reapproximated with #0 vicryl. the patient then underwent an irrigation at every level of closure and the patient was quite hemostatic. we reapproximated the rectus musculature with care being taken not to incorporate any underlying structures. the patient had three interrupted sutures of this. the fascia was reapproximated with two stitches of #0 vicryl going from each apex towards the midline. the scarpa's fascia was reapproximated with #0 gut. there was noted no fascial defects and the skin was closed with #0 vicryl.,prior to closing the abdominal cavity, the uterus appeared to be intact and bladder appeared to have clear urine and appeared to be intact. the patient was hemostatic. all counts were correct and the patient tolerated the procedure well. we will see her back in recovery.

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

procedure performed:, right heart catheterization.,indication: , refractory chf to maximum medical therapy.,procedure: , after risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient and the patient's family in detail, informed consent was obtained both verbally and in writing. the patient was taken to cardiac catheterization suite where the right internal jugular region was prepped and draped in the usual sterile fashion. 1% lidocaine solution was used to infiltrate the skin overlying the right internal jugular vein. once adequate anesthesia has been obtained, a thin-walled #18 gauge argon needle was used to cannulate the right internal jugular vein. a steel guidewire was then inserted through the needle into the vessel without resistance. small nick was then made in the skin and the needle was removed. an #8.5 french venous sheath was then advanced over the guidewire into the vascular lumen without resistance. the guidewire and dilator were then removed. the sheath was then flushed. a swan-ganz catheter was inserted to 20 cm and the balloon was inflated. under fluoroscopic guidance, the catheter was advanced into the right atrium through the right ventricle and into the pulmonary artery wedge position. hemodynamics were measured along the way. pulmonary artery saturation was obtained. the swan was then kept in place for the patient to be transferred to the icu for further medical titration. the patient tolerated the procedure well. the patient returned to the cardiac catheterization holding area in stable and satisfactory condition.,findings:, body surface area equals 2.04, hemoglobin equals 9.3, o2 is at 2 liters nasal cannula. pulmonary artery saturation equals 37.8. pulse oximetry on 2 liters nasal cannula equals 93%. right atrial pressure is 8, right ventricular pressure equals 59/9, pulmonary artery pressure equals 61/31 with mean of 43, pulmonary artery wedge pressure equals 21, cardiac output equals 3.3 by the fick method, cardiac index is 1.6 by the fick method, systemic vascular resistance equals 1821, and transpulmonic gradient equals 22.,impression: ,exam and swan findings consistent with low perfusion given that the mixed venous o2 is only 38% on current medical therapy as well as elevated right-sided filling pressures and a high systemic vascular resistance.,plan: , given that the patient is unable to tolerate vasodilator therapy secondary to significant orthostasis and the fact that the patient will not respond to oral titration at this point due to lack of cardiac reserve, the patient will need to be discharged home on primacor. the patient is unable to continue with his dobutamine therapy secondary to nonsustained ventricular tachycardia. at this time, we will transfer the patient to the intensive care unit for titration of the primacor therapy. we will also increase his lasix to 80 mg iv q.d. we will increase his amiodarone to 400 mg daily. we will also continue with his coumadin therapy. as stated previously, we will discontinue vasodilator therapy starting with the isordil.

cc: ,difficulty with speech.,hx:, this 84 y/o rhf presented with sudden onset word finding and word phonation difficulties. she had an episode of transient aphasia in 2/92 during which she had difficulty with writing, written and verbal comprehension, and exhibited numerous semantic and phonemic paraphasic errors of speech. these problems resolved within 24 hours of onset and she had no subsequent speech problems prior to this presentation. workup at that time revealed a right to left shunt on trans-thoracic echocardiogram. carotid doppler studies showed 0-15% bica stenosis and a lica aneurysm (mentioned above). brain ct was unremarkable. she was placed on asa after the 2/92 event.,in 5/92 she was involved in a motor vehicle accident and suffered a fractured left humerus and left occipital scalp laceration. hct at that time showed a small area of slightly increased attenuation at the posterior right claustrum only. this was not felt to be a contusion; nevertheless, she was placed on dilantin seizure prophylaxis. her left arm was casted and she returned home.,5 hours prior to presentation today, the patient began having difficulty finding words and putting them into speech. she was able to comprehend speech. this continued for an hour; then partially resolved for one hour; then returned; then waxed and waned. there was no reported weakness, numbness, incontinence, seizure-like activity, incoordination, ha, nausea, vomiting, or lightheadedness,meds:, asa , dph, tenormin, premarin, hctz,pmh:, 1)transient fluent aphasia 2/92 (which resolved), 2)bilateral carotid endarterectomies 1986, 3)htn, 4)distal left internal carotid artery aneurysm.,exam:, bp 168/70, pulse 82, rr 16, 35.8f,ms:a & o x 3, difficulty following commands, speech fluent, and without dysarthria. there were occasional phonemic paraphasic errors.,cn: unremarkable.,motor: 5/5 throughout except for 4+ right wrist extension and right knee flexion.,sensory: unremarkable.,coordination: mild left finger-nose-finger dysynergia and dysmetria.,gait: mildly unsteady tandem walk.,station: no romberg sign.,reflexes: slightly more brisk at the left patella than on the right. plantar responses were flexor bilaterally.,the remainder of the neurologic exam and the general physical exam were unremarkable.,labs:, cbc wnl, gen screen wnl, , pt/ptt wnl, dph 26.2mcg/ml, cxr wnl, ekg: lbbb, hct revealed a left subdural hematoma.,course:, patient was taken to surgery and the subdural hematoma was evacuated. her mental status, language skills, improved dramatically. the dph dosage was adjusted appropriately.

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.

findings:,there is severe tendinitis of the common extensor tendon origin with diffuse intratendinous inflammation (coronal t2 image #1452, sagittal t2 image #1672). there is irregularity of the deep surface of the tendon consistent with mild fraying (#1422 and 1484) however there is no distinct tear.,there is a joint effusion of the radiocapitellar articulation with mild fluid distention.,the radial collateral (proper) ligament remains intact. there is periligamentous inflammation of the lateral ulnar collateral ligament (coronal t2 image #1484) of the radial collateral ligamentous complex. there is no articular erosion or osteochondral defect with no intra-articular loose body.,there is minimal inflammation of the subcutis adipose space extending along the origin of the common flexor tendon (axial t2 image #1324). the common flexor tendon otherwise is normal.,there is minimal periligamentous inflammation of the anterior band of the ulnar collateral ligament (coronal t2 image #1516, axial t2 image #1452) with an intrinsically normal ligament.,the ulnotrochlear articulation is normal.,the brachialis and biceps tendons are normal with a normal triceps tendon. the anterior, posterior, medial and lateral muscular compartments are normal.,the radial, median and ulnar nerves are normal with no apparent ulnar neuritis.,impression:,lateral epicondylitis with severe tendinitis of the common extensor tendon origin and minimal deep surface fraying, without a discrete tendon tear.,periligamentous inflammation of the radial collateral ligamentous complex as described above with intrinsically normal ligaments.,small joint effusion of the radiocapitellar articulation with no osteochondral defect or intra-articular loose body.,mild peritendinous inflammation of the subcutis adipose space adjacent to the common flexor tendon origin with an intrinsically normal tendon.,minimal periligamentous inflammation of the anterior band of the ulnar collateral ligament with an intrinsically normal ligament.

title of operation: , revision laminectomy l5-s1, discectomy l5-s1, right medial facetectomy, preparation of disk space and arthrodesis with interbody graft with bmp.,indications for surgery: ,please refer to medical record, but in short, the patient is a 43-year-old male known to me, status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain, failed conservative therapy. risks and benefits of surgery were explained in detail including risk of bleeding, infection, stroke, heart attack, paralysis, need for further surgery, hardware failure, persistent symptoms, and death. this list was inclusive, but not exclusive. an informed consent was obtained after all patient's questions were answered.,preoperative diagnosis: ,severe lumbar spondylosis l5-s1, collapsed disk space, hypermobility, and herniated disk posteriorly.,postoperative diagnosis: , severe lumbar spondylosis l5-s1, collapsed disk space, hypermobility, and herniated disk posteriorly.,anesthesia: , general anesthesia and endotracheal tube intubation.,disposition: , the patient to pacu with stable vital signs.,procedure in detail: ,the patient was taken to the operating room. after adequate general anesthesia with endotracheal tube intubation was obtained, the patient was placed prone on the jackson table. lumbar spine was shaved, prepped, and draped in the usual sterile fashion. an incision was carried out from l4 to s1. hemostasis was obtained with bipolar and bovie cauterization. a weitlaner was placed in the wound and a subperiosteal dissection was carried out identifying the lamina of l4, l5, and sacrum. at this time, laminectomy was carried out of l5-s1. thecal sac was retracted rightward and the foramen was opened and unilateral medial facetectomy was carried out in the disk space. at this time, the disk was entered with a #15 blade and bipolar. the disk was entered with straight up and down-biting pituitaries, curettes, and the high speed drill and we were able to takedown calcified herniated disk. we were able to reestablish the disk space, it was very difficult, required meticulous dissection and then drilling with a diamond bur in the disk space underneath the spinal canal, very carefully holding the spinal canal out of harm's way as well as the exiting nerve root. once this was done, we used rasps to remove more disk material anteriorly and under the midline to the left side and then we put in interbody graft of bmp 8 mm graft from medtronic. at this time, dr. x will dictate the posterolateral fusion, pedicle screw fixation to l4 to s1 with compression and will dictate the closure of the wound. there were no complications.

reason for consultation:, newly diagnosed cholangiocarcinoma.,history of present illness: , the patient is a very pleasant 77-year-old female who is noted to have an increase in her liver function tests on routine blood work in december 2009. ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis. common bile duct was noted to be 10 mm in size on that ultrasound. she then underwent a ct scan of the abdomen in july 2010, which showed intrahepatic ductal dilatation with the common bile duct size being 12.7 mm. she then underwent an mri mrcp, which was notable for stricture of the distal common bile duct. she was then referred to gastroenterology and underwent an ercp. on august 24, 2010, she underwent the endoscopic retrograde cholangiopancreatography. she was noted to have a stricturing mass of the mid-to-proximal common bile duct consistent with cholangiocarcinoma. a temporary biliary stent was placed across the biliary stricture. blood work was obtained during the hospitalization. she was also noted to have an elevated ca99. she comes in to clinic today for initial medical oncology consultation. after she sees me this morning, she has a follow-up consultation with a surgeon.,past medical history: ,significant for hypertension and hyperlipidemia. in july, she had eye surgery on her left eye for a muscle repair. other surgeries include left ankle surgery for a fractured ankle in 2000.,current medications: , diovan 80/12.5 mg daily, lipitor 10 mg daily, lutein 20 mg daily, folic acid 0.8 mg daily and multivitamin daily.,allergies: ,no known drug allergies.,family history: , notable for heart disease. she had three brothers that died of complications from open heart surgery. her parents and brothers all had hypertension. her younger brother died at the age of 18 of infection from a butcher's shop. he was cutting argentinean beef and contracted an infection and died within 24 hours. she has one brother that is living who has angina and a sister who is 84 with dementia. she has two adult sons who are in good health.,social history: , the patient has been married to her second husband for the past ten years. her first husband died in 1995. she does not have a smoking history and does not drink alcohol.,review of systems: ,the patient reports a change in her bowels ever since she had the stent placed. she has noted some weight loss, but she notes that that is due to not eating very well. she has had some mild fatigue, but prior to her diagnosis she had absolutely no symptoms. as mentioned above, she was noted to have abnormal alkaline phosphatase and total bilirubin, ast and alt, which prompted the followup. she has had some difficulty with her vision that has improved with her recent surgical procedure. she denies any fevers, chills, night sweats. she has had loose stools. the rest of her review of systems is negative.,physical exam:,vitals:

preoperative diagnosis: , cataract to right eye.,postoperative diagnosis: , cataract to right eye.,procedure performed: ,cataract extraction with intraocular lens implant of the right eye, anterior vitrectomy of the right eye.,lens implant used: ,see below.,complications: , posterior capsular hole, vitreous prolapse.,anesthesia: ,topical.,procedure in detail: ,the patient was identified in the preoperative holding area before being escorted back to the operating room suite. hemodynamic monitoring was begun. time-out was called and the patient eye operated upon and lens implant intended were verbally verified. three drops of tetracaine were applied to the operative eye. the patient was then prepped and draped in usual sterile fashion for intraocular surgery. a lid speculum was placed. two paracentesis sites were created approximately 120 degrees apart straddling the temple using a slit knife. the anterior chamber was irrigated with a dilute 0.25% solution of non-preserved lidocaine and filled with viscoat. the clear corneal temporal incision was fashioned. the anterior chamber was entered by introducing a keratome. the continuous tear capsulorrhexis was performed using the bent needle cystotome and completed with utrata forceps. the cataractous lens was then hydrodissected and phacoemulsified using a modified phaco-chop technique. following removal of the last nuclear quadrant, there was noted to be a posterior capsular hole nasally. this area was tamponaded with healon. the anterior chamber was swept with a cyclodialysis spatula and there was noted to be vitreous prolapse. an anterior vitrectomy was then performed bimanually until the vitreous was cleared from the anterior chamber area. the sulcus area of the lens was then inflated using healon and a v9002 16.0 diopter intraocular lens was unfolded and centered in the sulcus area with haptic secured in the sulcus. there was noted to be good support. miostat was injected into the anterior chamber and viscoelastic agent rinsed out of the eye with miostat. gentle bimanual irrigation, aspiration was performed to remove remaining viscoelastic agents anteriorly. the pupil was noted to constrict symmetrically. wounds were checked with weck-cels and found to be free of vitreous. bss was used to re-inflate the anterior chamber to normal depth as confirmed by tactile pressure at about 12. all corneal wounds were then hydrated, checked and found to be watertight and free of vitreous. a single 10-0 nylon suture was placed temporarily as prophylaxis and the knot buried. lid speculum was removed. tobradex ointment, light patch and a soft shield were applied. the patient was taken to the recovery room, awake and comfortable. we will follow up in the morning for postoperative check. he will not be given diamox due to his sulfa allergy. the intraoperative course was discussed with both he and his wife.

history of present illness: , the patient is a 35-year-old woman who reports that on the 30th of october 2008, she had a rupture of her membranes at nine months of pregnancy, and was admitted to hospital and was given an epidural anesthetic. i do not have the records from this hospital admission, but apparently the epidural was administered for approximately 14 to 18 hours. she was sitting up during the epidural.,she did not notice any difference in her lower extremities at the time she had the epidural; however, she reports that she was extremely sleepy and may not have been aware of any change in strength or sensation in her lower extremities at that time. she delivered on the 31st of october, by cesarean section, because she had failed to progress and had pyrexia.,she also had a foley catheter placed at that time. on the 1st of november 2008, they began to mobilize her and it was at that time that she first noticed that she could not walk. she was aware that she could not move her legs at all, and then within a few days, she was aware that she could move toes in the left foot but could not move her right foot at all. since that time, there has been a gradual improvement in strength to the point that she now has limited movement in her left leg and severely restricted movement in her right leg. she is not able to walk by herself, and needs assistance to stand. she was discharged from hospital after the cesarean section on the 3rd of november. unfortunately, we do not have the records and we do not know what the discussion was between the anesthesiologist and the patient at the time of discharge. she was then seen at abc hospital on november 05, 2008. she had an mri scan of her spine, which showed no evidence of an abnormality, specifically there were no cord changes and no evidence of a hematoma. she also had an emg study at that time by dr. x, which was abnormal but not diagnostic and this was repeated again in december. at the present time, she also complains of a pressure in both her legs and in her thighs. she complains that her right foot hurts and that she has some hyperesthesia there. she has been taking gabapentin to try to reduce the discomfort, although she is on a very low dose and the effect is minimal. she has no symptoms in her arms, her bowel and bladder function is normal, and her bulbar function is normal. there is no problem with her vision, swallowing, or respiratory function.,past medical history: , unremarkable except as noted above. she has seasonal allergies.,current medications:, gabapentin 300 mg b.i.d., centrum once a day, and another multivitamin.,allergies: , she has no medication allergies, but does have seasonal allergies.,family history: , there is a family history of diabetes and hypertension. there is no family history of a neuropathy or other neurological disease. she has one child, a son, born on october 31, 2008.,social history: , the patient is a civil engineer, who currently works from home. she is working approximately half time because of limitations imposed on her by her disability, need to attend frequent physical therapy, and also the needs of looking after her baby. she does not smoke and does not drink and has never done either.,general physical examination:,vital signs: p 74, bp 144/75, and a pain score of 0.,general: her general physical examination was unremarkable.,cardiovascular: normal first and second heart sound, regular pulse with normal volume.,respiratory: unremarkable, both lung bases were clear, and respiration was normal.,gi: unremarkable, with no organomegaly and normal bowel sounds.,neurological exam:,mse: the patient's orientation was normal, fund of knowledge was normal, memory was normal, speech was normal, calculation was normal, and immediate and long-term recall was normal. executive function was normal.,cranial nerves: the cranial nerve examination ii through xii was unremarkable. both disks were normal, with normal retina. pupils were equal and reactive to light. eye movements were full. facial sensation and strength was normal. bulbar function was normal. the trapezius had normal strength.,motor: muscle tone showed a slight increase in tone in the lower extremities, with normal tone in the upper extremities. muscle strength was 5/5 in all muscle groups in the upper extremities. in the lower extremities, the hip flexors were 1/5 bilaterally, hip extensors were 1/5 bilaterally, knee extension on the right was 1/5 and on the left was 3-/5, knee flexion was 2/5 on the right and 3-/5 on the left, foot dorsiflexion was 0/5 on the right and 1/5 on the left, foot plantar flexion was 4-/5 on the right and 4+/5 on the left, toe extension was 0/5 on the right and 4-/5 on the left, toe flexion was 4-/5 on the right and 4+/5 on the left.,reflexes: reflexes in the upper extremities were 2+ bilaterally. in the lower extremities, they were 0 bilaterally at the knee and ankles. the abdominal reflexes were present above the umbilicus and absent below the umbilicus. the plantar responses were mute. the jaw reflex was normal.,sensation: vibration was moderately decreased in the right great toe and was mildly decreased in the left great toe. there was a sensory level to light touch at approximately t7 posteriorly and approximately t9 anteriorly. there was a range of sensation, but clearly there was a decrease in sensation below this level but not complete loss of sensation. to pain, the sensory level is even less clear, but appeared to be at about t7 on the right side. in the lower extremities, there was a slight decrease in pin and light touch in the right great toe compared to the left. there was no evidence of allodynia or hyperesthesia. joint position sense was mildly reduced in the right toe and normal on the left.,coordination: coordination for rapid alternating movements and finger-to-nose testing was normal. coordination could not be tested in the lower extremities.,gait: the patient was unable to stand and therefore we were unable to test gait or romberg's. there was no evidence of focal back tenderness.,review of outside records: , i have reviewed the records from abc hospital, including the letter from dr. y and the emg report dated 12/17/2008 from dr. x. the emg report shows evidence of a lumbosacral polyradiculopathy below approximately t6. the lower extremity sensory responses are essentially normal; however, there is a decrease in the amplitude of the motor responses with minimal changes in latency. i do have the mri of lumbar spine report from 11/06/2008 with and without contrast. this showed a minimal concentric disc bulge of l4-l5 without disc herniation, but was otherwise unremarkable. the patient brought a disc with a most recent mri study; however, we were unable to open this on our computers. the verbal report is that the study was unremarkable except for some gadolinium enhancement in the lumbar nerve roots. a doppler of the lower extremities showed no evidence of deep venous thrombosis in either lower extremity. chest x-ray showed some scoliosis on the lumbar spine, curve to the left, but no evidence of other abnormalities. a ct pelvis study performed on november 07, 2008 showed some nonspecific fluid in the subcutaneous fat of the back, posterior to l4 and l5 levels; however, there were no pelvic masses or other abnormalities. we were able to obtain an update of the report from the mri of the lumbar spine with and without contrast dated 12/30/2008. the complete study included the cervical, thoracic, and lumbar spine. there was diffuse enhancement of the nerve roots of the cauda equina that had increased in enhancement since prior exam in november. it was also reported that the patient was given intravenous methylprednisolone and this had had no effect on strength in her lower extremities.,impression: , the patient has a condition that is temporarily related to the epidural injection she was given at the end of october 2008, prior to her cesarean section. it appears she became aware of weakness within two days of the administration of the epidural, she was very tired during the epidural and may have missed some change in her neurological function. she was severely weak in both lower extremities, slightly worse on the right than the left. there has been some interval improvement in her strength since the beginning of november 2008. her emg study from the end of december is most consistent with a lumbosacral polyradiculopathy. the mri findings of gadolinium enhancement in the lumbar nerve roots would be most consistent with an inflammatory radiculitis most likely related to the epidural anesthesia or administration of the epidural. there had been no response to iv methylprednisolone given to her at abc. the issue of having a lumbar puncture to look for evidence of inflammatory cells or an elevated protein had been discussed with her at both abc and by myself. the patient did not wish to consider a lumbar puncture because of concerns that this might worsen her condition. at the present time, she is able to stand with aid but is unable to walk. there is no evidence on her previous emg of a demyelinating neuropathy.,recommendations:,1. the diagnostic issues were discussed with the patient at length. she is informed that this is still early in the course of the problem and that we expect her to show some improvement in her function over the next one to two years, although it is unclear as to how much function she will regain.,2. she is strongly recommended to continue with vigorous physical therapy, and to continue with the plan to mobilize her as much as possible, with the goal of trying to get her ambulatory. if she is able to walk, she will need bilateral afos for her ankles, to improve her overall mobility. i am not prescribing these because at the present time she does not need them.,3. we discussed increasing the dose of gabapentin. the paresthesias that she has may indicate that she is actually regaining some sensory function, although there is a concern that as recovery continues, she may be left with significant neuropathic pain. if this is the case, i have advised her to increase her gabapentin dose from 300 mg b.i.d. gradually up to 300 mg four times a day and then to 600 mg to 900 mg four times a day. she may need other neuropathic pain medications as needed. she will determine whether her current symptoms are significant enough to require this increase in dosage.,4. the patient will follow up with dr. y and his team at abc hospital. she will also continue with physical therapy within the abc system.

indications for procedures: , impending open-heart surgery for atrial septectomy and bilateral bidirectional glenn procedure.,the patient was already under general anesthesia in the operating room. antibiotic prophylaxis with cephazolin and gentamicin were already given. a strict aseptic technique was used including use of gowns, mask, and gloves, etc. the skin was cleansed with alcohol and then prepped with chloraprep solution.,procedure #1:, insertion of central venous line.,description of procedure #1: , attention was directed to the right groin. a cook 4-french double-lumen 12-cm long central venous heparin-coated catheter kit was opened. using the 21-gauge needle that comes with this kit, the needle was inserted approximately 2 cm below the right inguinal ligament just medial to the pulsations of the femoral artery. there was good venous blood return on the first try. using the seldinger technique, the soft j-end of the wire was inserted through the needle without resistance approximately 15 cm. it was then exchanged for a 5-french dilator followed by the 4-french double-lumen catheter and the wire was removed intact. there was good blood return from both lumens, which were flushed with heparinized saline. the catheter was sutured to the skin at three points with #4-0 silk for stabilization.,procedure #2:, insertion of arterial line.,description of procedure #2:, attention was directed to the left wrist, which was placed on wrist rest. the allen test was normal. a cook 2.5-french 5 cm long arterial catheter kit was opened. a 22-gauge iv cannula was used to enter the artery, which was done on the first try with good pulsatile blood return. using the seldinger technique, the catheter was exchanged for a 2.5-french catheter and the wire was removed intact. there was pulsatile blood return and the catheter was flushed with heparinized saline solution. it was sutured to the skin with #4-0 silk at three points for stabilization.,both catheters functioned well throughout the procedure. the distal circulation of the leg and the hand was intact immediately after insertion, approximately 20 minutes later, and at the end of the procedure. there were no complications.,procedure #3: , insertion of transesophageal echocardiography probe.,description of procedure #3: , the probe was inserted under direct vision because initially there was some resistance to insertion. under direct vision, using the #2 miller blade, the upper esophageal opening was visualized and the probe was passed easily without resistance. there was good visualization of the heart. the probe was used by the pediatric cardiologist for preoperative and postoperative diagnostic echocardiography. the probe was removed at the end. there was no trauma and there was no blood tingeing.,

diagnosis: , aortic valve stenosis with coronary artery disease associated with congestive heart failure. the patient has diabetes and is morbidly obese.,procedures: , aortic valve replacement using a mechanical valve and two-vessel coronary artery bypass grafting procedure using saphenous vein graft to the first obtuse marginal artery and left radial artery graft to the left anterior descending artery.,anesthesia: , general endotracheal,incision: , median sternotomy,indications: , the patient presented with severe congestive heart failure associated with the patient's severe diabetes. the patient was found to have moderately stenotic aortic valve. in addition, the patient had significant coronary artery disease consisting of a chronically occluded right coronary artery but a very important large obtuse marginal artery coming off as the main circumflex system. the patient also has a left anterior descending artery which has moderate disease and this supplies quite a bit of collateral to the patient's right system. it was decided to perform a valve replacement as well as coronary artery bypass grafting procedure.,findings: , the left ventricle is certainly hypertrophied· the aortic valve leaflet is calcified and a severe restrictive leaflet motion. it is a tricuspid type of valve. the coronary artery consists of a large left anterior descending artery which is associated with 60% stenosis but a large obtuse marginal artery which has a tight proximal stenosis.,the radial artery was used for the left anterior descending artery. flow was excellent. looking at the targets in the posterior descending artery territory, there did not appear to be any large branches. on the angiogram these vessels appeared to be quite small. because this is a chronically occluded vessel and the patient has limited conduit due to the patient's massive obesity, attempt to bypass to this area was not undertaken. the patient was brought to the operating room,procedure: , the patient was brought to the operating room and placed in supine position. a median sternotomy incision was carried out and conduits were taken from the left arm as well as the right thigh. the patient weighs nearly three hundred pounds. there was concern as to taking down the left internal mammary artery. because the radial artery appeared to be a good conduit the patient would have arterial graft to the left anterior descending artery territory. the patient was cannulated after the aorta and atrium were exposed and full heparinization.,the patient went on cardiopulmonary bypass and the aortic cross-clamp was applied cardioplegia was delivered through the coronary sinuses in a retrograde manner. the patient was cooled to 32 degrees. iced slush was applied to the heart. the aortic valve was then exposed through the aortic root by transverse incision. the valve leaflets were removed and the #23 st. jude mechanical valve was secured into position by circumferential pledgeted sutures. at this point, aortotomy was closed.,the first obtuse marginal artery was a very large target and the vein graft to this target indeed produced an excellent amount of flow. proximal anastomosis was then carried out to the foot of the aorta. the left anterior descending artery does not have severe disease but is also a very good target and the radial artery was anastomosed to this target in an end-to-side manner. the two proximal anastomoses were then carried out to the root of the aorta.,the patient came off cardiopulmonary bypass after aortic cross-clamp was released. the patient was adequately warmed. protamine was given without adverse effect. sternal closure was then done using wires. the subcutaneous layers were closed using vicryl suture. the skin was approximated using staples.

chief complaint: , headache.,history of present illness:, this is a 16-year-old white female who presents here to the emergency department in a private auto with her mother for evaluation of headache. she indicates intense constant right frontal headache, persistent since onset early on monday, now more than 48 hours ago. indicates pressure type of discomfort with throbbing component. it is as high as a 9 on a 0 to 10 scale of intensity. she denies having had similar discomfort in the past. denies any trauma.,review of systems: no fever or chills. no sinus congestion or nasal drainage. no cough or cold symptoms. no head trauma. mild nausea. no vomiting or diarrhea. other systems reviewed and are negative.,pmh: , acne. psychiatric history is unremarkable.,psh: , right knee surgery.,sh: , the patient is single. living at home. no smoking or alcohol.,fh: , noncontributory.,allergies: ,no drug allergies.,medications: , accutane and ovcon.,physical examination:,vitals: temperature of 97.8 degrees f., pulse of 80, respiratory rate of 16, and blood pressure is 131/96.,general: this is a 16-year-old white female. she is awake, alert, and oriented x3. she does appear bit uncomfortable.,head: normocephalic and atraumatic.,eyes: the pupils were equal and reactive to light. extraocular movements are intact.,ent: tms are clear. nose and throat are unremarkable.,neck: there is no evidence of nuchal rigidity. she does, however, have notable tenderness and spasm of the right trapezius and rhomboid muscles when she extends up to the right paracervical muscles. palpation clearly causes having exacerbation of her discomfort.,chest: thorax is unremarkable.,gi: abdomen is nontender.,muscles: extremities are unremarkable.,neuro: cranial nerves ii through xii are grossly intact. motor and sensory are grossly intact. ,skin: skin is warm and dry.,ed course:, the patient was given iv norflex 60 mg, zofran 4 mg, and morphine sulfate 4 mg and with that has significant improvement in her discomfort.,diagnoses:,1. muscle tension cephalgia.,2. right trapezius and rhomboid muscle spasm.,plan: , scripts were given for darvocet-n 100 one every 4 to 6 hours #15, soma one 4 times a day #20. she was instructed to apply warm compresses and perform gentle massage. follow up with regular provider as needed. return if any problems.

hospital course:, the patient is an 1812 g baby boy born by vaginal delivery to a 32-year-old gravida 3, para 2 at 34 weeks of gestation. mother had two previous c-sections. baby was born at 5:57 on 07/30/2006. mother received ampicillin 2 g 4 hours prior to delivery. mother came with preterm contractions, with progressive active labor in spite of the terbutaline and magnesium sulfate. baby was born with apgar scores of 8 and 9 at delivery. fluid was cleared. nuchal cord x1. prenatal was at abc valley. prenatal labs were o positive, antibody negative, rubella immune, rpr nonreactive. baby was suctioned on perineum with good support. the baby was admitted to the nicu for prematurity and to rule out sepsis. baby's cry was good. color, tone, and __________ mild retractions. cbc, crp, blood cultures were done. iv fluids of d10 at a rate of 6 ml an hour. ampicillin and gentamicin were started via protocol. at the time of admission, the patient was stable on room air and has feeding issues. baby was fed ebm 22 and neosure per os. ampicillin and gentamicin were started per protocol but were discontinue when blood cultures came out negative after 48 hours. the patient continues on feeding issues, will not suck properly, was kept in the nicu, and put on og tube for a couple of days after which p.o. feeds were advanced. also, the baby was able to suck properly and was tolerating feeds. the baby was fed ebm 22 and neosure was added a day before discharge. at the time of discharge, baby was stable on room air, baby was tolerated p.o. foods and was sucking properly, was taking ad lib feeds and gaining weight.,admission diagnoses:, respiratory distress, rule out sepsis and prematurity.,discharge diagnoses:, stable, ex-34-week preemie.,pediatrician after discharge will be dr. x.,discharge instructions: , to follow up with dr. x in 2 to 3 days, an appointment was made for 08/14/2006. cpr teaching was completed on 08/11/2006 to parents. formula feeding schedule with breast and neosure 2 to 3 ounces per feed. ad lib feeding on demand.

history of present illness: , the patient is an 18-year-old girl brought in by her father today for evaluation of a right knee injury. she states that approximately 3 days ago while playing tennis she had a non-contact injury in which she injured the right knee. she had immediate pain and swelling. at this time, she complains of pain and instability in the knee. the patient's past medical history is significant for having had an acl injury to the knee in 2008. she underwent anterior cruciate ligament reconstruction by dr. x at that time, subsequently in the same year she developed laxity of the graft due in part to noncompliance and subsequently, she sought attention from dr. y who performed a revision acl reconstruction at the end of 2008. the patient states she rehabbed the knee well after that and did fine with good stability of the knee until this recent injury.,past medical history:, she claims no chronic illnesses.,past surgical history: , she had an anterior cruciate ligament reconstruction in 03/2008, and subsequently had a revision acl reconstruction in 12/2008. she has also had arm surgery when she was 6 years old.,medications: , she takes no medications on a regular basis,allergies: , she is allergic to keflex and has skin sensitivity to steri-strips.,social history: ,the patient is single. she is a full-time student at university. uses no tobacco, alcohol, or illicit drugs. she exercises weekly, mainly tennis and swelling.,review of systems: ,significant for recent weight gain, occasional skin rashes. the remainder of her systems negative.,physical examination,general: the patient is 4 foot 10 inches tall, weighs 110 pounds.,extremities: she ambulates with some difficulty with a marked limp on the right side. inspection of the knee reveals a significant effusion in the knee. she has difficulty with passive range of motion of the knee secondary to pain. she does have tenderness to palpation at the medial joint line and has a positive lachman's exam.,neurovascular: she is neurovascularly intact.,impression: , right knee injury suggestive of a recurrent anterior cruciate ligament tear, possible internal derangement.,plan: , the patient will be referred for an mri of the right knee to evaluate the integrity of her revision acl graft. in the meantime, she will continue to use ice as needed. moderate her activities and use crutches. she will follow up as soon as the mri is performed.

problem list:,1. generalized osteoarthritis and osteoporosis with very limited mobility.,2. adult failure to thrive with history of multiple falls, none recent.,3. degenerative arthritis of the knees with chronic bilateral knee pain.,4. chronic depression.,5. hypertension.,6. hyperthyroidism.,7. aortic stenosis with history of chf and bilateral pleural effusions.,8. right breast mass, slowly enlarging. patient refusing workup.,9. status post orif of the right wrist, now healed.,10. anemia of chronic disease.,11. hypoalbuminemia.,12. chronic renal insufficiency.,current medications:, acetaminophen 325 mg 2 tablets twice daily, coreg 6.25 mg twice daily, docusate sodium 100 mg 1 cap twice daily, ibuprofen 600 mg twice daily with food, lidoderm patch 5% to apply 1 patch to both knees every morning and off in the evening, one vitamin daily, ferrous sulfate 325 mg daily, furosemide 20 mg q.a.m., tapazole 5 mg daily, potassium chloride 10 meq daily, zoloft 50 mg daily, ensure t.i.d., and p.r.n. medications.,allergies:, nkda.,code status:, dnr, healthcare proxy, durable power of attorney.,diet:, regular with regular consistency with thin liquids and ground meat.,restraints: , none. she does have a palm protector in her right hand.,interval history:, no significant change over the past month has occurred. the patient mainly complains about pain in her back. on a scale from 1 to 10, it is 8 to 10, worse at night before she goes to bed. she is requesting something more for the pain. other than that, she complains about her generalized pain. there has been no significant change in her weight. no fever or chills. no complaint of headaches or visual changes, chest pain, shortness of breath, dyspnea on exertion, orthopnea, or pnd. no hemoptysis or night sweats. no change in her bowels, abdominal pain, bright red rectal bleeding, or melena. no nausea or vomiting. her appetite is fair. she is a picky eater but definitely likes her candy. there has been no change in her depression. it seems to be stable on the zoloft 50 mg daily, which she has been on since october 17, 2006. she denies feeling depressed to me but complains of being bored, stating she just sits and watches tv or sometimes may go to activities but not very seldom due to her back pain. no history of seizures. she denies any tremors. she is hyperthyroid and is on replacement.,physical examination: , an elderly female, sitting in a wheelchair, in no acute distress, very kyphotic. she is very pleasant and alert. vital signs per chart. skin is normal in texture and turgor for her age. she does have dry lips, which she picks at and was picking at her lips while i was talking with her. heent: normocephalic, atraumatic. she has nevi above her left eye, which she states she has had since birth and has not changed. pupils are equal, round and reactive to light and accommodation. no exophthalmos or lid lag. anicteric sclerae. conjunctivae pink, nasal passages clear. she is edentulous but does have her upper dentures in. no mucosal ulcerations. external ears normal. neck is supple. no increased jvd, cervical or supraclavicular adenopathy. no thyromegaly or masses. trachea is midline. her chest is very kyphotic, clear to a&p. heart: regular rate and rhythm with a 2-3/6 systolic murmur heard best at the left sternal border. abdomen: soft. good bowel sounds. nontender. unable to appreciate any organomegaly or masses as she is sitting in a wheelchair. extremities are without edema, cyanosis, clubbing, or tremor. she does have lidoderm patches over both of her knees and is wearing a brace in her right hand.,laboratory tests: , albumin was 3.2 on 12/06/06. dietary is aware. electrolytes done 11/28/06, her sodium was 144, potassium 4.4, chloride 109, bicarbonate 26, anion gap 9, bun 28, creatinine 1.2, gfr 44. digoxin was done and was less than 0.9, but she is not on digoxin. cbc showed a white count of 7400, hemoglobin 11.1, hematocrit 35.9, mcv of 95.2, and platelet count of 252,000. her tsh was 1.52. no changes were made in her tapazole.,assessment and plan:, we will continue present therapy except we will add tylenol no. 3 to take 1 tablet before bed as needed for her back pain. if she does develop drowsiness from this, then the cns side effects will help her sleep. during the day, her daughter likes the patient to remain alert and will use the ibuprofen at that time as long as she does not develop any gi symptoms. we will make sure that she is taking the ibuprofen with food. no further laboratory tests will be done at this time.

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

reason for consult: , for evaluation of left-sided chest pain, 5 days post abdominal surgery.,past medical history:, none.,history of present complaint: , this 87-year-old patient has been admitted in this hospital on 12/03/08. the patient underwent laparoscopic appendicectomy by dr. x. the patient had postoperative paralytic ileus, which has resolved. the patient had developed left-sided chest pain yesterday. in the postoperative period, the patient has had fluid retention, had gain about 25 pounds, and he had swelling of the lower extremities.,review of systems:,constitutional symptoms: no recent fever.,ent: unremarkable.,respiratory: he denies cough but develop this left-sided chest pain, which does not increase with inspiration, pain is located on the left posterior axillary line and over the fourth and fifth rib.,cardiovascular: no known heart problems.,gastrointestinal: the patient denies nausea or vomiting. he is status post laparoscopic appendicectomy, and he is tolerating oral diet.,genitourinary: no dysuria, no hematuria.,endocrine: negative for diabetes or thyroid problems.,neurologic: no history of cva or tia.,rest of review of systems unremarkable.,social history: ,the patient is a nonsmoker. he denies use of alcohol.,family history: , noncontributory.,physical examination:,general: an 87-year-old gentleman, not toxic looking.,head and neck: oral mucosa is moist.,chest: clear to auscultation. no wheezing. no crepitations. there is reproducible tenderness over the left posterior-lateral axis.,cardiovascular: first and second heart sounds were heard. no murmurs appreciated.,abdomen: slightly distended. bowel sounds are positive.,extremities: he has 2+ to 3+ pedal swelling.,neurologic: the patient is alert and oriented x3. examination is nonfocal.,laboratory data: , white count is 12,500, hemoglobin is 13, hematocrit is 39, and platelets 398,000. glucose is 123, total protein is 6, and albumin is 2.9.,assessment and plan:,1. ruptured appendicitis. the patient is 6 days post surgery. he is tolerating oral fluids and moving bowels.,2. left-sided chest pain, need to rule out pe by distance of pretty low probability. the patient, however, has low-oxygen saturation. we will do ultrasound of the lower extremity and if this is positive we would proceed with the ct angiogram.,3. fluid retention, manage as per surgeon.,4. paralytic ileus, resolving.,5. leukocytosis, we will monitor.

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

her past medical history includes insulin requiring diabetes mellitus for the past 28 years. she also has a history of gastritis and currently is being evaluated for inflammatory bowel disease. she is scheduled to see a gastroenterologist in the near future. she is taking econopred 8 times a day to the right eye and nevanac, od, three times a day. she is allergic to penicillin.,the visual acuity today was 20/50, pinholing, no improvement in the right eye. in the left eye, the visual acuity was 20/80, pinholing, no improvement. the intraocular pressure was 14, od and 9, os. anterior segment exam shows normal lids, ou. the conjunctiva is quiet in the right eye. in the left eye, she has an area of sectoral scleral hyperemia superonasally in the left eye. the cornea on the right eye shows a paracentral area of mild corneal edema. in the left eye, cornea is clear. anterior chamber in the right eye shows trace cell. in the left eye, the anterior chamber is deep and quiet. she has a posterior chamber intraocular lens, well centered and in sulcus of the left eye. the lens in the left eye shows 3+ nuclear sclerosis. vitreous is clear in both eyes. the optic nerves appear healthy in color and normal in size with cup-to-disc ratio of approximately 0.48. the maculae are flat in both eyes. the retinal periphery is flat in both eyes.,ms. abc is recovering well from her cataract operation in the right eye with residual corneal swelling, which should resolve in the next 2 to 3 weeks. she will continue her current drops. in the left eye, she has an area of what appears to be sectoral scleritis. i did a comprehensive review of systems today and she reports no changes in her pulmonary, dermatologic, neurologic, gastroenterologic or musculoskeletal systems. she is, however, being evaluated for inflammatory bowel disease. the mild scleritis in the left eye may be a manifestation of this. we will notify her gastroenterologist of this possibility of scleritis and will start ms. abc on a course of indomethacin 25 mg by mouth two times a day. i will see her again in one week. she will check with her primary physician prior to starting the indocin.

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

reason for consultation: ,followup of seizures.,history of present illness:, this is a 47-year-old african-american female, well known to the neurology service, who has been referred to me for the first time evaluation of her left temporal lobe epilepsy that was diagnosed in august of 2002. at that time, she had one generalized tonic-clonic seizure. apparently she had been having several events characterized by confusion and feeling unsteady lasting for approximately 60 seconds. she said these events were very paroxysmal in the sense they suddenly came on and would abruptly stop. she had two eegs at that time, one on august 04, 2002 and second on november 01, 2002, both of which showed rare left anterior temporal sharp waves during drowsiness and sleep. she also had an mri done on september 05, 2002, with and without contrast that was negative. her diagnosis was confirmed by dr. x at johns hopkins hospital who reviewed her studies as well as examined the patient and felt that actually her history and findings were consistent with diagnosis of left temporal lobe epilepsy. she was initially started on trileptal, but had some problems with the medication subsequently keppra, which she said made her feel bad and subsequently changed in 2003 to lamotrigine, which she has been taking since then. she reports no seizures in the past several years. she currently is without complaint.,in terms of seizure risk factors she denies head trauma, history of cns infection, history of cva, childhood seizures, febrile seizures. there is no family history of seizures.,past medical history: , significant only for hypertension and left temporal lobe epilepsy.,family history: , remarkable only for hypertension in her father. her mother died in a motor vehicle accident.,social history: ,she works running a day care at home. she has three children. she is married. she does not smoke, use alcohol or illicit drugs.,review of systems: , please see note in chart. only endorses weight gain and the history of seizures, as well as some minor headaches treated with over-the-counter medications.,current medications: ,lamotrigine 150 mg p.o. b.i.d., verapamil, and hydrochlorothiazide.,allergies: , flagyl and aspirin.,physical examination: , blood pressure is 138/88, heart rate is 76, respiratory rate is 18, and weight is 224 pounds, pain scale is none.,general examination: please see note in chart, which is essentially unremarkable except mild obesity.,neurological examination: , again, please see note in chart. mental status is normal, cranial nerves are intact, motor is normal bulk and tone throughout with no weakness appreciated in upper and lower extremities bilaterally. there is no drift and there are no abnormalities to orbit. sensory examination, light touch, and temperature intact at all distal extremities. cerebellar examination, she has normal finger-to-nose, rapid alternating movements, heel-to-shin, and foot tap.,she rises easily from the chair. she has normal step, stride, arm swing, toe, heel, and tandem. deep tendon reflexes are 2 and equal at biceps, brachioradialis, patella, and 1 at the ankles.,she was seen in the emergency room for chest pain one month ago. ct of the head was performed, which i reviewed, dated september 07, 2006. the findings were within the range of normal variation. there is no evidence of bleeding, mass, lesions, or any evidence of atrophy.,impression: , this is a pleasant 47-year-old african-american female with what appears to be cryptogenic left temporal lobe epilepsy that is very well controlled on her current dose of lamotrigine.,plan:,1. continue lamotrigine 150 mg p.o. b.i.d.,2. i discussed with the patient the option of a trial of medications. we need to repeat her eeg as well as her mri prior to weaning her medications. the patient wants to continue her lamotrigine at this time. i concur.,3. the patient will be following up with me in six months.,

preoperative diagnosis: , severe post thoracotomy pain.,postoperative diagnosis: , severe post thoracotomy pain.,procedure: , intercostal block, left.,procedure detail: , with the patient in the icu bed who was having a large amount of intravenous narcotic to control his thoracotomy pain, after obtaining informed consent, his left posterior chest was prepped and draped in the usual fashion and marcaine 0.025% was injected in the spaces four to eight sequentially. a total of 40 ml of marcaine was used.,the patient tolerated the procedure well and experienced immediate benefit out of the procedure.

date of injury : october 4, 2000,date of examination : september 5, 2003,examining physician : x y, md,prior to the beginning of the examination, it is explained to the examinee that this examination is intended for evaluative purposes only, and that it is not intended to constitute a general medical examination. it is explained to the examinee that the traditional doctor-patient relationship does not apply to this examination, and that a written report will be provided to the agency requesting this examination. it has also been emphasized to the examinee that he should not attempt any physical activity beyond his tolerance, in order to avoid injury.,chief complaint: ,aching and mid back pain.,history of present injury: , based upon the examinee's perspective: ,mr. abc is a 52-year-old self-employed, independent consultant for demilee-usa. he is also a mechanical engineer. he reports that he was injured in a motor vehicle accident that occurred in october 4, 2000. at that time, he was employed as a purchasing agent for ibiken-usa. on the date of the motor vehicle accident, he was sitting in the right front passenger's seat, wearing seat and shoulder belt safety harnesses, in his 1996 or 1997 volvo 850 wagon automobile driven by his son. the vehicle was completely stopped and was "slammed from behind" by a van. the police officer, who responded to the accident, told mr. abc that the van was probably traveling at approximately 30 miles per hour at the time of impact.,during the impact, mr. abc was restrained in the seat and did not contact the interior surface of the vehicle. he experienced immediate mid back pain. he states that the volvo automobile sustained approximately $4600 in damage.,he was transported by an ambulance, secured by a cervical collar and backboard to the emergency department. an x-ray of the whole spine was obtained, and he was evaluated by a physician's assistant. he was told that it would be "okay to walk." he was prescribed pain pills and told to return for reevaluation if he experienced increasing pain.,he returned to the kaiser facility a few days later, and physical therapy was prescribed. mr. abc states that he was told that "these things can take a long time." he indicates that after one year he was no better. he then states that after two years he was no better and worried if the condition would never get better.,he indicates he saw an independent physician, a general practitioner, and an mri was ordered. the mri study was completed at abcd hospital. subsequently, mr. abc returned and was evaluated by a physiatrist. the physiatrist reexamined the original thoracic spine x-rays that were taken on october 4, 2000, and stated that he did not know why the radiologist did not originally observe vertebral compression fractures. mr. abc believes that he was told by the physiatrist that it involved either t6-t7 or t7-t8.,mr. abc reports that the physiatrist told him that little could be done besides participation in core strengthening. mr. abc describes his current exercise regimen, consisting of cycling, and it was deemed to be adequate. he was told, however, by the physiatrist that he could also try a pilates type of core exercise program.,the physiatrist ordered a bone scan, and mr. abc is unsure of the results. he does not have a formal follow up scheduled with kaiser, and is awaiting re-contact by the physiatrist.,he denies any previous history of symptomatology or injuries involving his back.,current symptoms: ,he reports that he has the same mid back pain that has been present since the original injury. it is located in the same area, the mid thoracic spine area. it is described as a pain and an ache and ranges from 3/10 to 6/10 in intensity, and the intensity varies, seeming to go in cycles. the pain has been staying constant.,when i asked whether or not the pain have improved, he stated that he was unable to determine whether or not he had experienced improvement. he indicates that there may be less pain, or conversely, that he may have developed more of a tolerance for the pain. he further states that "i can power through it." "i have learned how to manage the pain, using exercise, stretching, and diversion techniques." it is primary limitation with regards to the back pain involves prolonged sitting. after approximately two hours of sitting, he has required to get up and move around, which results in diminishment of the pain. he indicates that prior to the motor vehicle accident, he could sit for significantly longer periods of time, 10 to 12 hours on a regular basis, and up to 20 hours, continuously, on an occasional basis.,he has never experienced radiation of the pain from the mid thoracic spine, and he has never experienced radicular symptoms of radiation of pain into the extremities, numbness, tingling, or weakness.,again, aggravating activities include prolonged sitting, greater than approximately two hours.,alleviating activities include moving around, stretching, and exercising. also, if he takes ibuprofen, it does seem to help with the back pain.,he is not currently taking medications regularly, but list that he takes occasional ibuprofen when the pain is too persistent.,he indicates that he received several physical therapy sessions for treatment, and was instructed in stretching and exercises. he has subsequently performed the prescribed stretching and exercises daily, for nearly three years.,with regards to recreational activities, he states that he has not limited his activities due to his back pain.,he denies bowel or bladder dysfunction.,files review: ,october 4, 2000: an ambulance was dispatched to the scene of a motor vehicle accident on south and partlow road. the ems crew arrived to find a 49-year-old male sitting in the front passenger seat of a vehicle that was damaged in a rear-end collision and appeared to have minimal damage. he was wearing a seatbelt and he denied loss of consciousness. he also denied a pertinent past medical history. they noted pain in the lower cervical area, mid thoracic and lumbar area. they placed him on a backboard and transported him to medical center.,october 4, 2000: he was seen in the emergency department of medical center. the provider is described as "unknown." the history from the patient was that he was the passenger in the front seat of a car that was stopped and rear-ended. he stated that he did not exit the car because of pain in his upper back. he reported he had been wearing the seatbelt and harness at that time. he denied a history of back or neck injuries. he was examined on a board and had a cervical collar in place. he was complaining of mid back pain. he denied extremity weakness. sensory examination was intact. there was no tenderness with palpation or flexion in the neck. the back was a little tender in the upper thoracic spine area without visible deformity. there were no marks on the back. his x-ray was described as "no acute bony process." listed visit diagnosis was a sprain-thoracic, and he was prescribed hydrocodone/acetaminophen tablets and motrin 800 mg tablets.,october 4, 2000: during the visit, a clinician's report of disability document was signed by dr. m, authorizing time loss from october 4, 2000, through october 8, 2000. the document also advised no heavy lifting, pushing, pulling, or overhead work for two weeks. during this visit, a thoracic spine x-ray series, two views, was obtained and read by dr. jr. the findings demonstrate no evidence of acute injury. no notable arthritic findings. the pedicles and paravertebral soft tissues appear unremarkable.,november 21, 2000: an outpatient progress note was completed at kaiser, and the clinician of record was dr. h. the history obtained documents that mr. abc continued to experience the same pain that he first noted after the accident, described as a discomfort in the mid thoracic spine area. it was non-radiating and described as a tightness. he also reported that he was hearing clicking noises that he had not previously heard. he denied loss of strength in the arms. the physical examination revealed good strength and normal deep tendon reflexes in the arms. there was minimal tenderness over t4 through t8, in an approximate area. the visit diagnosis listed was back pain. also described in the assessment was residual pain from mva, suspected bruised muscles. he was prescribed motrin 800 mg tablets and an order was sent to physical therapy. dr. n also documents that if the prescribed treatment measures were not effective, then he would suggest a referral to a physiatrist. also, the doctor wanted him to discuss with physical therapy whether or not they thought that a chiropractor would be beneficial.,december 4, 2000: he was seen at kaiser for a physical therapy visit by philippe justel, physical therapist. the history obtained from mr. abc is that he was not improving. symptoms described were located in the mid back, centrally. the examination revealed mild tenderness, centrally at t3-t8, with very poor segmental mobility. the posture was described as rigid t/s in flexion. range of motion was described as within normal limits, without pain at the cervical spine and thoracic spine. the plan listed included two visits per week for two weeks, for mobilization. it is also noted that the physical therapist would contact the md regarding a referral to a chiropractor.,december 8, 2000: he was seen at kaiser for a physical therapy visit by mr. justel. it was noted that the subjective category of the document revealed that there was no real change. it was noted that mr. abc tolerated the treatment well and that he was to see a chiropractor on monday.,december 11, 2000: he presented to the chiropractic wellness center. there is a form titled 'chiropractic case history,' and it documents that mr. abc was involved in a motor vehicle accident, in which he was rear-ended in october. he has had mid back pain since that time. the pain is worsened with sitting, especially at a computer. the pain decreases when he changes positions, and sometimes when he walks. mr. abc reports that he occasionally takes 800 mg doses of ibuprofen. he reported he went to physical therapy treatment on two occasions, which helped for a few hours only. he did report that he had a previous history of transitory low back pain.,during the visit, he completed a modified oswestry disability questionnaire, and a wc/pi subjective complaint form. he listed complaints of mid and low back pain of a sore and aching character. he rated the pain at grade 3-5/10, in intensity. he reported difficulty with sitting at a table, bending forward, or stooping. he reported that the pain was moderate and comes and goes.,during the visit at the chiropractic wellness center, a spinal examination form was completed. it documents palpation tenderness in the cervical, thoracic, and lumbar spine area and also palpation tenderness present in the suboccipital area, scalenes, and trapezia. active cervical range of motion measured with goniometry reveals pain and restriction in all planes. active thoracic range of motion measured with inclinometry revealed pain and restriction in rotation bilaterally. active lumbosacral range of motion measured with inclinometry reveals pain with lumbar extension, right lateral flexion, and left lateral flexion.,december 11, 2000: he received chiropractic manipulation treatment, and he was advised to return for further treatment at a frequency of twice a week.,december 13, 2000: he returned to the chiropractic wellness center to see joe smith, dc, and it is documented that his middle back was better.,december 13, 2000: a personal injury patient history form is completed at the chiropractic wellness center. mr. abc reported that on october 4, 2000, he was driving his 1996 volvo 850 vehicle, wearing seat and shoulder belt safety harnesses, and completely stopped. he was rear-ended by a vehicle traveling at approximately 30 miles per hour. the impact threw him back into his seat, and he felt back pain and determined that it was not wise to move about. he reported approximate damage to his vehicle of $4800. he reported continuing mid and low back pain, of a dull and semi-intense nature. he reported that he was an export company manager for ibiken-usa, and that he missed two full days of work, and missed 10-plus partial days of work. he stated that he was treated initially after the motor vehicle accident at kaiser and received painkillers and ibuprofen, which relieved the pain temporarily. he specifically denied ever experiencing similar symptoms.,december 26, 2000: a no-show was documented at the chiropractic wellness center.,april 5, 2001: he received treatment at the chiropractic wellness center. he reported that two weeks previously, his mid back pain had worsened.,april 12, 2001: he received chiropractic treatment at the chiropractic wellness center.,april 16, 2001: he did not show up for his chiropractic treatment.,april 19, 2001: he did not show up for his chiropractic treatment.,april 26, 2001: he received chiropractic manipulation treatment at the chiropractic wellness center. he reported that his mid back pain increased with sitting at the computer. at the conclusion of this visit, he was advised to return to the clinic as needed.,september 6, 2002: an mri of the thoracic spine was completed at abcd hospital and read by dr. rl, radiologist. dr. d noted the presence of minor anterior compression of some mid thoracic vertebrae of indeterminate age, resulting in some increased kyphosis. some of the mid thoracic discs demonstrate findings consistent with degenerative disc disease, without a significant posterior disc bulging or disc herniation. there are some vertebral end-plate abnormalities, consistent with small schmorl's nodes, one on the superior aspect of t7, which is compressed anteriorly, and on the inferior aspect of t6.,may 12, 2003: he was seen at the outpatient clinic by dr. l, internal medicine specialist. he was there for a health screening examination, and listed that his only complaints are for psoriasis and chronic mid back pain, which have been present since a 2000 motor vehicle accident. mr. abc reported that an outside mri showed compression fractures in the thoracic spine. the history further documents that mr. abc is an avid skier and volunteers on the ski patrol. the physical examination revealed that he was a middle-aged caucasian male in no acute distress. the diagnosis listed from this visit is back pain and psoriasis. dr. l documented that he spent one hour in the examination room with the patient discussing what was realistic and reasonable with regard to screening testing. dr. l also stated that since mr. abc was experiencing chronic back pain, he advised him to see a physiatrist for evaluation. he was instructed to bring the mri to the visit with that practitioner.,june 10, 2003: he was seen at the physiatry clinic by dr. r, physiatrist. the complaint listed is mid back pain. in the subjective portion of the chart note, dr. r notes that mr. abc is involved in the import/export business, and that he is physically active in cycling, skiing, and gardening. he is referred by dr. l because of persistent lower thoracic pain, following a motor vehicle accident, on october 4, 2000. mr. abc told dr. r that he was the restrained passenger of a vehicle that was rear-ended at a moderate speed. he stated that he experienced immediate discomfort in his thoracic spine area without radiation. he further stated that thoracic spine x-rays were obtained at the sunnyside emergency room and read as normal. it is noted that mr. abc was treated conservatively and then referred to physical therapy where he had a number of visits in late of 2002 and early 2003. no further chart entries were documented about the back problem until mr. abc complained to dr. l that he still had ongoing thoracic spine pain during a visit the previous month. he obtained an mri, out of pocket, at abcd hospital and stated that he paid $1100 for it. dr. r asked to see the mri and was told by mr. abc that he would have to reimburse or pay him $1100 first. he then told the doctor that the interpretation was that he had a t7 and t8 compression fracture. mr. abc reported his improvement at about 20%, compared to how he felt immediately after the accident. he described that his only symptoms are an aching pain that occurs after sitting for four to five hours. if he takes a break from sitting and walks around, his symptoms resolve. he is noted to be able to bike, ski, and be active in his garden without any symptoms at all. he denied upper extremity radicular symptoms. he denied lower extremity weakness or discoordination. he also denied bowel or bladder control or sensation issues. dr. r noted that mr. abc was hostile about the kaiser health plan and was quite uncommunicative, only reluctantly revealing his history. the physical examination revealed that he moved about the examination room without difficulty and exhibited normal lumbosacral range of motion. there was normal thoracic spine motion with good chest expansion. neurovascular examination of the upper extremities was recorded as normal. there was no spasticity in the lower extremities. there was no tenderness to palpation or percussion up and down the thoracic spine. dr. r reviewed the thoracic spine films and noted the presence of "a little compression of what appears to be t7 and t8 on the lateral view." dr. r observed that this was not noted on the original x-ray interpretation. he further stated that the mri, as noted above, was not available for review. dr. r assessed that mr. abc was experiencing minimal thoracic spine complaints that probably related to the motor vehicle accident three years previously. the doctor further stated that "the patient's symptoms are so mild as to almost not warrant intervention." he discussed the need to make sure that mr. abc's workstation was ergonomic and that mr. abc could pursue core strengthening. he further recommended that mr. abc look into participation in a pilates class. mr. abc was insistent, so dr. r made plans to order a bone scan to further discriminate the etiology of his symptoms. he advised mr. abc that the bone scan results would probably not change treatment. as a result of this visit, dr. r diagnosed thoracic spine pain (724.1) and ordered a bone scan study.

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

history of present illness:, briefly, this is a 17-year-old male, who has had problems with dysphagia to solids and recently had food impacted in the lower esophagus. he is now having upper endoscopy to evaluate the esophagus after edema and inflammation from the food impaction has resolved, to look for any stricture that may need to be dilated, or any other mucosal abnormality.,procedure performed: , egd.,prep: , cetacaine spray, 100 mcg of fentanyl iv, and 5 mg of versed iv.,findings:, the tip of the endoscope was introduced into the esophagus, and the entire length of the esophagus was dotted with numerous, white, punctate lesions, suggestive of eosinophilic esophagitis. there were come concentric rings present. there was no erosion or flame hemorrhage, but there was some friability in the distal esophagus. biopsies throughout the entire length of the esophagus from 25-40 cm were obtained to look for eosinophilic esophagitis. there was no stricture or barrett mucosa. the bony and the antrum of the stomach are normal without any acute peptic lesions. retroflexion of the tip of the endoscope in the body of the stomach revealed a normal cardia. there were no acute lesions and no evidence of ulcer, tumor, or polyp. the pylorus was easily entered, and the first, second, and third portions of the duodenum are normal. adverse reactions: none.,final impression: ,esophageal changes suggestive of eosinophilic esophagitis. biopsies throughout the length of the esophagus were obtained for microscopic analysis. there was no evidence of stricture, barrett, or other abnormalities in the upper gi tract.

admitting diagnoses:,1. leiomyosarcoma.,2. history of pulmonary embolism.,3. history of subdural hematoma.,4. pancytopenia.,5. history of pneumonia.,procedures during hospitalization:,1. cycle six of civi-cad (cytoxan, adriamycin, and dtic) from 07/22/2008 to 07/29/2008.,2. cta, chest pe study showing no evidence for pulmonary embolism.,3. head ct showing no evidence of acute intracranial abnormalities.,4. sinus ct, normal mini-ct of the paranasal sinuses.,history of present illness: ,ms. abc is a pleasant 66-year-old caucasian female who first palpated a mass in the left posterior arm in spring of 2007. the mass increased in size and she was seen by her primary care physician and referred to orthopedic surgeon. mri showed inflammation and was thought to be secondary to rheumatoid arthritis. the mass increased in size. she eventually underwent a partial resection found to have pathologic grade 2 leiomyosarcoma, margins were impossible to assess, but were likely positive. she was evaluated by dr. x and dr. y and a decision was made to proceed with preoperative chemotherapy. she began treatment with civi-cad in december 2007. her course was complicated by pulmonary embolus, pneumonia, and subdural hematoma while on anticoagulation. she eventually underwent surgical resection on may 1, 2008 with small area of residual disease, but otherwise clear margins.,hospital course:,1. leiomyosarcoma, the patient was admitted to hem/onco b service under attending dr. xyz for cycle six of continuous iv infusion cytoxan, adriamycin, and dtic, which she tolerated well.,2. history of pulmonary embolism. upon admission, the patient reported an approximate two-week history of dyspnea on exertion and some mild chest pain. she underwent a cta, which showed no evidence of pulmonary embolism and the patient was started on prophylactic doses of lovenox at 40 mg a day. she had no further complaints throughout the hospitalization with any shortness of breath or chest pain.,3. history of subdural hematoma, also on admission the patient noted some mild intermittent headaches that were fleeting in nature, several a day that would resolve on their own. her headaches were not responding to pain medication and so on 07/24/2008, we obtained a head ct that showed no evidence of acute intracranial abnormalities. the patient also had a history of sinusitis and so a sinus ct scan was obtained, which was normal.,4. pancytopenia. on admission, the patient's white blood count was 3.4, hemoglobin 11.3, platelet count 82, and anc of 2400. the patient's counts were followed throughout admission. she did not require transfusion of red blood cells or platelets; however, on 07/26/2008 her anc did dip to 900 and she was placed on neutropenic diet. at discharge her anc is back up to 1100 and she is taken off neutropenic diet. her white blood cell count at discharge was 1.4 and her hemoglobin was 11.2 with a platelet count of 140.,5. history of pneumonia. during admission, the patient did not exhibit any signs or symptoms of pneumonia.,disposition: , home in stable condition.,diet: , regular and less neutropenic.,activity: , resume same activity.,followup: ,the patient will have lab work at dr. xyz on 08/05/2008 and she will also return to the cancer center on 08/12/2008 at 10:20 a.m. the patient is also advised to monitor for any fevers greater than 100.5 and should she have any further problems in the meantime to please call in to be seen sooner.

cc:, sudden onset blindness.,hx:, this 58 y/o rhf was in her usual healthy state, until 4:00pm, 1/8/93, when she suddenly became blind. tongue numbness and slurred speech occurred simultaneously with the loss of vision. the vision transiently improved to "severe blurring" enroute to a local er, but worsened again once there. while being evaluated she became unresponsive, even to deep noxious stimuli. she was transferred to uihc for further evaluation. upon arrival at uihc her signs and symptoms were present but markedly improved.,pmh:, 1) hysterectomy many years previous. 2) herniorrhaphy in past. 3) djd, relieved with nsaids.,fhx/shx:, married x 27yrs. husband denied tobacco/etoh/illicit drug use for her.,unremarkable fhx.,meds:, none.,exam:, vitals: 36.9c. hr 93. bp 151/93. rr 22. 98% o2sat.,ms: somnolent, but arousable to verbal stimulation. minimal speech. followed simple commands on occasion.,cn: blinked to threat from all directions. eom appeared full, pupils 2/2 decreasing to 1/1. +/+corneas. winced to pp in all areas of face. +/+gag. tongue midline. oculocephalic reflex intact.,motor: ue 4/5 proximally. full strength in all other areas. normal tone and muscle bulk.,sensory: withdrew to pp in all extremities.,gait: nd.,reflexes: 2+/2+ throughout ue, 3/3 patella, 2/2 ankles, plantar responses were flexor bilaterally.,gen exam: unremarkable.,course: ,mri brain revealed bilateral thalamic strokes. transthoracic echocardiogram (tte) showed an intraatrial septal aneurysm with right to left shunt. transesophageal echocardiogram (tee) revealed the same. no intracardiac thrombus was found. lower extremity dopplers were unremarkable. carotid duplex revealed 0-15% bilateral ica stenosis. neuroophthalmologic evaluation revealed evidence of a supranuclear vertical gaze palsy ou (diminished up and down gaze). neuropsychologic assessment 1/12-15/93 revealed severe impairment of anterograde verbal and visual memory, including acquisition and delayed recall and recognition. speech was effortful and hypophonic with very defective verbal associative fluency. reading comprehension was somewhat preserved, though she complained that despite the ability to see type clearly, she could not make sense of words. there was impairment of 2-d constructional praxis. a follow-up neuropsychology evaluation in 7/93 revealed little improvement. laboratory studies, tsh, ft4, crp, esr, gs, pt/ptt were unremarkable. total serum cholesterol 195, triglycerides 57, hdl 43, ldl 141. she was placed on asa and discharged1/19/93.,she was last seen on 5/2/95 and was speaking fluently and lucidly. she continued to have mild decreased vertical eye movements. coordination and strength testing were fairly unremarkable. she continues to take asa 325 mg qd.

preoperative diagnosis: , esophageal foreign body.,postoperative diagnosis:, esophageal foreign body, us penny.,procedure: , esophagoscopy with foreign body removal.,anesthesia: , general.,indications: , the patient is a 17-month-old baby girl with biliary atresia, who had a delayed diagnosis and a late attempted kasai portoenterostomy, which failed. the patient has progressive cholestatic jaundice and is on the liver transplant list at abcd. the patient is fed by mouth and also with nasogastric enteral feeding supplements. she has had an __________ cough and relatively disinterested in oral intake for the past month. she was recently in the gi clinic and an x-ray was ordered to check her tube placement and an incidental finding of a coin in the proximal esophagus was noted. based on the history, it is quite possible this coin has been there close to a month. she is brought to the operating room now for attempted removal. i met with the parents and talked to them at length about the procedure and the increased risk in a child with a coin that has been in for a prolonged period of time. hopefully, there will be no coin migration or significant irrigation that would require prolonged hospitalization.,operative findings: , the patient had a penny lodged in the proximal esophagus in the typical location. there was no evidence of external migration and surrounding irritation was noted, but did not appear to be excessive. the coin actually came out with relative ease after which endoscopically identified.,description of operation: , the patient came to the operating room and had induction of general anesthesia. she was slow to respond to the usual propofol and other inducing agents and may be has some difficulty with tolerance or __________ tolerance to these medications. after her endotracheal tube was placed and securely taped to the left side of her mouth, i positioned the patient with a prominent shoulder roll and neck hyperextension and then used the laryngoscope to elevate the tiny glottic mechanism. a rigid esophagoscope was then inserted into the proximal esophagus, and the scope was gradually advanced with the lumen directly in frontal view. this was facilitated by the nasoenteric feeding tube that was in place, which i followed carefully until the edge of the coin could be seen. at this location, there was quite a bit of surrounding mucosal inflammation, but the coin edge could be clearly seen and was secured with the coin grasping forceps. i then withdrew the scope, forceps, and the coin as one unit, and it was easily retrieved. the patient tolerated the procedure well. there were no intraoperative complications. there was only one single coin noted, and she was awakened and taken to the recovery room in good condition.

chief complaint:, altered mental status.,history of present illness:, the patient is a 69-year-old male transferred from an outlying facility with diagnosis of a stroke. history is taken mostly from the emergency room record. the patient is unable to give any history and no family member is present for questioning. when asked why he came to the emergency room, the patient replies that it started about 2 pm yesterday. however, he is unable to tell me exactly what started at 2 pm yesterday. the patient's speech is clear, but he speaks nonsensically using words in combinations that don't make any sense. no other history of present illness is available.,past medical history:, per the emergency room record, significant for atrial fibrillation, hypertension, and hyperlipidemia.,past surgical history:, unknown.,family history:, unknown.,social history:, the patient denies smoking and drinking.,medications:, per the emergency room record, medications are lotensin 20 mg daily, toprol 50 mg daily, plavix 75 mg daily and aspirin 81 mg daily.,allergies:, unknown.,review of systems:, unobtainable secondary to the patient's condition.,physical examination:,vital signs: temperature: 97.9. pulse: 79. respiratory rate: 20. blood pressure: 117/84.,general: well-developed, well-nourished male in no acute distress.,heent: eyes: pupils are equal, round and reactive. there is no scleral icterus. ears, nose and throat: his oropharynx is moist. his hearing is normal.,neck: no jvd. no thyromegaly.,cardiovascular: irregular rhythm. no lower extremity edema.,respiratory: clear to auscultation bilaterally with normal effort.,abdomen: nontender. nondistended. bowel sounds are positive.,musculoskeletal: there is no clubbing of the digits. the patient's strength is 5/5 throughout.,neurological: babinski's are downgoing bilaterally. deep tendon reflexes are 2+ throughout.,laboratory data:, by report, head ct from the outlying facility was negative. an ekg showed atrial fibrillation with a rate of 75. there is no indication of any acute cardiac ischemia. a chest x-ray shows no acute pulmonary process, but does show cardiomegaly.,labs are as follows: white count 9.4, hemoglobin 17.2, hematocrit 52.5, platelet count 219. ptt 24, pt 13, inr 0.96. sodium 135, potassium 3.6, chloride 99, bicarb 27, bun 13, creatinine 1.4, glucose 161, calcium 9, magnesium 1.9, total protein 7, albumin 3.7, ast 22, alt 41, alkaline phosphatase 85, total bilirubin 0.7, total cholesterol 193. cardiac isoenzymes are negative times one with a troponin of 0.09.,assessment and plan:,1. probable stroke. the patient has an expressive aphasia. he does not have dysarthria, however. also, his strength is not affected. i suspect that the patient has had strokes or tias in the past because he was taking aspirin and plavix at home. head ct is reportedly negative. i will ask our radiologist to re-read the head ct. i will also order mri and mra, carotid doppler ultrasound and echocardiogram in addition to a fasting lipid profile. i will consult neurology to evaluate and continue his aspirin and plavix.,2. atrial fibrillation. the patient's rate is controlled currently. i will continue him on his amiodarone 200 mg twice daily and consult chi to evaluate him.,3. hypertension. i will continue his home medications and add clonidine as needed.,4. hyperlipidemia. the patient takes no medications for this currently. i will check a fasting lipid profile.,5. hyperglycemia. it is unknown whether the patient has a history of diabetes. his glucose is currently 171. i will start him on sliding scale insulin for now and monitor closely.,6. renal insufficiency. it is also unknown whether the patient has a history of this and what his baseline creatinine might be. currently he has only mild renal insufficiency. this does not appear to be prerenal. will monitor for now.

indication: ,chest pain.,interpretation: , resting heart rate of 71, blood pressure 100/60. ekg normal sinus rhythm. the patient exercised on bruce for 8 minutes on stage iii. peak heart rate was 151, which is 87% of the target heart rate, blood pressure of 132/54. total mets was 10.1. ekg revealed nonspecific st depression in inferior and lateral leads. the test was terminated because of fatigue. the patient did have chest pain during exercise that resolved after termination of the exercise.,in summary:,1. positive exercise ischemia with st depression 0.5 mm.,2. chest pain resolved after termination of exercise.,3. good exercise duration, tolerance and double product.,nuclear interpretation:,resting and stress images were obtained with 10.1 mci and 34.1 mci of tetraphosphate injected intravenously by standard protocol. nuclear myocardial perfusion scan demonstrates homogenous and uniform distribution with tracer uptake without any evidence of reversible or fixed defect. gated spect revealed normal wall motion, ejection fraction of 68%. end-diastolic volume of 77, end-systolic volume of 24.,in summary:,1. normal nuclear myocardial perfusion scan.,2. ejection fraction of 68% by gated spect.

procedure performed:, picc line insertion.,description of procedure:, the patient was identified by myself on presentation to the angiography suite. his right arm was prepped and draped in sterile fashion from the antecubital fossa up. under ultrasound guidance, a #21-gauge needle was placed into his right cephalic vein. a guidewire was then threaded through the vein and advanced without difficulty. an introducer was then placed over the guidewire. we attempted to manipulate the guidewire to the superior vena cava; however, we could not pass the point of the subclavian vein and we tried several maneuvers and then opted to do a venogram. what we did was we injected approximately 4 ml of visipaque 320 contrast material through the introducer and did a mapping venogram and it turned out that the cephalic vein was joining into the subclavian vein. it was very tortuous area. we made several more attempts using the mapping system to pass the glide over that area, but we were unable to do that. decision was made at that point then to just do a midline catheter. the catheter was cut to 20 cm, then we inserted back to the introducer. the introducer was removed. the catheter was secured by two #3-0 silk sutures. appropriate imaging was then taken. sterile dressing was applied. the patient tolerated the procedure nicely and was discharged from angiography in satisfactory condition back to the general floor. we may make another attempt in the near future using a different approach.,

preoperative diagnosis:, diarrhea, suspected irritable bowel.,postoperative diagnosis:, normal colonoscopy., premedications: , versed 5 mg, demerol 75 mg iv.,reported procedure:, the rectal exam revealed no external lesions. the prostate was normal in size and consistency.,the colonoscope was inserted into the cecum with ease. the cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, sigmoid colon, and rectum were normal. the scope was retroflexed in the rectum and no abnormality was seen, so the scope was straightened, withdrawn, and the procedure terminated.,endoscopic impression:, normal colonoscopy - no evidence of inflammatory disease, polyp, or other neoplasm. these findings are certainly consistent with irritable bowel syndrome.

history of present illness:, patient is a three years old male who about 45 minutes prior admission to the emergency room ingested about two to three tablets of celesta 40 mg per tablets. mom called to the poison control center and the recommendation was to take the patient to the emergency room and be evaluated. the patient was alert and did not vomit during the transport to the emergency room. mom left the patient and his little one-year-old brother in the room by themselves and she went outside of the house for a couple of minutes, and when came back, she saw the patient having the celesta foils in his hands and half of tablet was moist and on the floor. the patient said that the pills "didn't taste good," so it is presumed that the patient actually ingested at least two-and-a-half tablets of celesta, 40 mg per tablet.,past medical history:, baby was born premature and he required hospitalization, but was not on mechanical ventilation. he doesn't have any hospitalizations after the new born. no surgeries.,immunizations: , up-to-date.,allergies: , not known drug allergies.,physical examination,vital signs: temperature 36.2 celsius, pulse 112, respirations 24, blood pressure 104/67, weight 15 kilograms.,general: alert, in no acute distress.,skin: no rashes.,heent: head: normocephalic, atraumatic. eyes: eomi, perrl. nasal mucosa clear. throat and tonsils, normal. no erythema, no exudates.,neck: supple, no lymphadenopathy, no masses.,lungs: clear to auscultation bilateral.,heart: regular rhythm and rate without murmur. normal s1, s2.,abdomen: soft, nondistended, nontender, present bowel sounds, no hepatosplenomegaly, no masses.,extremities: warm. capillary refill brisk. deep tendon reflexes present bilaterally.,neurological: alert. cranial nerves ii through xii intact. no focal exam. normal gait.,radiographic data: , patient has had an ekg done at the admission and it was within normal limits for the age.,emergency room course: , patient was under observation for 6 hours in the emergency room. he had two more ekgs during observation in the emergency room and they were all normal. his vital signs were monitored every hour and were within normal limits. there was no vomiting, no diarrhea during observation. patient did not receive any medication or has had any other lab work besides the ekg.,assessment and plan: , three years old male with accidental ingestion of celesta. discharged home with parents, with a followup in the morning with his primary care physician.

indication: , paroxysmal atrial fibrillation.,history of present illness: ,the patient is a pleasant 55-year-old white female with multiple myeloma. she is status post chemotherapy and autologous stem cell transplant. latter occurred on 02/05/2007. at that time, she was on telemetry monitor and noticed to be in normal sinus rhythm.,as part of study protocol for investigational drug for prophylaxis against mucositis, she had electrocardiogram performed on 02/06/2007. this demonstrated underlying rhythm of atrial fibrillation with rapid ventricular response at 125 beats per minute. she was subsequently transferred to telemetry for observation. cardiology consultation was requested. prior to formal consultation, the patient did have an echocardiogram performed on 02/06/2007, which showed a structurally normal heart with normal left ventricular (lv) systolic function, ejection fraction of 60%, aortic sclerosis without stenosis, a trivial pericardial effusion with no evidence for immunocompromise and mild tricuspid regurgitation with normal pulmonary atrial pressures. overall, essentially normal heart.,at the time of my evaluation, the patient felt somewhat jittery and nervous, but otherwise asymptomatic.,past medical history:, multiple myeloma, diagnosed in june of 2006, status post treatment with thalidomide and coumadin. subsequently, with high-dose chemotherapy followed by autologous stem cell transplant.,past surgical history: , cosmetic surgery of the nose and forehead.,allergies:, no known drug allergies.,current medications,1. acyclovir 400 mg p.o. b.i.d.,2. filgrastim 300 mcg subcutaneous daily.,3. fluconazole 200 mg daily.,4. levofloxacin 250 mg p.o. daily.,5. pantoprazole 40 mg daily.,6. ursodiol 300 mg p.o. b.i.d.,7. investigational drug is directed ondansetron 24 mg p.r.n.,family history: , unremarkable. father and mother both alive in their mid 70s. father has an unspecified heart problem and diabetes. mother has no significant medical problems. she has one sibling, a 53-year-old sister, who has a pacemaker implanted for unknown reasons.,social history: , the patient is married. has four adult children. good health. she is a lifetime nonsmoker, social alcohol drinker.,review of systems: , prior to treatment for her multiple myeloma, she was able to walk four miles nonstop. currently, she has dyspnea on exertion on the order of one block. she denies any orthopnea or paroxysmal nocturnal dyspnea. she denies any lower extremity edema. she has no symptomatic palpitations or tachycardia. she has never had presyncope or syncope. she denies any chest pain whatsoever. she denies any history of coagulopathy or bleeding diathesis. her oncologic disorder is multiple myeloma. pulmonary review of systems is negative for recurrent pneumonias, bronchitis, reactive airway disease, exposure to asbestos or tuberculosis. gastrointestinal (gi) review of systems is negative for known gastroesophageal reflux disease, gi bleed, and hepatobiliary disease. genitourinary review of systems is negative for nephrolithiasis or hematuria. musculoskeletal review of systems is negative for significant arthralgias or myalgias. central nervous system (cns) review of systems is negative for tic, tremor, transient ischemic attack (tia), seizure, or stroke. psychiatric review of systems is negative for known affective or cognitive disorders.,physical examination,general: this is a well-nourished, well-developed white female who appears her stated age and somewhat anxious.,vital signs: she is afebrile at 97.4 degrees fahrenheit with a heart rate ranging from 115 to 150 beats per minute, irregularly irregular. respirations are 20 breaths per minute and blood pressure ranges from 90/59 to 107/68 mmhg. oxygen saturation on room air is 94%.,heent: benign being normocephalic and atraumatic. extraocular motions are intact. her sclerae are anicteric and conjunctivae are noninjected. oral mucosa is pink and moist.,neck: jugular venous pulsations are normal. carotid upstrokes are palpable bilaterally. there is no audible bruit. there is no lymphadenopathy or thyromegaly at the base of the neck.,chest: cardiothoracic contour is normal. lungs, clear to auscultation in all lung fields.,cardiac: irregularly irregular rhythm and rate. s1, s2 without a significant murmur, rub, or gallop appreciated. point of maximal impulse is normal, no right ventricular heave.,abdomen: soft with active bowel sounds. no organomegaly. no audible bruit. nontender.,lower extremities: nonedematous. femoral pulses were deferred.,laboratory data: , ekg, electrocardiogram showed underlying rhythm of atrial fibrillation with a rate of 125 beats per minute. nonspecific st-t wave abnormality is seen in the inferior leads only.,white blood cell count is 9.8, hematocrit of 30 and platelets 395. inr is 0.9. sodium 136, potassium 4.2, bun 43 with a creatinine of 2.0, and magnesium 2.9. ast and alt 60 and 50. lipase 343 and amylase 109. bnp 908. troponin was less than 0.02.,impression: , a middle-aged white female undergoing autologous stem cell transplant for multiple myeloma, now with paroxysmal atrial fibrillation.,currently enrolled in a blinded study, where she may receive a drug for prophylaxis against mucositis, which has at least one reported incident of acceleration of preexisting tachycardia.,recommendations,1. atrial fibrillation. the patient is currently hemodynamically stable, tolerating her dysrhythmia. however, given the risk of thromboembolic complications, would like to convert to normal sinus rhythm if possible. given that she was in normal sinus rhythm approximately 24 hours ago, this is relatively acute onset within the last 24 hours. we will initiate therapy with amiodarone 150 mg intravenous (iv) bolus followed by mg/minute at this juncture. if she does not have spontaneous cardioversion, we will consider either electrical cardioversion or anticoagulation with heparin within 24 hours from initiation of amiodarone.,as part of amiodarone protocol, please check tsh. given her preexisting mild elevation of transaminases, we will follow lfts closely, while on amiodarone.,2. thromboembolic risk prophylaxis, as discussed above. no immediate indication for anticoagulation. if however she does not have spontaneous conversion within the next 24 hours, we will need to initiate therapy. this was discussed with dr. x. preference would be to run intravenous heparin with ptt of 45 during her thrombocytopenic nadir and initiation of full-dose anticoagulation once nadir is resolved.,3. congestive heart failure. the patient is clinically euvolemic. elevated bnp possibly secondary to infarct or renal insufficiency. follow volume status closely. follow serial bnps.,4. followup. the patient will be followed while in-house, recommendations made as clinically appropriate.

exam:, ct abdomen & pelvis w&wo contrast, ,reason for exam: , status post aortobiiliac graft repair. , ,technique: , 5 mm spiral thick spiral ct scanning was performed through the entire abdomen and pelvis utilizing intravenous dynamic bolus contrast enhancement. no oral or rectal contrast was utilized. comparison is made with the prior ct abdomen and pelvis dated 10/20/05. there has been no significant change in size of the abdominal aortic aneurysm centered roughly at the renal artery origin level which has dimensions of 3.7 cm transversely x 3.4 ap. just below this level is the top of the endoluminal graft repair with numerous surrounding surgical clips. the size of the native aneurysm component at this level is stable at 5.5 cm in diameter with mural thrombus surrounding the enhancing endolumen. there is no abnormal entrance of contrast agent into the mural thrombus to indicate an endoluminal leak. further distally, there is extension of the graft into both proximal common iliac arteries without evidence for endoluminal leak at this level either. no exoluminal leakage is identified at any level. there is no retroperitoneal hematoma present. the findings are unchanged from the prior exam. ,the liver, spleen, pancreas, adrenals and right kidney are unremarkable with moderate diffuse atrophy of the pancreas present. there is advanced atrophy of the left kidney. no hydronephrosis is present. no acute findings are identified elsewhere in the abdomen. ,the lung bases are clear. ,concerning the remainder of the pelvis, no acute pathology is identified. there is prominent streak artifact from the left total hip replacement. there is diffuse moderate sigmoid diverticulosis without evidence for diverticulitis. the bladder grossly appears normal. a hysterectomy has been performed. ,impression:,1. no complications identified regarding endoluminal aortoiliac graft repair as described. the findings are stable compared to the study of 10/20/04. ,2. stable mild aneurysm of aortic aneurysm, centered roughly at renal artery level. ,3. no other acute findings noted. ,4. advanced left renal atrophy.

procedure performed:,1. right heart catheterization.,2. left heart catheterization.,3. left ventriculogram.,4. aortogram.,5. bilateral selective coronary angiography.,anesthesia:, 1% lidocaine and iv sedation including versed 1 mg.,indication:, the patient is a 48-year-old female with severe mitral stenosis diagnosed by echocardiography, moderate aortic insufficiency and moderate to severe pulmonary hypertension who is being evaluated as a part of a preoperative workup for mitral and possible aortic valve repair or replacement. she has had atrial fibrillation and previous episodes of congestive heart failure. she has dyspnea on exertion and occasionally orthopnea and paroxysmal nocturnal dyspnea.,procedure:, after the risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient in detail, informed consent was obtained, both verbally and in writing. the patient was taken to the cardiac catheterization lab where the procedure was performed. the right inguinal area was thoroughly cleansed with betadine solution and the patient was draped in the usual manner. 1% lidocaine solution was used to anesthetize the right inguinal area. once adequate anesthesia had been attained, a thing wall argon needle was used to cannulate the right femoral vein. a guidewire was advanced into the lumen of the vein without resistance. the needle was removed and the guidewire was secured to the sterile field. the needle was flushed and then used to cannulate the right femoral artery. a guidewire was advanced through the lumen of the needle without resistance. a small nick was made in the skin and the needle was removed. this pressure was held. a #6 french arterial sheath was advanced over the guidewire without resistance. the dilator and guidewire were removed. fio2 sample was obtained and the sheath was flushed. an #8 french sheath was advanced over the guidewire into the femoral vein after which the dilator and guidewire were removed and the sheath was flushed. a swan-ganz catheter was advanced through the venous sheath into a pulmonary capillary was positioned and the balloon was temporarily deflated. an angulated pigtail catheter was advanced into the left ventricle under direct fluoroscopic visualization with the use of a guidewire. the guidewire was removed. the catheter was connected to a manifold and flushed. left ventricular pressures were continuously measured and the balloon was re-inflated and pulmonary capillary wedge pressure was remeasured. using dual transducers together and the mitral valve radius was estimated. the balloon was deflated and mixed venous sample was obtained. hemodynamics were measured. the catheter was pulled back in to the pulmonary artery right ventricle and right atrium. the right atrial sample was obtained and was negative for shunt. the swan-ganz catheter was then removed and a left ventriculogram was performed in the rao projection with a single power injection of non-ionic contrast material. pullback was then performed which revealed a minimal lv-ao gradient. since the patient had aortic insufficiency on her echocardiogram, an aortogram was performed in the lao projection with a single power injection of non-ionic contrast material. the pigtail catheter was then removed and a judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. the guidewire was removed. the catheter was connected to the manifold and flushed. the ostium of the left main coronary artery was carefully engaged. using multiple hand injections of non-ionic contrast material, the left coronary system was evaluated in different views. this catheter was then removed and a judkins right #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire. the guidewire was removed. the catheter was connected to the manifold and flushed. the ostium of the right coronary artery was then engaged and using hand injections of non-ionic contrast material, the right coronary system was evaluated in different views. this catheter was removed. the sheaths were flushed final time. the patient was taken to the postcatheterization holding area in stable condition.,findings:,hemodynamics: , right atrial pressure 9 mmhg, right ventricular pressure is 53/14 mmhg, pulmonary artery pressure 62/33 mmhg with a mean of 46 mmhg. pulmonary capillary wedge pressure is 29 mmhg. left ventricular end diastolic pressure was 13 mmhg both pre and post left ventriculogram. cardiac index was 2.4 liters per minute/m2. cardiac output 4.0 liters per minute. the mitral valve gradient was 24.5 and mitral valve area was calculated to be 0.67 cm2. the aortic valve area is calculated to be 2.08 cm2.,left ventriculogram: , no segmental wall motion abnormalities were noted. the left ventricle was somewhat hyperdynamic with an ejection fraction of 70%. 2+ to 3+ mitral regurgitation was noted.,aortogram: , there was 2+ to 3+ aortic insufficiency noted. there was no evidence of aortic aneurysm or dissection.,left main coronary artery: , this was a moderate caliber vessel and it is rather long. it bifurcates into the lad and left circumflex coronary artery. no angiographically significant stenosis is noted.,left anterior descending artery:, the lad begins as a moderate caliber vessel ________ anteriorly in the intraventricular groove. it tapers in its mid portion to become small caliber vessel. luminal irregularities are present, however, no angiographically significant stenosis is noted.,left circumflex coronary artery: , the left circumflex coronary artery begins as a moderate caliber vessel. small obtuse marginal branches are noted and this is the nondominant system. lumen irregularities are present throughout the circumflex system. however no angiographically significant stenosis is noted.,right coronary artery: , this is the moderate caliber vessel and it is the dominant system. no angiographically significant stenosis is noted, however, mild luminal irregularities are noted throughout the vessel.,impression:,1. nonobstructive coronary artery disease.,2. severe mitral stenosis.,3. 2+ to 3+ mitral regurgitation.,4. 2+ to 3+ aortic insufficiency.

preoperative diagnoses:,1. right renal mass.,2. hematuria.,postoperative diagnoses:,1. right renal mass.,2. right ureteropelvic junction obstruction.,procedures performed:,1. cystourethroscopy.,2. right retrograde pyelogram.,3. right ureteral pyeloscopy.,4. right renal biopsy.,5. right double-j 4.5 x 26 mm ureteral stent placement.,anesthesia: , sedation.,specimen: , urine for cytology and culture sensitivity, right renal pelvis urine for cytology, and right upper pole biopsies.,indication:, the patient is a 74-year-old male who was initially seen in the office with hematuria. he was then brought to the hospital for other medical problems and found to still have hematuria. he has a cat scan with abnormal appearing right kidney and it was felt that he will benefit from cystoscope evaluation.,procedure: ,after consent was obtained, the patient was brought to the operating room and placed in the supine position. he was given iv sedation and placed in dorsal lithotomy position. he was then prepped and draped in the standard fashion. a #21 french cystoscope was then passed through his ureter on which patient was noted to have a hypospadias and passed through across the ends of the bladder. the patient was noted to have mildly enlarged prostate, however, it was non-obstructing.,upon visualization of the bladder, the patient was noted to have some tuberculation to the bladder. there were no masses or any other abnormalities noted other than the tuberculation. attention was then turned to the right ureteral orifice and an open-end of the catheter was then passed into the right ureteral orifice. a retrograde pyelogram was performed. upon visualization, there was no visualization of the upper collecting system on the right side. at this point, a guidewire was then passed through the open-end of the ureteral catheter and the catheter was removed. the bladder was drained and the cystoscope was removed. the rigid ureteroscope was then passed into the bladder and into the right ureteral orifice with the assistance of a second glidewire. the ureteroscope was taken all the way through the proximal ureter just below the upj and there were noted to be no gross abnormalities. the ureteroscope was removed and an amplatz wire then passed through the scope up into the collecting system along the side of the previous wire. the ureteroscope was removed and a ureteral dilating sheath was passed over the amplatz wire into the right ureter under fluoroscopic guidance. the amplatz wire was then removed and the flexible ureteroscope was passed through the sheath into the ureter. the ureteroscope was passed up to the upj at which point there was noted to be difficulty entering the ureter due to upj obstruction. the wire was then again passed through the flexible scope and the flexible scope was removed. a balloon dilator was then passed over the wire and the upj was dilated with balloon dilation. the dilator was then removed and again the cystoscope was passed back up into the right ureter and was able to enter the collecting system. upon visualization of the collecting system of the upper portion, there was noted to be papillary mass within the collecting system. the ________ biopsy forceps were then passed through the scope and two biopsies were taken of the papillary mass. once this was done, the wire was left in place and the ureteroscope was removed. the cystoscope was then placed back into the bladder and a 26 x 4.5 mm ureteral stent was passed over the wire under fluoroscopic and cystoscopic guidance into the right renal pelvis. the stent was noted to be clear within the right renal pelvis as well as in the bladder. the bladder was drained and the cystoscope was removed. the patient tolerated the procedure well. he will be transferred to the recovery room and back to his room. it has been discussed with his primary physician that the patient will likely need a nephrectomy. he will be scheduled for an echocardiogram tomorrow and then decision will be made where the patient will be stable for possible nephrectomy on wednesday.

preoperative diagnosis: , dental caries.,postoperative diagnosis:, dental caries.,procedure: , dental restoration.,clinical history: ,this 2-year, 10-month-old male has not had any prior dental treatment because of his unmanageable behavior in a routine dental office setting. he was referred to me for that reason to be treated under general anesthesia for his dental work. cavities have been noted by his parents and pediatrician that have been noted to be pretty severe. there are no contraindications to this procedure. he is healthy. his history and physical is in the chart.,procedure: ,the patient was brought to the operating room at 10:15 and placed in the supine position. dr. x administered the general anesthetic after which 2 bite-wing and 2 periapical x-rays were exposed and developed and his teeth were examined. a throat pack was then placed. tooth d had caries on the distal surface which was excavated and the tooth was restored with composite. teeth e and f had caries in the mesial and distal surfaces, these carious lesions were excavated and the teeth were restored with composite. tooth g had caries in the mesial surface which was excavated and the tooth was restored with composite. teeth i and l both had caries on the occlusal surfaces which were excavated and upon excavation of the caries in tooth i the pulp was perforated and a therapeutic pulpotomy was therefore necessary. this was done using ferric sulfate and zinc oxide eugenol. for final restorations, amalgam restorations were placed involving the occlusal surfaces both teeth i and l. a prophylaxis was done and topical fluoride applied and the excess was suctioned thoroughly. the throat pack was removed and the patient was awakened and brought to the recovery room in good condition at 11:30. there was no blood loss.

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.

identifying data:, the patient is a 45-year-old white male. he is unemployed, presumably on disability and lives with his partner.,chief complaint: , "i'm in jail because i was wrongly arrested." the patient is admitted on a 72-hour involuntary treatment act for grave disability.,history of present illness: , the patient has minimal insight into the circumstances that resulted in this admission. he reports being diagnosed with aids and schizophrenia for some time, but states he believes that he has maintained his stable baseline for many months of treatment for either condition. prior to admission, the patient was brought to emergency room after he attempted to shoplift from a local department store, during which he apparently slapped his partner. the patient was disorganized with police and emergency room staff, and he was ultimately detained on a 72-hour involuntary treatment act for grave disability.,on the interview, the patient is still disorganized and confused. he believes that he has been arrested and is in jail. reports a history of mental health treatment, but denies benefiting from this in the past and does not think that it is currently necessary.,i was able to contact his partner by telephone. his partner reports the patient is paranoid and has bizarre behavior at baseline over the time that he has known him for the last 16 years, with occasional episodes of symptomatic worsening, from which he spontaneously recovers. his partner estimates the patient spends about 20% of the year in episodes of worse symptoms. his partner states that in the last one to two months, the patient has become worse than he has ever seen him with increased paranoia above the baseline and he states the patient has been barricading himself in his house and unplugging all electrical appliances for unclear reasons. he also reports the patient has been sleeping less and estimates his average duration to be three to four hours a night. he also reports the patient has been spending money impulsively in the last month and has actually incurred overdraft charges on his checking account on three different occasions recently. he also reports that the patient has been making threats of harm to him and that his partner no longer feels that he is safe having him at home. he reports that the patient has been eating regularly with no recent weight loss. he states that the patient is observed responding to internal stimuli, occasionally at baseline, but this has gotten worse in the last few months. his partner was unaware of any obvious medical changes in the last one to two months coinciding with onset of recent symptomatic worsening. he reports of the patient's longstanding poor compliance with treatment of his mental health or age-related conditions and attributes this to the patient's dislike of taking medicine. he also reports that the patient has expressed the belief in the past that he does not suffer from either condition.,past psychiatric history: , the patient's partner reports that the patient was diagnosed with schizophrenia in his 20s and he has been hospitalized on two occasions in the 1980s and that there was a third admission to a psychiatric facility, but the date of this admission is currently unknown. the patient was last enrolled in an outpatient mental health treatment in mid 2009. he dropped out of care about six months ago when he moved with his partner. his partner reports the patient was most recently prescribed seroquel, which, though the patient denied benefiting from, his partner felt was "useful, but not dosed high enough." past medication trials that the patient reports include haldol and lithium, neither of which he found to be particularly helpful.,medical history: , the patient reports being diagnosed with hiv and aids in 1994 and believes this was secondary to unprotected sexual contact in the years prior to his diagnosis. he is currently followed at clinic, where he has both an assigned physician and a case manager, but treatment compliance has been poor with no use of antiretroviral meds in the last year. the patient is fairly vague on his history of aids related conditions, but does identify the following: thrush, skin lesions, and lung infections; additional details of these problems are not currently known.,current medications: , none.,allergies:, no known drug allergies.,social and developmental history: , the patient lives with his partner. he is unemployed. details of his educational and occupational history are not currently known. his source of finances is also unknown, though social security disability is presumed.,substance and alcohol history: , the patient smoked one to two packs per day for most of the last year, but has increased this to two to three packs per day in the last month. his partner reports that the patient consumed alcohol occasionally, but denies any excessive or binge use recently. the patient reports smoking marijuana a few times in his life, but not recently. denies other illicit substance use.,legal history: ,unknown.,genetic psychiatric history:, also unknown.,mental status exam:,attitude: the patient demonstrates only variable cooperation with interview, requires frequent redirection to respond to questions. his appearance is cachectic. the patient is poorly groomed.,psychomotor: there is no psychomotor agitation or retardation. no other observed extrapyramidal symptoms or tardive dyskinesia.,affect: his affect is fairly detached.,mood: describes his mood is "okay.",speech: his speech is normal rate and volume. tone, his volume was decreased initially, but this improved during the course of the interview.,thought process: his thought processes are markedly tangential.,thought content: the patient is fairly scattered. he will provide history with frequent redirection, but he does not appear to stay on one topic for any length of time. he denies currently auditory or visual hallucinations, though his partner says that this is a feature present at baseline. paranoid delusions are elicited.,homicidal/suicidal ideation: he denies suicidal or homicidal ideation. denies previous suicide attempts.,cognitive assessment: cognitively, he is alert and oriented to person and year only. his memory is intact to names of his madison clinic providers.,insight/judgment: his insight is absent as evidenced by his repeated questioning of the validity of his aids and mental health diagnoses. his judgment is poor as evidenced by his longstanding pattern of minimal engagement in treatment of his mental health and physical health conditions.,assets: his assets include his housing and his history of supportive relationship with his partner over many years.,limitations: his limitations include his aids and his history of poor compliance with treatment.,formulation: ,the patient is a 45-year-old white male with a history of schizophrenia and aids. he was admitted for disorganized and assaultive behaviors while off all medications for the last six months. it is unclear to me how much his presentation is a direct expression of an aids-related condition, though i suspect the impact of his hiv status is likely to be substantial.,diagnoses:,axis i: schizophrenia by history. rule out aids-induced psychosis. rule out aids-related cognitive disorder.,axis ii: deferred.,axis iii: aids (stable by his report). anemia.,axis iv: relationship strain and the possibility that he may be unable to return to his home upon discharge; minimal engagement in mental health and hiv-related providers.,axis v: global assessment functioning is currently 15.,plan: , i will attempt to increase the database, will specifically request records from the last mental health providers. the internal medicine service will evaluate and treat any acute medical issues that could be helpful to collaborate with his providers at clinic regarding issues related to his aids diagnosis. with the patient's permission, i will start quetiapine at a dose of 100 mg at bedtime, given the patient's partner report of partial, but response to this agent in the past. i anticipate titrating further for effect during the course of his admission.

preoperative diagnosis:, congenital bilateral esotropia, 42 prism diopters.,procedure:, bilateral rectus recession with the microscopic control, 8 mm, both eyes.,postoperative diagnosis: , congenital bilateral esotropia, 42 prism diopters.,complications:, none.,procedure in detail: , the patient was taken to the surgery room and placed in the supine position. the general anesthesia was achieved with intubation with no problems. both eyes were prepped and draped in usual manner. the attention was turned the right eye and a hole was made in the drape and a self-retaining eye speculum was placed ensuring eyelash in the eye drape. the microscope was focused on the palpebral limbus and the eyeball was rotated medially and laterally with no problem. the eyeball rotated medially and upwards by holding the limbus at 7 o'clock position. inferior fornix conjunctival incision was made and tenons capsule buttonholed. the lateral rectus muscle was engaged over the muscle hook and the tenons capsule was retracted with the tip of the muscle hook. the tenons capsule was buttonholed. the tip of the muscle hook and tenons capsule was cleaned from the insertion of the muscle. __________ extension of the muscle was excised. the 7-0 vicryl sutures were placed at the insertion of the muscle and double locked at the upper and lower borders. the muscle was disinserted from original insertion. the suture was passed 8 mm posterior to the insertion of the muscle in double sewed fashion. the suture was pulled, tied, and cut. the muscle was in good position. the conjunctiva was closed with 7-0 vicryl suture in running fashion. the suture was pulled, tied, and cut. the eye speculum was taken out.,similar procedure performed on the left rectus muscle and it was recessed by 8 mm from its original insertion. the suture was pulled, tied and cut. the eye speculum was taken out after the conjunctiva was sewed up and the suture was cut. tobradex eye drops were instilled in both eyes and the patient extubated and was in good condition. to be seen in the office in 1 week.

preoperative diagnosis: , acute appendicitis.,postoperative diagnosis: , acute appendicitis.,procedure: , laparoscopic appendectomy.,anesthesia: , general endotracheal.,indications: , patient is a pleasant 31-year-old gentleman who presented to the hospital with acute onset of right lower quadrant pain. history as well as signs and symptoms are consistent with acute appendicitis as was his cat scan. i evaluated the patient in the emergency room and recommended that he undergo the above-named procedure. the procedure, purpose, risks, expected benefits, potential complications, alternative forms of therapy were discussed with him and he was agreeable with surgery.,findings: , patient was found to have acute appendicitis with an inflamed appendix, which was edematous, but essentially no suppuration.,technique: ,the patient was identified and then taken into the operating room, where after induction of general endotracheal anesthesia, the abdomen was prepped with betadine solution and draped in sterile fashion. an infraumbilical incision was made and carried down by blunt dissection to the level of the fascia, which was grasped with an allis clamp and two stay sutures of 2-0 vicryl were placed on either side of the midline. the fascia was tented and incised and the peritoneum entered by blunt finger dissection. a hasson cannula was placed and a pneumoperitoneum to 15 mmhg pressure was obtained. patient was placed in the trendelenburg position, rotated to his left, whereupon under direct vision, the 12-mm midline as well as 5-mm midclavicular and anterior axillary ports were placed. the appendix was easily visualized, grasped with a babcock's. a window was created in the mesoappendix between the appendix and the cecum and the endo gia was introduced and the appendix was amputated from the base of the cecum. the mesoappendix was divided using the endo gia with vascular staples. the appendix was placed within an endo bag and delivered from the abdominal cavity. the intra-abdominal cavity was irrigated. hemostasis was assured within the mesentery and at the base of the cecum. all ports were removed under direct vision and then wounds were irrigated with saline antibiotic solution. the infraumbilical defect was closed with a figure-of-eight 0 vicryl suture. the remaining wounds were irrigated and then everything was closed subcuticular with 4-0 vicryl suture and steri-strips. patient tolerated the procedure well, dressings were applied, and he was taken to recovery room in stable condition.

preoperative diagnosis: , right pleural effusion with respiratory failure and dyspnea.,postoperative diagnosis: , right pleural effusion with respiratory failure and dyspnea.,procedure: , ultrasound-guided right pleurocentesis.,anesthesia: , local with lidocaine.,technique in detail: , after informed consent was obtained from the patient and his mother, the chest was scanned with portable ultrasound. findings revealed a normal right hemidiaphragm, a moderate right pleural effusion without septation or debris, and no gliding sign of the lung on the right. using sterile technique and with ultrasound as a guide, a pleural catheter was inserted and serosanguinous fluid was withdrawn, a total of 1 l. the patient tolerated the procedure well. portable x-ray is pending.

chief complaint:, toothache.,history of present illness: ,this is a 29-year-old male who has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled. complains of new tooth pain. the patient states his current toothache is to both upper and lower teeth on the left side for approximately three days. the patient states that he would have gone to see his regular dentist but he has missed so many appointments that they now do not allow him to schedule regular appointments, he has to be on standby appointments only. the patient denies any other problems or complaints. the patient denies any recent illness or injuries. the patient does have oxycontin and vicodin at home which he uses for his knee pain but he wants more pain medicines because he does not want to use up that medicine for his toothache when he wants to say this with me.,review of systems: , constitutional: no fever or chills. no fatigue or weakness. no recent weight change. heent: no headache, no neck pain, the toothache pain for the past three days as previously mentioned. there is no throat swelling, no sore throat, no difficulty swallowing solids or liquids. the patient denies any rhinorrhea. no sinus congestion, pressure or pain, no ear pain, no hearing change, no eye pain or vision change. cardiovascular: no chest pain. respirations: no shortness of breath or cough. gastrointestinal: no abdominal pain. no nausea or vomiting. genitourinary: no dysuria. musculoskeletal: no back pain. no muscle or joint aches. skin: no rashes or lesions. neurologic: no vision or hearing change. no focal weakness or numbness. normal speech. hematologic/lymphatic: no lymph node swelling has been noted.,past medical history: , chronic knee pain.,current medications: , oxycontin and vicodin.,allergies:, penicillin and codeine.,social history: , the patient is still a smoker.,physical examination:, vital signs: temperature 97.9 oral, blood pressure is 146/83, pulse is 74, respirations 16, oxygen saturation 98% on room air and interpreted as normal. constitutional: the patient is well nourished and well developed. the patient is a little overweight but otherwise appears to be healthy. the patient is calm, comfortable, in no acute distress, and looks well. the patient is pleasant and cooperative. heent: eyes are normal with clear conjunctiva and cornea bilaterally. there is no icterus, injection, or discharge. pupils are 3 mm and equally round and reactive to light bilaterally. there is no absence of light sensitivity or photophobia. extraocular motions are intact bilaterally. ears are normal bilaterally without any sign of infection. there is no erythema, swelling of canals. tympanic membranes are intact without any erythema, bulging or fluid levels or bubbles behind it. nose is normal without rhinorrhea or audible congestion. there is no tenderness over the sinuses. neck: supple, nontender, and full range of motion. there is no meningismus. no cervical lymphadenopathy. no jvd. mouth and oropharynx shows multiple denture and multiple dental caries. the patient has tenderness to tooth #12 as well as tooth #21. the patient has normal gums. there is no erythema or swelling. there is no purulent or other discharge noted. there is no fluctuance or suggestion of abscess. there are no new dental fractures. the oropharynx is normal without any sign of infection. there is no erythema, exudate, lesion or swelling. the buccal membranes are normal. mucous membranes are moist. the floor of the mouth is normal without any abscess, suggestion of ludwig's syndrome. cardiovascular: heart is regular rate and rhythm without murmur, rub, or gallop. respirations: clear to auscultation bilaterally without shortness of breath. gastrointestinal: abdomen is normal and nontender. musculoskeletal: no abnormalities are noted to back, arms and legs. the patient has normal use of his extremities. skin: no rashes or lesions. neurologic: cranial nerves ii through xii are intact. motor and sensory are intact to the extremities. the patient has normal speech and normal ambulation. psychiatric: the patient is alert and oriented x4. normal mood and affect. hematologic/lymphatic: no cervical lymphadenopathy is palpated.,emergency department course: , the patient did request a pain shot and the patient was given dilaudid of 4 mg im without any adverse reaction.,diagnoses:,1. odontalgia.,2. multiple dental caries.,condition upon disposition: ,stable.,disposition: , to home.,plan: , the patient was given a list of local dental clinics that he can follow up with or he can choose to stay with his own dentist that he wishes. the patient was requested to have reevaluation within two days. the patient was given a prescription for percocet and clindamycin. the patient was given drug precautions for the use of these medicines. the patient was offered discharge instructions on toothache but states that he already has it. he declined the instructions. the patient was asked to return to the emergency room, should he have any worsening of his condition or develop any other problems or symptoms of concern.

preoperative diagnoses:,1. pelvic pain.,2. ectopic pregnancy.,postoperative diagnoses:,1. pelvic pain.,2. ectopic pregnancy.,3. hemoperitoneum.,procedures performed:,1. dilation and curettage (d&c).,2. laparoscopy.,3. right salpingectomy.,4. lysis of adhesions.,5. evacuation of hemoperitoneum.,anesthesia: , general endotracheal.,estimated blood loss: , scant from the operation, however, there was approximately 2 liters of clotted and old blood in the abdomen.,specimens:, endometrial curettings and right fallopian tube.,complications: , none.,findings: , on bimanual exam, the patient has a small anteverted uterus, it is freely mobile. no adnexal masses, however, were appreciated on the bimanual exam. laparoscopically, the patient had numerous omental adhesions to the vesicouterine peritoneum in the fundus of the uterus. there were also adhesions to the left fallopian tube and the right fallopian tube. there was a copious amount of blood in the abdomen approximately 2 liters of clotted and unclotted blood. there was some questionable gestational tissue ________ on the left sacrospinous ligament. there was an apparent rupture and bleeding ectopic pregnancy in the isthmus portion of the right fallopian tube.,procedure:, after an informed consent was obtained, the patient was taken to the operating room and the 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. a weighted speculum was then placed in the vagina. the interior wall of vagina elevated with the uterine sound and the anterior lip of the cervix was grasped with the vulsellum tenaculum. the cervix was then serially dilated with hank dilators to a size #20 hank and then a sharp curettage was performed obtaining a moderate amount of decidual appearing tissue and the tissue was then sent to pathology. at this point, the uterine manipulator was placed in the cervix and attached to the anterior cervix and vulsellum tenaculum and weighted speculum were removed. next, attention was then turned to the abdomen. the surgeons all are removed the dirty gloves in the previous portion of the case. next, a 2 cm incision was made immediately inferior to umbilicus. the superior aspect of the umbilicus was grasped with a towel clamp and a veress needle was inserted through this incision. next, a syringe was used to inject normal saline into the veress needle. the normal saline was seen to drop freely, so a veress needle was connected to the co2 gas which was started at its lowest setting. the gas was seen to flow freely with normal resistance, so the co2 gas was advanced to a higher setting. the abdomen was insufflated to an adequate distension. once an adequate distention was reached, the co2 gas was disconnected. the veress needle was removed and a size #11 step trocar was placed. the introducer was removed and the trocar was connected to the co2 gas and a camera was inserted. next, a 1 cm incision was made in the midline approximately two fingerbreadths below the pubic symphysis after transilluminating with the camera. a veress needle and a step sheath were inserted through this incision. next, the veress needle was removed and a size #5 trocar was inserted under direct visualization. next a size #5 port was placed approximately five fingerbreadths to the left of the umbilicus in a similar fashion. a size #12 port was placed in a similar fashion approximately six fingerbreadths to the right of the umbilicus and also under direct visualization. the laparoscopic dissector was inserted through the suprapubic port and this was used to dissect the omental adhesions bluntly from the vesicouterine peritoneum and the bilateral fallopian tubes. next, the dorsey suction irrigator was used to copiously irrigate the abdomen. approximate total of 3 liters of irrigation was used and the majority of all blood clots and free blood was removed from the abdomen.,once the majority of blood was cleaned from the abdomen, the ectopic pregnancy was easily identified and the end of the fallopian tube was grasped with the grasper from the left upper quadrant and the ligasure device was then inserted through the right upper quadrant with # 12 port. three bites with the ligasure device were used to transect the mesosalpinx inferior to the fallopian tube and then transect the fallopian tube proximal to the ectopic pregnancy. an endocatch bag was then placed to the size #12 port and this was used to remove the right fallopian tube and ectopic pregnancy. this was then sent to the pathology. next, the right mesosalpinx and remains of the fallopian tube were examined again and they were seemed to be hemostatic. the abdomen was further irrigated. the liver was examined and appeared to be within normal limits. at this point, the two size #5 ports and a size #12 port were removed under direct visualization. the camera was then removed. the co2 gas was disconnected and the abdomen was desufflated. the introducer was then replaced in a size #11 port and the whole port and introducer was removed as a single unit. all laparoscopic incisions were closed with a #4-0 undyed vicryl in a subcuticular interrupted fashion. they were then steri-stripped and bandaged appropriately. at the end of the procedure, the uterine manipulator was removed from the cervix and the patient was taken to recovery in stable condition. the patient tolerated the procedure well. sponge, lap, and needle counts were correct x2. she was discharged home with a postoperative hemoglobin of 8.9. she was given iron 325 mg to be taken twice a day for five months and darvocet-n 100 mg to be taken every four to six hours for pain. she will follow up within a week in the ob resident clinic.

medications:,1. versed intravenously.,2. demerol intravenously.,description of the procedure: , after informed consent was obtained, the patient was placed in the left lateral decubitus position and sedated with the above medications. the olympus video colonoscope was inserted through the anus and was advanced in retrograde fashion through the sigmoid colon, descending colon, around the splenic flexure, into the transverse colon, around the hepatic flexure, down the ascending colon, into the cecum. the cecum was identified by the presence of the appendiceal orifice and the ileocecal valve. the colonoscope was then advanced through the ileocecal valve into the terminal ileum, which was normal on examination. the scope was then pulled back into the cecum and then slowly withdrawn. the mucosa was examined in detail. the mucosa was entirely normal. upon reaching the rectum, retroflex examination of the rectum was normal. the scope was then straightened out, the air removed and the scope withdrawn. the patient tolerated the procedure well. there were no apparent complications.,

history of present illness: , the patient is a 35-year-old woman who reports that on the 30th of october 2008, she had a rupture of her membranes at nine months of pregnancy, and was admitted to hospital and was given an epidural anesthetic. i do not have the records from this hospital admission, but apparently the epidural was administered for approximately 14 to 18 hours. she was sitting up during the epidural.,she did not notice any difference in her lower extremities at the time she had the epidural; however, she reports that she was extremely sleepy and may not have been aware of any change in strength or sensation in her lower extremities at that time. she delivered on the 31st of october, by cesarean section, because she had failed to progress and had pyrexia.,she also had a foley catheter placed at that time. on the 1st of november 2008, they began to mobilize her and it was at that time that she first noticed that she could not walk. she was aware that she could not move her legs at all, and then within a few days, she was aware that she could move toes in the left foot but could not move her right foot at all. since that time, there has been a gradual improvement in strength to the point that she now has limited movement in her left leg and severely restricted movement in her right leg. she is not able to walk by herself, and needs assistance to stand. she was discharged from hospital after the cesarean section on the 3rd of november. unfortunately, we do not have the records and we do not know what the discussion was between the anesthesiologist and the patient at the time of discharge. she was then seen at abc hospital on november 05, 2008. she had an mri scan of her spine, which showed no evidence of an abnormality, specifically there were no cord changes and no evidence of a hematoma. she also had an emg study at that time by dr. x, which was abnormal but not diagnostic and this was repeated again in december. at the present time, she also complains of a pressure in both her legs and in her thighs. she complains that her right foot hurts and that she has some hyperesthesia there. she has been taking gabapentin to try to reduce the discomfort, although she is on a very low dose and the effect is minimal. she has no symptoms in her arms, her bowel and bladder function is normal, and her bulbar function is normal. there is no problem with her vision, swallowing, or respiratory function.,past medical history: , unremarkable except as noted above. she has seasonal allergies.,current medications:, gabapentin 300 mg b.i.d., centrum once a day, and another multivitamin.,allergies: , she has no medication allergies, but does have seasonal allergies.,family history: , there is a family history of diabetes and hypertension. there is no family history of a neuropathy or other neurological disease. she has one child, a son, born on october 31, 2008.,social history: , the patient is a civil engineer, who currently works from home. she is working approximately half time because of limitations imposed on her by her disability, need to attend frequent physical therapy, and also the needs of looking after her baby. she does not smoke and does not drink and has never done either.,general physical examination:,vital signs: p 74, bp 144/75, and a pain score of 0.,general: her general physical examination was unremarkable.,cardiovascular: normal first and second heart sound, regular pulse with normal volume.,respiratory: unremarkable, both lung bases were clear, and respiration was normal.,gi: unremarkable, with no organomegaly and normal bowel sounds.,neurological exam:,mse: the patient's orientation was normal, fund of knowledge was normal, memory was normal, speech was normal, calculation was normal, and immediate and long-term recall was normal. executive function was normal.,cranial nerves: the cranial nerve examination ii through xii was unremarkable. both disks were normal, with normal retina. pupils were equal and reactive to light. eye movements were full. facial sensation and strength was normal. bulbar function was normal. the trapezius had normal strength.,motor: muscle tone showed a slight increase in tone in the lower extremities, with normal tone in the upper extremities. muscle strength was 5/5 in all muscle groups in the upper extremities. in the lower extremities, the hip flexors were 1/5 bilaterally, hip extensors were 1/5 bilaterally, knee extension on the right was 1/5 and on the left was 3-/5, knee flexion was 2/5 on the right and 3-/5 on the left, foot dorsiflexion was 0/5 on the right and 1/5 on the left, foot plantar flexion was 4-/5 on the right and 4+/5 on the left, toe extension was 0/5 on the right and 4-/5 on the left, toe flexion was 4-/5 on the right and 4+/5 on the left.,reflexes: reflexes in the upper extremities were 2+ bilaterally. in the lower extremities, they were 0 bilaterally at the knee and ankles. the abdominal reflexes were present above the umbilicus and absent below the umbilicus. the plantar responses were mute. the jaw reflex was normal.,sensation: vibration was moderately decreased in the right great toe and was mildly decreased in the left great toe. there was a sensory level to light touch at approximately t7 posteriorly and approximately t9 anteriorly. there was a range of sensation, but clearly there was a decrease in sensation below this level but not complete loss of sensation. to pain, the sensory level is even less clear, but appeared to be at about t7 on the right side. in the lower extremities, there was a slight decrease in pin and light touch in the right great toe compared to the left. there was no evidence of allodynia or hyperesthesia. joint position sense was mildly reduced in the right toe and normal on the left.,coordination: coordination for rapid alternating movements and finger-to-nose testing was normal. coordination could not be tested in the lower extremities.,gait: the patient was unable to stand and therefore we were unable to test gait or romberg's. there was no evidence of focal back tenderness.,review of outside records: , i have reviewed the records from abc hospital, including the letter from dr. y and the emg report dated 12/17/2008 from dr. x. the emg report shows evidence of a lumbosacral polyradiculopathy below approximately t6. the lower extremity sensory responses are essentially normal; however, there is a decrease in the amplitude of the motor responses with minimal changes in latency. i do have the mri of lumbar spine report from 11/06/2008 with and without contrast. this showed a minimal concentric disc bulge of l4-l5 without disc herniation, but was otherwise unremarkable. the patient brought a disc with a most recent mri study; however, we were unable to open this on our computers. the verbal report is that the study was unremarkable except for some gadolinium enhancement in the lumbar nerve roots. a doppler of the lower extremities showed no evidence of deep venous thrombosis in either lower extremity. chest x-ray showed some scoliosis on the lumbar spine, curve to the left, but no evidence of other abnormalities. a ct pelvis study performed on november 07, 2008 showed some nonspecific fluid in the subcutaneous fat of the back, posterior to l4 and l5 levels; however, there were no pelvic masses or other abnormalities. we were able to obtain an update of the report from the mri of the lumbar spine with and without contrast dated 12/30/2008. the complete study included the cervical, thoracic, and lumbar spine. there was diffuse enhancement of the nerve roots of the cauda equina that had increased in enhancement since prior exam in november. it was also reported that the patient was given intravenous methylprednisolone and this had had no effect on strength in her lower extremities.,impression: , the patient has a condition that is temporarily related to the epidural injection she was given at the end of october 2008, prior to her cesarean section. it appears she became aware of weakness within two days of the administration of the epidural, she was very tired during the epidural and may have missed some change in her neurological function. she was severely weak in both lower extremities, slightly worse on the right than the left. there has been some interval improvement in her strength since the beginning of november 2008. her emg study from the end of december is most consistent with a lumbosacral polyradiculopathy. the mri findings of gadolinium enhancement in the lumbar nerve roots would be most consistent with an inflammatory radiculitis most likely related to the epidural anesthesia or administration of the epidural. there had been no response to iv methylprednisolone given to her at abc. the issue of having a lumbar puncture to look for evidence of inflammatory cells or an elevated protein had been discussed with her at both abc and by myself. the patient did not wish to consider a lumbar puncture because of concerns that this might worsen her condition. at the present time, she is able to stand with aid but is unable to walk. there is no evidence on her previous emg of a demyelinating neuropathy.,recommendations:,1. the diagnostic issues were discussed with the patient at length. she is informed that this is still early in the course of the problem and that we expect her to show some improvement in her function over the next one to two years, although it is unclear as to how much function she will regain.,2. she is strongly recommended to continue with vigorous physical therapy, and to continue with the plan to mobilize her as much as possible, with the goal of trying to get her ambulatory. if she is able to walk, she will need bilateral afos for her ankles, to improve her overall mobility. i am not prescribing these because at the present time she does not need them.,3. we discussed increasing the dose of gabapentin. the paresthesias that she has may indicate that she is actually regaining some sensory function, although there is a concern that as recovery continues, she may be left with significant neuropathic pain. if this is the case, i have advised her to increase her gabapentin dose from 300 mg b.i.d. gradually up to 300 mg four times a day and then to 600 mg to 900 mg four times a day. she may need other neuropathic pain medications as needed. she will determine whether her current symptoms are significant enough to require this increase in dosage.,4. the patient will follow up with dr. y and his team at abc hospital. she will also continue with physical therapy within the abc system.

reason for referral: , the patient was referred to me by dr. x of the hospitalist service at children's hospital due to a recent admission for pseudoseizures. this was a 90-minute initial intake completed on 10/19/2007 with the patient's mother. i have reviewed with her the boundaries of confidentiality and the treatment consent form, and she stated that she had understood these concepts.,presenting problem: , it is reported that the patient was recently hospitalized and has been hospitalized in 2 occasions for pseudoseizure activity. these were confirmed by video eeg and consist of trembling, shaking, and things of that nature. she does have a history of focal seizures and perhaps simple seizures, which were diagnosed when she was 5 years old, but the seizure activity that was documented during the hospital stay is of a significant different quality. i had met with them in the hospital and introduced myself and gathered some basic background information, but this is a supplement to that information, which is contained within this chart. it was reported to me that she has been under considerable stress. first of all, it should be noted that the patient is developmentally delayed. although she is 17 years old, she operates at about a fourth grade level. mother reported that the patient becomes stressed because she thinks that everyone is against her, that she cannot do anything unless someone is there, that she needs a lot of direction, that she gets confused easily, that she thinks that people become angry at her, that she misinterprets what people are saying and thinks that they are upset. it is reported, the patient feels that her mother yells at her, and that is mad at her often. it was reported that in addition she recently has had change in her visitation with her father, that she within the last 6 months, has started seeing her father every other weekend after he had been discharged from prison. she reported that what is stress for her is that sometimes he does not always show up for visits or is late and that upsets her a lot and that she is upset when she has to leave him, also additional stressor is at school. she reports that she has no friends that she feels unwanted and picked on. she gets confused easily at school, worries about things, and believes that the teachers become angry with her. in regards to her mood, mother reported that she is usually happy, unless things do not go her way, and then, she becomes upset and says that nobody cares about her. she sits in the couch, she become angry, does not speak. mother sends her to her room, and she calms down, takes a couple of deep breaths, and that passes. it is reported that the patient has "always been this way" and that is not a change in her behavior. mother did think that she did seem a little more depressed, that she seems more lonely. over the last few months, she has seemed a little bit more down because she does not have any friends and that she is bored. mother reported that she frequently complains of being bored, but has always been this way. no sleep disturbance was noted. no changes in weight. no suicidal ideation. no deficits in energy were noted. mother did report that she does tend to worry, but her worries tend to be because she gets confused, does not understand what she needs to do, and is quite rigid, but mother did not feel that the worry was actually affecting her functioning on a daily basis.,developmental history:, the patient was the 5 pound 12 ounce product of an unplanned pregnancy and normal spontaneous vaginal delivery. she was delivered at 36 weeks' gestation. mother reported that she received prenatal care. difficulties during the pregnancy were denied. the use of drugs, alcohol, tobacco during the pregnancy were denied. no eating or sleeping difficulties during the perinatal period were reported. temperament was described as easy. the patient is described as a cuddly baby. in terms of serious injuries, they were denied. serious illnesses: she has been diagnosed since age 5 with seizures. mother was not able to tell me the exact kind of seizures, but it would appear from i could gather that they are focal seizures and possibly simple-to-complex partial seizures. the patient does not have a history of allergy or toileting problems. she is currently taking trileptal 450 mg b.i.d., and she is currently taking depakote, although she is going to be weaned off the depakote by her neurologist. she is taking prevacid and ibuprofen. the neurologist that she sees is dr. y here at children's hospital.,family background:, in terms of family background, the patient lives with her mother age 38 and her mother's partner, who is age 40, and with her 16-year-old sister who does not have any developmental delays. mother had been married to the patient's father, but they were together as a couple beginning 1990, married in 1997, separated in 2002, and divorced in 2003; he lives in the abc area and visits them every other saturday, but there are no overnight visits. the paternal grandparents are both living here in california, but are separated. they are 3 paternal uncles and 2 paternal aunts. in terms of the maternal family, maternal grandmother and grandfather are deceased. maternal grandfather deceased in 1991 due to cancer. maternal grandmother deceased in 2001 due to cancer. there are 5 maternal aunts and 2 maternal uncles, all who live in california. she reported that the patient is particularly close to her maternal aunt, whose name is carmen. mother's partner had been married previously; he has 2 children from that relationship, a 23-year-old, and a 20-year-old female, who really are not part of the patient's daily life. in terms of other family background, it was reported that the mother's partner gets frustrated with the patient, does not completely understand the degree of her delay and how that may affect her ability to do things as well as her interpretation of things. the sister was described as having some resentment towards her older sister, that she feels like she was just to watch out for her, care for her, and that sister has always wanted to follow her around and do the things that she does. the biological father allegedly was in jail for a year due to drug possession. mother reported that he had a problem with methamphetamine. in addition, she reported there is an accusation that he had molested their niece; however, she stated that there was a trial, and he was found to be not guilty of that. she stated there was no evidence that he had ever molested the patient or her sister. there had been quite a bit of chaos in the family when the mother and father were together. there was a lot of arguing. there were a lot of moves, there was domestic violence both from father to mother and mother to father consisting mostly of pushing and shoving by mother's report. the patient did observe this. after the separation, it was reported that there were continued difficulties that the father took the patient and her sister from school without mother's knowledge and had filed to get custody of them and actually ended up having custody of them for a month, and told the patient and her sister that the mother had abandoned them. mother reported that they went to court, and there was a court order giving the mother custody back after the father went to jail. mother stated that was approximately 5 years ago. in terms of current, mother reports that she currently works 2 jobs from 8 to 5 on monday and friday and from 6 to 10 on monday, wednesday's, and friday's, but she does have the weekends off. the patient was reported also to have a job through her school on several weeknights.,mother reported that she graduated from high school, had a year of college. she was an average student, had learning difficulties in reading. no psychological or drug or alcohol history was reported by mother. in terms of the biological father, mother stated that he graduated from high school, had a couple of years of college, was a good student, no learning problems or psychological problems for him were reported. mother reported that he had a history of methamphetamine use.,other psychiatric history in the family was denied.,social history: , she reported that the patient feels like she does not have any friends, that she is lonely and bored, really does not do much for fun. her fun consists primarily of doing crafts with mother, sewing, painting, drawing, beadwork, and things like that. it was reported that she really feels that she is bored and does not have much to do.,academic background: ,the patient is in the 11th grade at high school. she has 2 regular education classes, mother could not tell me what they were, but the rest of her classes are special education. mother could not tell me what her iq was, although she noticed she works at about a 4th or 5th grade level. mother reported that the terminology most often used with the patient was developmental delay. her counselor's name is mr. xyz, but she reported that overall she is a good student, but she does have sometimes some difficulties at school, becoming upset or angry regarding the little things that she does not seem to understand. it is reported that the patient feels that she has no friends at school that she is lonely, and that is she does not really care for school. she reported that the patient is involved in a work program through the school where she works at pet extreme on mondays and wednesdays from 3 to 8 p.m. where she stocks shelves. it is reported that she does not like to go to school because she feels like nobody likes her. she is not involved in any kind of clubs or groups at school. mother reported that she is also not receiving cvrc services.,previous counseling: , mother reported that she has been in counseling before, but mother could not give me any information about that, who did the counseling, or what it was about. she does receive evidently some peer counseling at school because she gets upset and needs help in calming down.,diagnostic summary and impression:, it appears that the patient best qualifies for a diagnosis of conversion disorder, and information from neurology suggests that the "seizure episodes" are not true seizures, but appear to be pseudoseizures. the patient is experiencing quite bit of stress with a lot of changes in her life, also difficulty in functioning likely due to her developmental delay makes it difficult for her to understand.,plan:, my plan is to meet with the patient in approximately 1 to 2 weeks to complete a clinical interview with her, and then to begin teaching coping skills as well as explore ways for reducing her stress.,dsm iv diagnoses: ,axis i: conversion disorder (300.11).,axis ii: diagnoses deferred.,axis iii: seizure disorder.,axis iv: problems with primary support group, peer problems, and educational problems.,axis v: global assessment of functioning equals 60.

preoperative diagnoses:,1. left diabetic foot abscess and infection.,2. left calcaneus fracture with infection.,3. right first ray amputation.,postop diagnoses:,1. left diabetic foot abscess and infection.,2. left calcaneus fracture with infection.,3. right first ray amputation.,operation and procedure:,1. left below-the-knee amputation.,2. dressing change, right foot.,anesthesia: , general.,blood loss: , less than 100 ml.,tourniquet time:, 24 minutes on the left, 300 mmhg.,complications:, none.,drains: , a one-eighth-inch hemovac.,indications for surgery: , the patient is a 62 years of age with diabetes. he developed left heel abscess. he had previous debridements, developed a calcaneal fracture and has now had several debridement with placement of the antibiotic beads. after re-inspecting the wound last week, the plan was for possible debridement and he desired below-the-knee amputation. we are going to change the dressing on the right side also. the risks, benefits, and alternatives of surgery were discussed. the risks of bleeding, infection, damage to nerves and blood vessels, persistent wound healing problems, and the need for future surgery. he understood all the risks and desired operative treatment.,operative procedure in detail: , after appropriate informed consent obtained, the patient was taken to the operating room and placed in the supine position. general anesthesia induced. once adequate anesthesia had been achieved, cast padding placed on the left proximal thigh and tourniquet was applied. the right leg was redressed. i took the dressing down. there was a small bit of central drainage, but it was healing nicely. adaptic and new sterile dressings were applied.,the left lower extremity was then prepped and draped in usual sterile fashion.,a transverse incision made about the mid shaft of the tibia. a long posterior flap was created. it was taken to the subcutaneous tissues with electrocautery. please note that tourniquet had been inflated after exsanguination of the limb. superficial peroneal nerve identified, clamped, and cut. anterior compartment was divided. the anterior neurovascular bundle identified, clamped, and cut. the plane was taken between the deep and superficial compartments. the superficial compartment was reflected posteriorly. tibial nerve identified, clamped, and cut. tibial vessels identified, clamped, and cut.,periosteum of the tibia elevated proximally along with the fibula. the tibia was then cut with gigli saw. it was beveled anteriorly and smoothed down with a rasp. the fibula was cut about a cm and a half proximal to this using a large bone cutter. the remaining posterior compartment was divided. the peroneal bundle identified, clamped, and cut. the leg was then passed off of the field. each vascular bundle was then doubly ligated with 0 silk stick tie and 0 silk free tie. the nerves were each pulled at length, injected with 0.25% marcaine with epinephrine, cut, and later retracted proximally. the tourniquet was released. good bleeding from the tissues and hemostasis obtained with electrocautery. copious irrigation performed using antibiotic-impregnated solution. a one-eighth-inch hemovac drain placed in the depth of wound adhering on the medial side. a gastroc soleus fascia brought up and attached to the anterior fascia and periosteum with #1 vicryl in an interrupted fashion. the remaining fascia was closed with #1 vicryl. subcutaneous tissues were then closed with 2-0 pds suture using 2-0 monocryl suture in interrupted fashion. skin closed with skin staples. xeroform gauze, 4 x 4, and a padded soft dressing applied. he was placed in a well-padded anterior and posterior slab splint with the knee in extension. he was then awakened, extubated, and taken to recovery in stable condition. there were no immediate operative complications, and he tolerated the procedure well.

preoperative diagnosis: , large and invasive recurrent pituitary adenoma.,postoperative diagnosis:, large and invasive recurrent pituitary adenoma.,operation performed: , endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma, endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus, harvesting of dermal fascia abdominal fat graft, placement of abdominal fat graft into sella turcica, reconstruction of sellar floor using autologous nasal bone creating a cranioplasty of less than 5 cm, repair of nasal septal deviation, using the operating microscope and microdissection technique, and placement of lumbar subarachnoid catheter connected to reservoir for aspiration and infusion.,indications for procedure: , this man has undergone one craniotomy and 2 previous transsphenoidal resections of his tumor, which is known to be an invasive pituitary adenoma. he did not return for followup or radiotherapy as instructed, and the tumor has regrown. for this reason, he is admitted for transsphenoidal reoperation with an attempt to remove as much tumor as possible. the high-risk nature of the procedure and the fact that postoperative radiation is mandatory was made clear to him. many risks including csf leak and blindness were discussed in detail. after clear understanding of all the same, he elected to proceed ahead with surgery.,procedure: ,the patient was placed on the operating table, and after adequate induction of general anesthesia, he was placed in the left lateral decubitus position. care was taken to pad all pressure points appropriately. the back was prepped and draped in usual sterile manner.,a 14-gauge tuohy needle was introduced into the lumbar subarachnoid space. clear and colorless csf issued forth. a catheter was inserted to a distance of 40 cm, and the needle was removed. the catheter was then connected to a closed drainage system for aspiration and infusion.,this no-touch technique is now a standard of care for treatment of patients with large invasive adenomas. via injections through the lumbar drain, one increases intracranial pressure and produces gentle migration of the tumor. this improves outcome and reduces complications by atraumatically dissecting the tumor away from the optic apparatus.,the patient was then placed supine, and the 3-point headrest was affixed. he was placed in the semi-sitting position with the head turned to the right and a roll placed under the left shoulder. care was taken to pad all pressure points appropriately. the fluoroscope c-arm unit was then positioned so as to afford an excellent view of the sella and sphenoid sinus in the lateral projection. the metallic arm was then connected to the table for the use of the endoscope. the oropharynx, nasopharynx, and abdominal areas were then prepped and draped in the usual sterile manner.,a transverse incision was made in the abdominal region, and several large pieces of fat were harvested for later use. hemostasis was obtained. the wound was carefully closed in layers.,i then advanced a 0-degree endoscope up the left nostril. the middle turbinate was identified and reflected laterally exposing the sphenoid sinus ostium. needle bovie electrocautery was used to clear mucosa away from the ostium. the perpendicular plate of the ethmoid had already been separated from the sphenoid. i entered into the sphenoid.,there was a tremendous amount of dense fibrous scar tissue present, and i slowly and carefully worked through all this. i identified a previous sellar opening and widely opened the bone, which had largely regrown out to the cavernous sinus laterally on the left, which was very well exposed, and the cavernous sinus on the right, which i exposed the very medial portion of. the opening was wide until i had the horizontal portion of the floor to the tuberculum sella present.,the operating microscope was then utilized. working under magnification, i used hypophysectomy placed in the nostril.,the dura was then carefully opened in the midline, and i immediately encountered tissue consistent with pituitary adenoma. a frozen section was obtained, which confirmed this diagnosis without malignant features.,slowly and meticulously, i worked to remove the tumor. i used the suction apparatus as well as the bipolar coagulating forceps and ring and cup curette to begin to dissect tumor free. the tumor was moderately vascular and very fibrotic.,slowly and carefully, i systematically entered the sellar contents until i could see the cavernous sinus wall on the left and on the right. there appeared to be cavernous sinus invasion on the left. it was consistent with what we saw on the mri imaging.,the portion working into the suprasellar cistern was slowly dissected down by injecting saline into the lumbar subarachnoid catheter. a large amount of this was removed. there was a csf leak, as the tumor was removed for the upper surface of it was very adherent to the arachnoid and could not be separated free.,under high magnification, i actually worked up into this cavity and performed a very radical excision of tumor. while there may be a small amount of tumor remaining, it appeared that a radical excision had been created with decompression of the optic apparatus. in fact, i reinserted the endoscope and could see the optic chiasm well.,i reasoned that i had therefore achieved the goal with that is of a radical excision and decompression. attention was therefore turned to closure.,the wound was copiously irrigated with bacitracin solution, and meticulous hemostasis was obtained. i asked anesthesiology to perform a valsalva maneuver, and there was no evidence of bleeding.,attention was turned to closure and reconstruction. i placed a very large piece of fat in the sella to seal the leak and verified that there was no fat in the suprasellar cistern by using fluoroscopy and looking at the pattern of the air. using a polypropylene insert, i reconstructed the sellar floor with this implant making a nice tight sling and creating a cranioplasty of less than 5 cm.,duraseal was placed over this, and the sphenoid sinus was carefully packed with fat and duraseal.,i inspected the nasal passages and restored the septum precisely to the midline repairing a previous septal deviation. the middle turbinates were then restored to their anatomic position. there was no significant intranasal bleeding, and for this reason, an open nasal packing was required. sterile dressings were applied, and the operation was terminated.,the patient tolerated the procedure well and left to the recovery room in excellent condition. the sponge and needle counts were reported as correct, and there were no intraoperative complications.,specimens were sent to pathology consisting of tumor.

reason for visit:, preop evaluation regarding gastric bypass surgery.,the patient has gone through the evaluation process and has been cleared from psychological, nutritional, and cardiac standpoint, also had great success on the preop medifast diet.,physical examination: , the patient is alert and oriented x3. temperature of 97.9, pulse of 76, blood pressure of 114/74, weight of 247.4 pounds. abdomen: soft, nontender, and nondistended.,assessment and plan:, the patient is currently in stable condition with morbid obesity, scheduled for gastric bypass surgery in less than two weeks. risks and benefits of the procedure were reiterated with the patient and significant other and mother, which included but not limited to death, pulmonary embolism, anastomotic leak, reoperation, prolonged hospitalization, stricture, small bowel obstruction, bleeding, and infection. questions regarding hospital course and recovery were addressed. we will continue on the medifast diet until the time of surgery and cleared for surgery.

history of present illness:, the patient is a two-and-a-half-month-old male who has been sick for the past three to four days. his mother has described congested sounds with cough and decreased appetite. he has had no fever. he has had no rhinorrhea. nobody else at home is currently ill. he has no cigarette smoke exposure. she brought him to the emergency room this morning after a bad coughing spell. he did not have any apnea during this episode.,past medical history:, unremarkable. he has had his two-month immunizations.,physical examination:,vital signs: temperature 99.1, oxygen saturations 98%, respirations by the nurse at 64, however, at my examination was much slower and regular in the 40s.,general: sleeping, easily aroused, smiling, and in no distress.,heent: soft anterior fontanelle. tms are normal. moist mucous membranes.,lungs: equal and clear.,chest: without retraction.,heart: regular in rate and rhythm without murmur.,abdomen: benign.,diagnostic studies:, chest x-ray ordered by er physician is unremarkable, but to me also.,assessment:, upper respiratory infection.,treatment: , use the bulb syringe and saline nose drops if there is any mucus in the anterior nares. smaller but more frequent feeds. discuss proper sleeping position. recheck if there is any fever or if he is no better in the next three days.

preoperative diagnosis: , thyroid goiter.,postoperative diagnosis: ,thyroid goiter.,procedure performed: , total thyroidectomy.,anesthesia:,1. general endotracheal anesthesia.,2. 9 cc of 1% lidocaine with 1:100,000 epinephrine.,complications:, none.,pathology: , thyroid.,indications: ,the patient is a female with a history of graves disease. suppression was attempted, however, unsuccessful. she presents today with her thyroid goiter. a thyroidectomy was indicated at this time secondary to the patient's chronic condition. indications, alternatives, risks, consequences, benefits, and details of the procedure including specifically the risk of recurrent laryngeal nerve paresis or paralysis or vocal cord dysfunction and possible trach were discussed with the patient in detail. she agreed to proceed. a full informed consent was obtained.,procedure: , the patient presented to abcd general hospital on 09/04/2003 with the history was reviewed and physical examinations was evaluated. the patient was brought by the department of anesthesiology, brought back to surgical suite and given iv access and general endotracheal anesthesia. a 9 cc of 1% lidocaine with 1:100,000 of epinephrine was infiltrated into the area of pre-demarcated above the suprasternal notch. time is allowed for full hemostasis to be achieved. the patient was then prepped and draped in the normal sterile fashion. a #10 blade was then utilized to make an incision in the pre-demarcated and anesthetized area. unipolar electrocautery was utilized for hemostasis. finger dissection was carried out in the superior and inferior planes. platysma was identified and dissected and a subplatysmal plane was created in the superior and inferior, medial and lateral directions using hemostat, metzenbaum, and blunt dissection. the strap muscles were identified. the midline raphe was not easily identifiable at this time. an incision was made through what appeared to be in the midline raphe and dissection was carried down to the thyroid. sternohyoid and sternothyroid muscles were identified and separated on the patient's right side and then subsequently on the left side. it was noted at this time that the thyroid lobule on the right side is a bi-lobule. kitner blunt dissection was utilized to bluntly dissect the overlying thyroid fascia as well as strap muscles off the thyroid, force in the lateral direction. this was carried down to the inferior and superior areas. the superior pole of the right lobule was then identified. a hemostat was placed in the cricothyroid groove and a kitner was placed in this area. a second kitner was placed on lateral aspect of the superior pole and the superior pole of the right thyroid was retracted inferiorly. careful dissection was then carried out in a very meticulous fashion in the superior lobe and identified the appropriate vessels and cauterized with bipolar or ligated with the suture ligature. this was carried out until the superior pole was identified. careful attention was made to avoid nerve injury in this area. dissection was then carried down again bluntly separating the inferior and superior lobes. the bilobed right thyroid was then retracted medially. the recurrent laryngeal nerve was then identified and tracked to its insertion. the overlying vessels of the middle thyroid vein as well as the associated structures were then identified and great attention was made to perform a right careful meticulous dissection to remove the fascial attachments superficial to the recurrent laryngeal nerve off the thyroid. when it was completed, this lobule was then removed from berry's ligament. there was noted to be no isthmus at this time and the entire right lobule was then sent to the pathology for further evaluation. attention was then diverted to the patient's left side. in a similar fashion, the sternohyoid and sternothyroid muscles were already separated. army-navy as well as femoral retractors were utilized to lateralize the appropriate musculature. the middle thyroid vein was identified. blunt dissection was carried out laterally to superiorly once again. a hemostat was utilized to make an opening in the cricothyroid groove and a kitner was then placed in this area. another kitner was placed on the lateral aspect of the superior lobe of the left thyroid and retracted inferiorly. once again, a careful meticulous dissection was utilized to identify the appropriate structures in the superior pole of the left thyroid and suture ligature as well as bipolar cautery was utilized for hemostasis. once again, a careful attention was made not to injure the nerve in this area. the superior pole was then freed appropriately and blunt dissection was carried down to lateral and inferior aspects. the inferior aspect was then identified. the inferior thyroid artery and vein were then identified and ligated. the left thyroid was then medialized and the recurrent laryngeal nerve has been identified. a careful dissection was then carried out to remove the fascial attachments superficial to the recurrent laryngeal nerve on the side as close to the thyroid gland as possible. the thyroid was then removed from the berry's ligament and it was then sent to pathology for further evaluation. evaluation of the visceral space did not reveal any bleeding at this time. this was irrigated and pinpoint areas were bipolored as necessary. surgicel was then placed bilaterally. the strap muscles as well as the appropriate fascial attachments were then approximated with a #3-0 vicryl suture in the midline. the platysma was identified and approximated with a #4-0 vicryl suture and the subdermal plane was approximated with a #4-0 vicryl suture. a running suture consisting of #5-0 prolene suture was then placed and fast absorbing #6-0 was then placed in a running fashion. steri-strips, tincoban, bacitracin and a pressure gauze was then placed. the patient was then admitted for further evaluation and supportive care. the patient tolerated the procedure well. the patient was transferred to postanesthesia care unit in stable condition.

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

preoperative diagnosis: , recurrent severe right auricular hematoma.,postoperative diagnosis: , recurrent severe right auricular hematoma.,title of procedure:, incision and drainage with bolster dressing placement of right ear recurrent auricular hematoma.,anesthesia: , xylocaine 1% with 1:100,000 dilution of epinephrine totaling 2 ml.,complications:, none.,findings: , approximately 5 ml of serosanguineous drainage.,procedure: , the patient underwent an incision and drainage procedure with stay suture placement on 05/28/2008 by me and also by dr. x on 05/23/2008 for a large near 100% auricular hematoma. she presents for suture removal; however, there is still fluid noted now at the antihelix fold above the concha bullosa below previous sutures placed by dr. x. it was recommended that this area be drained through the previous incision and drainage incision which has healed and wound care by the patient appears to be very poor if any at all being performed which may be complicating matters. consent was obtained. the patient is aware that the complications with this ear area severe and auricular deformity is inevitable; however, quick prompt aggressive drainage addressing fluid collections offers a best chance for improvement from an already very difficult situation.,the area was prepped in the usual manner, localized and the previous incision was reopened with a curved hemostat and about 5 ml of serosanguineous drainage was noted. a through-and-through keith needle bolster dressing was applied with cottonoid pledget on both sides of the ear to help compression. she tolerated this procedure very well.

mr. abc was transferred to room 123 this afternoon. we discussed this with the nurses, and it was of course cleared by dr. x. the patient is now on his third postoperative day for an open reduction and internal fixation for two facial fractures, as well as open reduction nasal fracture. he is on his eighth hospital day.,the patient had nasal packing in place, which was removed this evening. this will make it much easier for him to swallow. this will facilitate p.o. fluids and imf diet.,examination of the face revealed some decreased swelling today. he had good occlusion with intact intermaxillary fixation.,his tracheotomy tube is in place. it is a size 8 shiley nonfenestrated. he is being suctioned comfortably.,the patient is in need of something for sleep in the evening, so we have recommended halcion 5 mg at bedtime and repeat of 5 mg in 1 hour if needed.,tomorrow, we will go ahead and change his trach to a noncuffed or a fenestrated tube, so he may communicate and again this will facilitate his swallowing. hopefully, we can decannulate the tracheotomy tube in the next few days.,overall, i believe this patient is doing well, and we will look forward to being able to transfer him to the prison infirmary.

exam:,mri right ankle,clinical:,this is a 51 year old female who first came into the office 3/4/05 with right ankle pain. she stepped on ice the evening prior and twisted her ankle. pf's showed no frank fracture, dislocation, or subluxations.,findings:,received for interpretation is an mri examination performed on 4/28/2005.,there is a "high ankle sprain" of the distal tibiofibular syndesmotic ligamentous complex involving the anterior tibiofibular ligament with marked ligamentous inflammatory thickening and diffuse interstitial edema. there is osteoarthritic spur formation at the anterior aspect of the fibula with a small 2mm osseous structure within the markedly thickened anterior talofibular ligament suggesting a small ligamentous osseous avulsion. the distal tibiofibular syndesmotic ligamentous complex remains intact without a complete rupture. there is no widening of the ankle mortis. the posterior talofibular ligament remains intact.,there is marked ligamentous thickening of the anterior talofibular ligament of the lateral collateral ligamentous complex suggesting the sequela of a remote lateral ankle sprain. there is thickening of the posterior talofibular and calcaneofibular ligaments.,there is a flat retromalleolar sulcus.,there is a full-thickness longitudinal split tear of the peroneus brevis tendon within the retromalleolar groove. the tear extends to the level of the inferior peroneal retinaculum. there is anterior displacement of the peroneus longus tendon into the split peroneus tendon tear.,there is severe synovitis of the peroneus longus tendon sheath with prominent fluid distention. the synovitis extends to the level of the inferior peroneal retinaculum.,there is a focal area of chondral thinning of the hyaline cartilage of the medial talar dome with a focal area of subchondral plate cancellous marrow resorption consistent with and area of prior talar dome contusion but there is no focal osteochondral impaction or osteochondral defect.,there is minimal fluid within the tibiotalar articulation.,there is minimal fluid within the posterior subtalar articulation with mild anterior capsular prolapse. normal talonavicular and calcaneocuboid articulations. the anterior superior calcaneal process is normal.,there is mild tenosynovitis of the posterior tibialis tendon sheath but an intrinsically normal tendon. there is an os navicularis (type ii synchondrosis) with an intact synchondrosis and no active marrow stress phenomenon.,normal flexor digitorum longus tendon.,there is prominent fluid distention of the flexor hallucis longus tendon sheath with capsular distention proximal to the posterior talar processes with prominent fluid distention of the synovial sheath.,there is a loculated fluid collection within kager’s fat measuring approximately 1 x 1 x 2.5cm in size, extending to the posterior subtalar facet joint consistent with a ganglion of either posterior subtalar facet origin or arising from the flexor hallucis longus tendon sheath.,there is mild tenosynovitis of the achilles tendon with mild fusiform enlargement of the non-insertional watershed zone of the achilles tendon but there is no demonstrated tendon tear or tenosynovitis. there is a low-lying soleus muscle that extends to within 4cm of the teno-osseous insertion of the achilles tendon. there is no haglund’s deformity.,there is a plantar calcaneal spur measuring approximately 6mm in size, without a reactive marrow stress phenomenon. normal plantar fascia.,impression:,partial high ankle sprain with diffuse interstitial edema of the anterior tibiofibular ligament with a ligamentous chip avulsion but without a disruption of the anterior tibiofibular ligament.,marked ligamentous thickening of the lateral collateral ligamentous complex consistent with the sequela of a remote lateral ankle sprain.,full-thickness longitudinal split tear of the peroneus brevis tendon with severe synovitis of the peroneal tendon sheath.,post-traumatic deformity of the medial talar dome consistent with a prior osteochondral impaction injury but no osteochondral defect. residual subchondral plate cancellous marrow edema.,severe synovitis of the flexor hallucis longus tendon sheath with prominent fluid distention of the synovial sheath proximal to the posterior talar processes.,septated cystic structure within kager’s fat triangle extending along the superior aspect of the calcaneus consistent with a ganglion of either articular or synovial sheath origin.,plantar calcaneal spur but no reactive marrow stress phenomenon.,mild tendinosis of the achilles tendon but no tendinitis or tendon tear.,os navicularis (type ii synchondrosis) without an active marrow stress phenomenon.

chief complaint: , congestion and cough.,history of present illness: ,the patient is a 5-month-old infant who presented initially on monday with a cold, cough, and runny nose for 2 days. mom states she had no fever. her appetite was good but she was spitting up a lot. she had no difficulty breathing and her cough was described as dry and hacky. at that time, physical exam showed a right tm, which was red. left tm was okay. she was fairly congested but looked happy and playful. she was started on amoxil and aldex and we told to recheck in 2 weeks to recheck her ear. mom returned to clinic again today because she got much worse overnight. she was having difficulty breathing. she was much more congested and her appetite had decreased significantly today. she also spiked a temperature yesterday of 102.6 and always having trouble sleeping secondary to congestion.,allergies: , she has no known drug allergies.,medications: ,none except the amoxil and aldex started on monday.,past medical history: ,negative.,social history: , she lives with mom, sister, and her grandparent.,birth history: , she was born, normal spontaneous vaginal delivery at woman's weighing 7 pounds 3 ounces. no complications. prevented, she passed her hearing screen at birth.,immunizations: , also up-to-date.,past surgical history: , negative.,family history: ,noncontributory.,physical examination:,vital signs: her respiratory rate was approximately 60 to 65.,general: she was very congested and she looked miserable. she had no retractions at this time.,heent: her right tm was still red and irritated with no light reflex. her nasal discharge was thick and whitish yellow. her throat was clear. her extraocular muscles were intact.,neck: supple. full range of motion.,cardiovascular exam: she was tachycardic without murmur.,lungs: revealed diffuse expiratory wheezing.,abdomen: soft, nontender, and nondistended.,extremities: showed no clubbing, cyanosis or edema.,laboratory data: ,her chem panel was normal. rsv screen is positive. chest x-ray and cbc are currently pending.,impression and plan: ,rsv bronchiolitis with otitis media. admit for oral orapred, iv rocephin, nebulizer treatments and oxygen as needed.

history: , patient is a 21-year-old white woman who presented with a chief complaint of chest pain. she had been previously diagnosed with hyperthyroidism. upon admission, she had complaints of constant left sided chest pain that radiated to her left arm. she had been experiencing palpitations and tachycardia. she had no diaphoresis, no nausea, vomiting, or dyspnea.,she had a significant tsh of 0.004 and a free t4 of 19.3. normal ranges for tsh and free t4 are 0.5-4.7 µiu/ml and 0.8-1.8 ng/dl, respectively. her symptoms started four months into her pregnancy as tremors, hot flashes, agitation, and emotional inconsistency. she gained 16 pounds during her pregnancy and has lost 80 pounds afterwards. she complained of sweating, but has experienced no diarrhea and no change in appetite. she was given isosorbide mononitrate and iv steroids in the er.,family history:, diabetes, hypertension, father had a coronary artery bypass graph (cabg) at age 34.,social history:, she had a baby five months ago. she smokes a half pack a day. she denies alcohol and drug use.,medications:, citalopram 10mg once daily for depression; low dose tramadol prn pain.,physical examination: , temperature 98.4; pulse 123; respiratory rate 16; blood pressure 143/74.,heent: she has exophthalmos and could not close her lids completely.,cardiovascular: tachycardia.,neurologic: she had mild hyperreflexiveness.,lab:, all labs within normal limits with the exception of sodium 133, creatinine 0.2, tsh 0.004, free t4 19.3 ekg showed sinus tachycardia with a rate of 122. urine pregnancy test was negative.,hospital course: , after admission, she was given propranolol at 40mg daily and continued on telemetry. on the 2nd day of treatment, the patient still complained of chest pain. ekg again showed tachycardia. propranolol was increased from 40mg daily to 60mg twice daily., a i-123 thyroid uptake scan demonstrated an increased thyroid uptake of 90% at 4 hours and 94% at 24 hours. the normal range for 4-hour uptake is 5-15% and 15-25% for 24-hour uptake. endocrine consult recommended radioactive i-131 for treatment of graves disease.,two days later she received 15.5mci of i-131. she was to return home after the iodine treatment. she was instructed to avoid contact with her baby for the next week and to cease breast feeding.,assessment / plan:,1. treatment of hyperthyroidism. patient underwent radioactive iodine 131 ablation therapy.,2. management of cardiac symptoms stemming from hyperthyroidism. patient was discharged on propranolol 60mg, one tablet twice daily.,3. monitor patient for complications of i-131 therapy such as hypothyroidism. she should return to endocrine clinic in six weeks to have thyroid function tests performed. long-term follow-up includes thyroid function tests at 6-12 month intervals.,4. prevention of pregnancy for one year post i-131 therapy. patient was instructed to use 2 forms of birth control and was discharged an oral contraceptive, taken one tablet daily.,5. monitor ocular health. patient was given methylcellulose ophthalmic, one drop in each eye daily. she should follow up in 6 weeks with the ophthalmology clinic.,6. management of depression. patient will be continued on citalopram 10 mg.

identifying data:, psychosis.,history of present illness: , the patient is a 28-year-old samoan female who was her grandmother's caretaker. her grandmother unfortunately had passed away recently and then the patient had developed erratic behavior. she had lived with her parents and son, but parents removed son from the home, secondary to the patient's erratic behavior. recently, she was picked up by kent police department "leaping on highway 99.",past medical history: , ptsd, depression, and substance abuse.,past surgical history: ,unknown.,allergies:, unknown.,medications: , unknown.,review of systems: , unable to obtain secondary to the patient being in seclusion.,objective:, vital signs that were previously taken revealed a blood pressure of 152/86, pulse of 106, respirations of 18, and temperature is 97.6 degrees fahrenheit. general appearance, heent, and history and physical examination was unable to be obtained today, as patient was put into seclusion.,laboratory data: , laboratory reviewed reveals a bmp, slightly elevated glucose at 100.2. previous urine tox was positive for thc. urinalysis was negative, but did note positive ua wbc's. cbc, slightly elevated leukocytosis at 12.0, normal range is 4 to 11.,assessment and plan:,axis i: psychosis. inpatient psychiatric team to follow.,axis ii: deferred.,axis iii: we were unable to perform physical examination on the patient today secondary to her being in seclusion. laboratory was reviewed revealing leukocytosis, possibly secondary to a uti. we will wait until the patient is out of seclusion to perform examination. should she have some complaints of dysuria or any suprapubic pain, then we will begin on appropriate antimicrobial therapy. we will followup with the patient should any new medical issues arise.

single chamber pacemaker implantation,preoperative diagnosis: , mobitz type ii block with av dissociation and syncope.,postoperative diagnosis: , mobitz type ii block, status post single chamber pacemaker implantation, boston scientific altrua 60, serial number 123456.,procedures:,1. left subclavian access under fluoroscopic guidance.,2. left subclavian venogram under fluoroscopic evaluation.,3. insertion of ventricular lead through left subclavian approach and ventricular lead is boston scientific dextrose model 12345, serial number 123456.,4. insertion of single-chamber pacemaker implantation, altrua, serial number 123456.,5. closure of the pocket after formation of pocket for pacemaker.,procedure in detail: ,the procedure was explained to the patient with risks and benefits. the patient agreed and signed the consent form. the patient was brought to the cath lab, draped and prepped in the usual sterile fashion, received 1.5 mg of versed and 25 mg of benadryl for conscious sedation.,access to the right subclavian was successful after the second attempt. the first attempt accessed the left subclavian artery. the needle was removed and manual compression applied for five minutes followed by re-accessing the subclavian vein successfully. the j-wire was introduced into the left subclavian vein.,the anterior wall chest was anesthetized with lidocaine 2%, 2-inch incision using a #10 blade was used.,the pocket was formed using blunt dissection as he was using the bovie cautery for hemostasis. the patient went asystole during the procedure. the transcutaneous pacer was used. the patient was oxygenating well. the patient had several compression applied by the nurse. however, her own rhythm resolved spontaneously and the percutaneous pacer was kept on standby.,after that, the j-wire was tunneled into the pocket and then used to put the #7-french sheath into the left subclavian vein. the lead from the boston scientific dextrose model 12345, serial number 12345 was inserted through the left subclavian to the right atrium; however, it was difficult to really enter the right ventricle; and while the lead was in place, the side port of the sheath was used to inject 15 ml of contrast to assess the subclavian and the right atrium. the findings were showing different anatomy, may be consistent with persistent left superior vena cava, and the angle to the right ventricle was different. at that point, the lead stylet was reshaped and was able to cross the tricuspid valve in a position consistent with the mid septal place.,at that point, the lead was actively fixated. the stylet was removed. the r-wave measured at 40 millivolts. the impedance was 580 and the threshold was 1.3 volt. the numbers were accepted and because of the patient's fragility and the different anatomy noticed in the right atrium, concern about putting a second lead with re-access of the subclavian was high. i decided to proceed with a single-chamber pacemaker as a backup system.,after that, the lead sleeve was used to actively fixate the lead in the anterior chest with two ethibond sutures in the usual fashion.,the lead was attached to the pacemaker in the header. the pacemaker was single-chamber pacemaker altura 60, serial number 123456. after that, the pacemaker was put in the pocket. pocket was irrigated with normal saline and was closed into two layers, deep interrupted #3-0 vicryl and surface as continuous #4-0 vicryl continuous.,the pacemaker was programmed as vvi 60, and with history is 10 to 50 beats per minute. the lead position will be evaluated with chest x-ray.,no significant bleeding noticed.,conclusion: ,successful single-chamber pacemaker implantation with left subclavian approach and venogram to assess the subclavian access site and the right atrial or right ventricle with asystole that resolved spontaneously during the procedure. no significant bleed.

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.

s: , the patient presents to podiatry clinic today at the request of her primary physician, dr. xyz for initial examination, evaluation, and treatment of her nails. the patient has last seen primary in december 2006.,primary medical history: , edema, venous insufficiency, schizophrenia, and anemia.,allergies: , the patient has no known allergies.,medications: , refer to chart.,o: , the patient presents in wheelchair, verbal and alert. vascular: she has absent pedal pulses bilaterally. trophic changes include absent hair growth and mycotic nails. skin texture is dry. skin color is rubor. classic findings include temperature change and edema +1. nails: hypertrophic with crumbly subungual debris, #1, #2, #3, #4, and #5 right and #1, #2, #3, #4, and #5 left.,a:,1. onychomycosis present, #1, #2, #3, #4, and #5 right and left.,2. peripheral vascular disease as per classic findings.,3. pain on palpation.,p: , nails #1, #2, #3, #4, and #5 right and #1, #2, #3, #4, and #5 left were debrided for length and thickness. the patient will be seen again at the request of the nursing staff for treatment of painful mycotic nails.

diagnosis: , left breast adenocarcinoma stage t3 n1b m0, stage iiia.,she has been found more recently to have stage iv disease with metastatic deposits and recurrence involving the chest wall and lower left neck lymph nodes.,current medications,1. glucosamine complex.,2. toprol xl.,3. alprazolam,4. hydrochlorothiazide.,5. dyazide.,6. centrum.,dr. x has given her some carboplatin and taxol more recently and feels that she would benefit from electron beam radiotherapy to the left chest wall as well as the neck. she previously received a total of 46.8 gy in 26 fractions of external beam radiotherapy to the left supraclavicular area. as such, i feel that we could safely re-treat the lower neck. her weight has increased to 189.5 from 185.2. she does complain of some coughing and fatigue.,physical examination,neck: on physical examination palpable lymphadenopathy is present in the left lower neck and supraclavicular area. no other cervical lymphadenopathy or supraclavicular lymphadenopathy is present.,respiratory: good air entry bilaterally. examination of the chest wall reveals a small lesion where the chest wall recurrence was resected. no lumps, bumps or evidence of disease involving the right breast is present.,abdomen: normal bowel sounds, no hepatomegaly. no tenderness on deep palpation. she has just started her last cycle of chemotherapy today, and she wishes to visit her daughter in brooklyn, new york. after this she will return in approximately 3 to 4 weeks and begin her radiotherapy treatment at that time.,i look forward to keeping you informed of her progress. thank you for having allowed me to participate in her care.

discharge diagnosis:,1. respiratory failure improved.,2. hypotension resolved.,3. anemia of chronic disease stable.,4. anasarca improving.,5. protein malnourishment improving.,6. end-stage liver disease.,history and hospital course: ,the patient was admitted after undergoing a drawn out process with a small bowel obstruction. his bowel function started to improve. he was on tpn prior to coming to hospital. he has remained on tpn throughout his time here, but his appetite and his p.o. intake have improved some. the patient had an episode while here where his blood pressure bottomed out requiring him to spend multiple days in the intensive care unit on dopamine. at one point, we were unsuccessful at weaning him off the dopamine, but after approximately 11 days, he finally started to tolerate weaning parameters, was successfully removed from dopamine, and has maintained his blood pressure without difficulty. the patient also was requiring bipap to help with his oxygenation and it appeared that he developed a left-sided pneumonia. this has been treated successfully with zyvox and levaquin and diflucan. he seems to be currently doing much better. he is only using bipap in the evening. as stated above, he is eating better. he had some evidence of redness and exquisite swelling around his genital and lower abdominal region. this may be mainly dependent edema versus anasarca. the patient has been diuresed aggressively over the last 4 to 5 days, and this seems to have made some improvement in his swelling. this morning, the patient denies any acute distress. he states he is feeling good and understands that he is being discharged to another facility for continued care and rehabilitation. he will be discharged to garden court skilled nursing facility.,discharge medications/instructions:, he is going to be going with protonix 40 mg daily, metoclopramide 10 mg every 6 hours, zyvox 600 mg daily for 5 days, diflucan 150 mg p.o. daily for 3 days, bumex 2 mg p.o. daily, megace 400 mg p.o. b.i.d., ensure 1 can t.i.d. with meals, and miralax 17 gm p.o. daily. the patient is going to require physical therapy to help with assistance in strength training. he is also going to need respiratory care to work with his bipap. his initial settings are at a rate of 20, pressure support of 12, peep of 6, fio2 of 40%. the patient will need a sleep study, which the nursing home will be able to set up.,physical examination:,vital signs: on the day of discharge, heart rate 99, respiratory rate 20, blood pressure 102/59, temperature 98.2, o2 sat 97%.,general: a well-developed white male who appears in no apparent distress.,heent: unremarkable.,cardiovascular: positive s1, s2 without murmur, rubs, or gallops.,lungs: clear to auscultation bilaterally without wheezes or crackles.,abdomen: positive for bowel sounds. soft, nondistended. he does have some generalized redness around his abdominal region and groin. this does appear improved compared to presentation last week. the swelling in this area also appears improved.,extremities: show no clubbing or cyanosis. he does have some lower extremity edema, 2+ distal pedal pulses are present.,neurologic: the patient is alert and oriented to person and place. he is alert and aware of surroundings. we have not had any difficulties with confusion here lately.,musculoskeletal: the patient moves all extremities without difficulty. he is just weak in general.,laboratory data: , lab work done today shows the following: white count 4.2, hemoglobin 10.2, hematocrit 30.6, and platelet count 184,000. electrolytes show sodium 139, potassium 4.1, chloride 98, co2 26, glucose 79, bun 56, and creatinine 1.4. calcium 8.8, phosphorus is a little high at 5.5, magnesium 2.2, albumin 3.9.,plan: ,discharge this gentleman from hospital and admit him to garden court snf where they can continue with his rehab and conditioning. hopefully, long-term planning will be discharge home. he has a history of end-stage liver disease with cirrhosis, which may make him a candidate for hospice upon discharge. the family initially wanted to bring the patient home, but he is too weak and requires too much assistance to adequately consider this option at this time.

procedure:, left heart catheterization, left ventriculography, coronary angiography, and successful stenting of tight lesion in the distal circumflex and moderately tight lesion in the mid right coronary artery. this gentleman has had a non-q-wave, troponin-positive myocardial infarction, complicated by ventricular fibrillation.,procedure details:, the patient was brought to the catheterization lab, the chart was reviewed, and informed consent was obtained. right groin was prepped and draped sterilely and infiltrated 2% xylocaine. using the seldinger technique, a #6-french sheath was placed in the right femoral artery. act was checked and was low. additional heparin was given. a #6-french pigtail catheter was passed. left ventriculography was performed. the catheter was exchanged for a #6-french jl4 catheter. nitroglycerin was given in the left main. left coronary angiography was performed. the catheter was exchanged for a #6-french __________ coronary catheter. nitroglycerin was given in the right main, and right coronary angiography was performed. films were closely reviewed, and it was felt that he had a significant lesion in the rca and the distal left circumflex is basically an om. considering his age and his course, it was elected to stent both these lesions. reopro was started, and the catheter was exchanged for a #6-french jr4 guide. reopro was given in the rca to prevent no reflow. a 0.014 universal wire was passed. the lesion was measured. a 4.5 x 18-mm stent was passed and deployed to moderate pressures with an excellent result. the catheter was removed and exchanged for a #6-french jl4 guide. the same wire was passed down the circumflex and the lesion measured. a 2.75 x 15-mm stent was deployed to a moderate pressure with an excellent result. plavix was given. the catheter was removed and sheath was in place. the results were explained to the patient and his wife.,findings,1. hemodynamics. please see attached sheet for details. ed was 20. there is no gradient across the aortic valve.,2. left ventriculography revealed septum upper limits of normal size with borderline normal lv systolic function with borderline normal wall motion, in which there is a question of diffuse, very minimal global hypokinesis. there is mild mr noted.,3. coronary angiography.,a. left main normal.,b. lad. some very minimal luminal irregularities. there is a 1st diagonal which has a branch that is 1.5 mm with a proximal 50% narrowing.,c. left circumflex is basically a marginal branch, in which distally there was a long 98% lesion.,d. the rca is large dominant and has a mid somewhat long 70% lesion.,4. stenting.,a. the rca revealed a lesion that went from 70% to a -5%.,b. the circumflex went from 95% to -5%.,conclusion,1. decreased left ventricular compliance.,2. borderline normal overall ejection fraction with mild mitral regurgitation.,3. triple-vessel coronary artery disease with a borderline lesion in a very small branch of the 1st diagonal and significant lesions in the mid dominant right coronary artery and the distal circumflex, which is basically old.,4. successful stenting of the right coronary artery and the circumflex.,recommendation: , reopro/stent protocol, plavix for at least 9 months, aggressive control of risk factors. i have ordered zocor and a fasting lipid panel.,aicd will be considered, realizing when this gentleman becomes ischemic he is at high risk for fibrillating.

impression: ,eeg during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.

chief complaint:, "i took ecstasy.",history of present illness: , this is a 17-year-old female who went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six ecstasy tablets. the patient upon returning to home was energetic and agitated and shaking and had one episode of nonbloody, nonbilious emesis. mother called the ems service when the patient vomited. on arrival here, the patient states that she no longer has any nausea and that she feels just fine. the patient states she feels wired but has no other problems or complaints. the patient denies any pain. the patient does not have any auditory of visual hallucinations. the patient denies any depression or suicidal ideation. the patient states that the alcohol and the ecstasy was done purely as a recreational thing and not as an attempt to harm herself. the patient denies any homicidal ideation. the patient denies any recent illness or recent injuries. the mother states that the daughter appears to be back to her usual self now.,review of systems: , constitutional: no recent illness. no fever or chills. heent: no headache. no neck pain. no vision change or hearing change. no eye or ear pain. no rhinorrhea. no sore throat. cardiovascular: no chest pain. no palpitations or racing heart. respirations: no shortness of breath. no cough. gastrointestinal: one episode of nonbloody, nonbilious emesis this morning without any nausea since then. the patient denies any abdominal pain. no change in bowel movements. genitourinary: no dysuria. musculoskeletal: no back pain. no muscle or joint aches. skin: no rashes or lesions. neurologic: no dizziness, syncope, or near syncope. psychiatric: the patient denies any depression, suicidal ideation, homicidal ideation, auditory hallucinations or visual hallucinations. endocrine: no heat or cold intolerance.,past medical history:, none.,past surgical history: , appendectomy when she was 9 years old.,current medications: , birth control pills.,allergies: , no known drug allergies.,social history: , the patient denies smoking cigarettes. the patient does drink alcohol and also uses illicit drugs.,physical examination: , vital signs: temperature is 98.8 oral, blood pressure 140/86, pulse is 79, respirations 16, oxygen saturation 100% on room air and is interpreted as normal. constitutional: the patient is well nourished, and well developed, appears to be healthy. the patient is calm and comfortable, in no acute distress and looks well. the patient is pleasant and cooperative. heent: head is atraumatic, normocephalic, and nontender. eyes are normal with clear cornea and conjunctiva bilaterally. the patient does have dilated pupils of approximately 8 mm each and are equally round and reactive to light bilaterally. no evidence of light sensitivity or photophobia. extraocular motions are intact bilaterally. nose is normal without rhinorrhea or audible congestion. ears are normal without any sign of infection. mouth and oropharynx are normal without any signs of infection. mucous membranes are moist. neck: supple and nontender. full range of motion. there is no jvd. cardiovascular: heart is regular rate and rhythm without murmur, rub or gallop. peripheral pulses are +3 and bounding. respirations: clear to auscultation bilaterally. no shortness of breath. no wheezes, rales or rhonchi. good air movement bilaterally. gastrointestinal: abdomen is soft, nontender, normal and benign. musculoskeletal: no abnormalities noted in back, arms, or legs. the patient is normal use of her extremities. skin: no rashes or lesions. neurologic: cranial nerves ii through xii are intact. motor and sensory are intact in all extremities. the patient has normal speech and normal ambulation. psychiatric: the patient is alert and oriented x4. the patient does not have any smell of alcohol and does not exhibit any clinical intoxication. the patient is quite pleasant, fully cooperative. hematologic/lymphatic: no lymphadenitis is noted. no bruising is noted.,diagnoses:,1. ecstasy ingestion.,2. alcohol ingestion.,3. vomiting secondary to stimulant abuse.,condition upon disposition: , stable disposition to home with her mother.,plan:, i will have the patient followup with her physician at the abc clinic in two days for reevaluation. the patient was advised to stop drinking alcohol, and taking ecstasy as this is not only in the interest of her health, but was also illegal. the patient is asked to return to the emergency room should she have any worsening of her condition, develop any other problems or symptoms of concern.

cc: ,gait difficulty.,hx: ,this 59 y/o rhf was admitted with complaint of gait difficulty. the evening prior to admission she noted sudden onset of lue and lle weakness. she felt she favored her right leg, but did not fall when walking. she denied any associated dysarthria, facial weakness, chest pain, sob, visual change, ha, nausea or vomiting.,pmh:, tonsillectomy, adenoidectomy, skull fx 1954, htn, ha.,meds: ,none on day of exam.,shx: ,editorial assistant at newspaper, 40pk-yr tobacco, no etoh/drugs.,fhx: ,noncontributory,admit exam: ,p95 r20, t36.6, bp169/104,ms: a&o to person, place and time. speech fluent and without dysarthria, naming-comprehension-reading intact. euthymic with appropriate affect.,cn: pupils 4/4 decreasing to 2/2 on exposure to light, fundi flat, vfftc, eomi, face symmetric with intact sensation, gag-shrug-corneal reflexes intact, tongue ml with full rom,motor: full strength throughout right side. mildly decreased left grip and left extensor hallucis longus. biceps/triceps/wrist flexors and extensor were full strength on left. however she demonstrated mild lue pronator drift and had difficulty standing on her lle despite full strength on bench testing of the lle.,sensory: no deficit to pp/t/vib/prop/ lt,coord: decreased speed and magnitude of fnf, finger tapping and hks, on left side only.,station: mild lue upward drift.,gait: tendency to drift toward the left. difficulty standing on lle.,reflexes were symmetric, plantar responses were flexor bilaterally.,gen exam unremarkable.,course: ,admit labs: esr, pt/ptt, gs, ua, ekg, and hct were unremarkable. hgb 13.9, hct 41%, plt 280k, wbc 5.5.,the patient was diagnosed with a probable lacunar stroke and entered into the toast study (trial of org10172[a low molecular weight heparin] in acute stroke treatment).,carotid duplex: 16-49%rica and 0-15%lica stenosis with anterograde vertebral artery flow, bilaterally. transthoracic echocardiogram showed mild mitral regurgitation, mild tricuspid regurgitation and a left to right shunt. there was no evidence of blood clot.,hospital course: 5 days after admission the patient began to complain of proximal lle and left flank pain. on exam, she had weakness of the quadriceps and hip flexors of the lle. her pain increased with left hip flexion. in addition, she complained of paresthesias about the lateral aspect of the medial anterior left thigh; and upon on sensory testing, she had decreased pp/temp sensation in a left femoral nerve distribution. she denied any back/neck pain and the rest of her neurologic exam remained unchanged from admission.,abdominal ct scan, 2/4/96, revealed a large left retroperitoneal iliopsoas hematoma.,hgb 8.9g/dl. she was transfused with 4 units of prbcs. she underwent surgical decompression and evacuation of the hematoma via a posterior flank approach on 2/6/96. her postoperative course was uncomplicated. she was discharged home on asa.,at follow-up, on 2/23/96, she complained of left sided paresthesias (worse in the lle than in the lue) and feeling of "swollen left foot." these symptoms had developed approximately 1 month after her stroke. her foot looked normal and her ue strength was 5/4+ proximally and distally, and le strength 5/4+ proximally and 5/5- distally. she was ambulatory. there was no evidence of lue upward drift. a somatosensory evoked potential study revealed an absent n20 and normal p14 potentials. this was suggestive of a lesion involving the right thalamus which might explain her paresthesia/dysesthesia as part of a dejerine-roussy syndrome.

preoperative diagnoses:,1. enlarged fibroid uterus.,2. hypermenorrhea.,postoperative diagnoses:,1. enlarged fibroid uterus.,2. hypermenorrhea.,3. secondary anemia.,procedure performed:,1. dilatation and curettage.,2. hysteroscopy.,gross findings: , uterus was anteverted, greatly enlarged, irregular and firm. the cervix is patulous and nulliparous without lesions. adnexal examination was negative for masses.,procedure: ,the patient was taken to the operating room where she was properly prepped and draped in sterile manner under general anesthesia. after bimanual examination, the cervix was exposed with a weighted vaginal speculum and the anterior lip of the cervix grasped with a vulsellum tenaculum. the uterus was sounded to a depth of 11 cm. the endocervical canal was then progressively dilated with hanks and hegar dilators to a #10 hegar. the acmi hysteroscope was then introduced into the uterine cavity using sterile saline solution as a distending media and with attached video camera. the endometrial cavity was distended with fluids and the cavity visualized. multiple irregular areas of fibroid degeneration were noted throughout the cavity. the coronal areas were visualized bilaterally with corresponding tubal ostia. a moderate amount of proliferative appearing endometrium was noted. there were no direct intraluminal lesions seen. the patient tolerated the procedure well. several pictures were taken of the endometrial cavity and the hysteroscope removed from the cavity.,a large sharp curet was then used to obtain a moderate amount of tissue, which was the sent to pathologist for analysis. the instrument was removed from the vaginal vault. the patient was sent to recovery area in satisfactory postoperative condition.

findings:,by dates the patient is 8 weeks, 2 days.,there is a gestational sac within the endometrial cavity measuring 2.1cm consistent with 6 weeks 4 days. there is a fetal pole measuring 7mm consistent with 6 weeks 4 days. there was no fetal heart motion on doppler or on color doppler.,there is no fluid within the endometrial cavity.,there is a 2.8 x 1.2cm right adnexal cyst.,impression:,gestational sac with a fetal pole but no fetal heart motion consistent with fetal demise at 6 weeks 4 days. by dates the patient is 8 weeks, 2 days.,a preliminary report was called by the ultrasound technologist to the referring physician.

cc: ,paraplegia.,hx:, this 32 y/o rhf had been performing missionary work in jos, nigeria for several years and delivered her 4th child by vaginal delivery on 4/10/97. the delivery was induced with pitocin, but was otherwise uncomplicated. for the first 4 days post-partum she noted clear liquid diarrhea without blood and minor abdominal discomfort. this spontaneous resolved without medical treatment. the second week post-partum she had 4-5 days of sinusitis, purulent nasal discharge and facial pain. she was otherwise well until 5/4/97 when stationed in a more rural area of nigeria, she noted a dull ache in both knees (lateral to the patellae) and proximal tibia, bilaterally. the pain was not relieved by massage and seemed more bothersome when seated or supine. she had no sensory loss at the time.,on 5/6/97, she awakened to pain radiating down her knees to her anterior tibia. over the next few hours the pain radiated circumferentially around both calves, and involved the soles of her feet and posterior ble to her buttocks. rising from bed became a laborious task and she required assistance to walk to the bathroom. ibuprofen provided minimal analgesia. by evening the sole of one foot was numb.,she awoke the next morning, 5/9/97, with "pins & needles" sensation in ble up to her buttocks. she was given darvocet for analgesia and took an airplane back to the larger city she was based in. during the one hour flight her ble weakness progressed to a non-weight bearing state (i.e. she could not stand). local evaluation revealed 3/3 proximal and 4/4 distal ble weakness. she had a sensory level to her waist on pp and lt testing. she also had mild lumbar back pain. local laboratory evaluation: wbc 12.7, esr 10. she was presumed to have guillain-barre syndrome and was placed on solu-cortef 1000mg qd and sandimmune iv igg 12.0 g.,on 5/10/97, she was airlifted to geneva, switzerland. upon arrival there she had total anesthesia from the feet up to the inguinal region, bilaterally. there was flaccid areflexic paralysis of ble and she was unable to void or defecate. straight catheterization of the bladder revealed a residual volume of 1000cc. on 5/12/ csf analysis revealed: protein 1.5g/l, glucose 2.2mmol/l, wbc 92 (o pmns, 100% lymphocytes), rbc 70, clear csf, bacterial-fungal-afb-cultures were negative. broad spectrum antibiotics and solu-medrol 1g iv qd were started. mri t-l-spine, 5/12/97 revealed an intradural t12-l1 lesion that enhanced minimally with gadolinium and was associated with spinal cord edema in the affected area. mri brain, 5/12/97, was unremarkable and showed no evidence of demyelinating disease. hiv, htlv-1, hsv, lyme, ebv, malaria and cmv serological titers were negative. on 5/15/97 the schistosomiasis mekongi ifat serological titer returned positive at 1:320 (normal<1:80). 5/12/97 csf schistosomiasis mekongi ifat and elisa were negative. she was then given a one day course of praziquantel 3.6g total in 3 doses; and started on prednisone 60 mg po qd; the broad spectrum antibiotics and solu-medrol were discontinued.,on 5/22/97, a rectal biopsy was performed to evaluate parasite eradication. the result came back positive for ova and granulomata after she had left for uihc. the organism was not speciated. 5/22/97 csf schistosomiasis elisa and ifat titers were positive at 1.09 and 1:160, respectively. these titers were not known when she initially arrived at uihc.,following administration of praziquantel, she regained some sensation in ble but the paraplegia, and urinary retention remained.,meds:, on 5/24/97 uihc arrival: prednisone 60mg qd, zantac 50 iv qd, propulsid 20mg tid, enoxaparin 20mg qd.,pmh:, 1)g4p4.,fhx:, unremarkable.,shx: ,missionary. married. 4 children ( ages 7,5,3,6 weeks).,exam:, bp110/70, hr72, rr16, 35.6c,ms: a&o to person, place and time. speech fluent and without dysarthria. lucid thought process.,cn: unremarkable.,motor: 5/5 bue strength. lower extremities: 1/1 quads and hamstrings, 0/0 distally.,sensory: decreased pp/lt/vib from feet to inguinal regions, bilaterally. t12 sensory level to temperature (ice glove).,coord: normal fnf.,station/gait: not done.,reflexes: 2/2 bue. 0/0 ble. no plantar responses, bilaterally.,rectal: decreased to no rectal tone. guaiac negative.,other: no lhermitte's sign. no paraspinal hypertonicity noted. no vertebral tenderness.,gen exam: unremarkable.,course:, mri t-l-spine, 5/24/97, revealed a 6 x 8 x 25 soft tissue mass at the l1 level posterior to the tip of the conus medullaris and extending into the canal below that level. this appeared to be intradural. there was mild enhancement. there was more enhancement along the distal cord surface and cauda equina. the distal cord had sign of diffuse edema. she underwent exploratory and decompressive laminectomy on 5/27/97, and was retreated with a one day course of praziquantel 40mg/kg/day. praziquantel is reportedly only 80% effective at parasite eradication.,she continued to reside on the neurology/neurosurgical service on 5/31/97 and remained paraplegic.

title of operation: , ligation (clip interruption) of patent ductus arteriosus.,indication for surgery: , this premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch. she has now been put forward for operative intervention.,preop diagnosis: ,1. patent ductus arteriosus.,2. severe prematurity.,3. operative weight less than 4 kg (600 grams).,complications: , none.,findings: , large patent ductus arteriosus with evidence of pulmonary over circulation. after completion of the procedure, left recurrent laryngeal nerve visualized and preserved. substantial rise in diastolic blood pressure.,details of the procedure: , after obtaining information consent, the patient was positioned in the neonatal intensive care unit, cribbed in the right lateral decubitus, and general endotracheal anesthesia was induced. the left chest was then prepped and draped in the usual sterile fashion and a posterolateral thoracotomy incision was performed. dissection was carried through the deeper planes until the second intercostal space was entered freely with no damage to the underlying lung parenchyma. the lung was quite edematous and was retracted anteriorly exposing the area of the isthmus. the pleura overlying the ductus arteriosus was inside and the duct dissected in a nearly circumferential fashion. it was then test occluded and then interrupted with a medium titanium clip. there was preserved pulsatile flow in the descending aorta. the left recurrent laryngeal nerve was identified and preserved. with excellent hemostasis, the intercostal space was closed with 4-0 vicryl sutures and the muscular planes were reapproximated with 5-0 caprosyn running suture in two layers. the skin was closed with a running 6-0 caprosyn suture. a sterile dressing was placed. sponge and needle counts were correct times 2 at the end of the procedure. the patient was returned to the supine position in which palpable bilateral femoral pulses were noted.,i was the surgical attending present in the neonatal intensive care unit and in-charge of the surgical procedure throughout the entire length of the case.

preoperative diagnosis: , prostate cancer.,postoperative diagnosis: , prostate cancer.,operation: , cystoscopy and removal of foreign objects from the urethra.,brachytherapy:, iodine 125.,anesthesia: , general endotracheal. the patient was given levaquin 500 mg iv preoperatively.,total seeds were 59. activity of 0.439, 30 seeds in the periphery with 10 needles and total of 8 seeds at the anterior of the fold, 4 needles. please note that the total needles placed on the top were actually 38 seeds and 22 seeds were returned back.,brief history: , this is a 72-year-old male who presented to us with elevated psa and prostate biopsy with gleason 6 cancer on the right apex. options such as watchful waiting, brachytherapy, radical prostatectomy, cryotherapy, and external beam radiation were discussed. risk of anesthesia, bleeding, infection, pain, mi, dvt, pe, incontinence, erectile dysfunction, urethral stricture, dysuria, burning pain, hematuria, future procedures, and failure of the procedure were all discussed. the patient understood all the risks, benefits, and options and wanted to proceed with the procedure. the patient wanted to wait until he came back from his summer vacations, so a one dose of zoladex was given. prostate size measured about 15 g in the or and about 22 g about two months ago. consent was obtained.,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 had a foley catheter placed sterilely. the scrotum was taped up using ioban. transrectal ultrasound was done. the prostate was measured 15 g. multiple images were taken. a volume study was done. this was given to the physicist, dr. x was present who is radiation oncologist who helped with implanting of the seeds. total of 38 seeds were placed in the patient with 10 peripheral needles and then 4 internal needles. total of 30 seeds were placed in the periphery and total of 8 seeds were placed in the inside. they were done directly under transrectal ultrasound vision. the seeds were placed directly under ultrasound guidance. there was a nice distribution of the seeds. a couple of more seeds were placed on the right side due to the location of the prostate cancer. subsequently at the end of the procedure, fluoroscopy was done. couple of images were obtained. cystoscopy was done at the end of the procedure where a seed was visualized right in the urethra, which was grasped and pulled out using grasper, which was difficult to get the seed off of the spacers, which was actually pulled out. there were no further seeds visualized in the bladder. the bladder appeared normal. at the end of the procedure, a foley catheter was kept in place of 18 french and the patient was brought to recovery in stable condition.

preoperative diagnosis: , low back syndrome - low back pain.,postoperative diagnosis: , same.,procedure:,1. bilateral facet arthrogram at l34, l45, l5s1.,2. bilateral facet injections at l34, l45, l5s1.,3. interpretation of radiograph.,anesthesia: ,iv sedation with versed and fentanyl.,estimated blood loss: , none.,complications: ,none.,indication: , pain in the lumbar spine secondary to facet arthrosis that was demonstrated by physical examination and verified with x-ray studies and imaging scans.,summary of procedure: , the patient was admitted to the or, consent was obtained and signed. the patient was taken to the operating room and was placed in the prone position. monitors were placed, including ekg, pulse oximeter and blood pressure monitoring. prior to sedation vitals signs were obtained and were continuously monitored throughout the procedure for amount of pain or changes in pain, ekg, respiration and heart rate and at intervals of three minutes for blood pressure. after adequate iv sedation with versed and fentanyl the procedure was begun.,the lumbar sacral regions were prepped and draped in sterile fashion with betadine prep and four sterile towels.,the facets in the lumbar regions were visualized with fluoroscopy using an anterior posterior view. a skin wheal was placed with 1% lidocaine at the l34 facet region on the left. under fluoroscopic guidance a 22 gauge spinal needle was then placed into the l34 facet on the left side. this was performed using the oblique view under fluoroscopy to the enable the view of the "scotty dog," after obtaining the "scotty dog" view the joints were easily seen. negative aspiration was carefully performed to verity that there was no venous, arterial or cerebral spinal fluid flow. after negative aspiration was verified, 1/8th of a cc of omnipaque 240 dye was then injected. negative aspiration was again performed and 1/2 cc of solution (solution consisting of 9 cc of 0.5% marcaine with 1 cc of triamcinolone) was then injected into the joint. the needle was then withdrawn out of the joint and 1.5 cc of this same solution was injected around the joint. the 22-gauge needle was then removed. pressure was place over the puncture site for approximately one minute. this exact same procedure was then repeated along the left-sided facets at l45, and l5s1. this exact same procedure was then repeated on the right side. at each level, vigilance was carried out during the aspiration of the needle to verify negative flow of blood or cerebral spinal fluid.,the patient was noted to have tolerated the procedure well without any complications.,interpretation of the radiograph revealed placement of the 22-gauge spinal needles into the left-sided and right-sided facet joints at, l34, l45, and l5s1. visualizing the "scotty dog" technique under fluoroscopy facilitated this. dye spread into each joint space is visualized. no venous or arterial run-off is noted. no epidural run-off is noted. the joints were noted to have chronic inflammatory changes noted characteristic of facet arthrosis.

chief complaint:, head injury.,history: , this 16-year-old female presents to children's hospital via paramedic ambulance with a complaint at approximately 6 p.m. while she was at band practice using her flag device. she struck herself in the head with the flag. there was no loss of consciousness. she did feel dizzy. she complained of a headache. she was able to walk. she continued to participate in her flag practice. she got dizzier. she sat down for a while and walked and during the second period of walking, she had some episodes of diplopia, felt that she might faint and was assisted to the ground and was transported via paramedic ambulance to children's hospital for further evaluation.,past medical history: , hypertension.,allergies:, denied to me; however, it is noted before several according to meditech.,current medications: , enalapril.,past surgical history: , she had some kind of an abdominal obstruction as an infant.,social history: , she is here with mother and father who lives at home. there is no smoking at home. there is second-hand smoke exposure.,family history: ,no noted family history of infectious disease exposure.,immunizations:, she is up-to-date on her shots, otherwise negative.,review of systems: ,on the 10-plus systems reviewed with the section of those noted on the template.,physical examination:,vital signs: her temperature 100 degrees, pulse 86, respirations 20, and her initial blood pressure 166/116, and a weight of 55.8 kg.,general: she is supine awake, alert, cooperative, and active child.,heent: head atraumatic, normocephalic. pupils equal, round, reactive to light. extraocular motions intact and conjugate. clear tms, nose and oropharynx. moist oral mucosa without noted lesions.,neck: supple, full painless nontender range motion.,chest: clear to auscultation, equal, stable to palpation.,heart: regular without rubs or murmurs.,abdomen: no abdominal bruits are heard.,extremities: equal femoral pulses are appreciated. equal radial and dorsalis pedis pulses are appreciated. he moves all extremities without difficulty. nontender. no deformity. no swelling.,skin: there was no significant bruising, lesions or rash about her abdomen. no significant bruising, lesions or rash.,neurologic: symmetric face and extremity motion. ambulates without difficulty. she is awake, alert, and appropriate.,medical decision making:, the differential entertained includes head injury, anxiety, and hypertensive emergency. she is evaluated in the emergency department with serial blood pressure examinations, which are noted to return to a more baseline state for her 130s/90s. her laboratory data shows a mildly elevated creatinine of 1.3. urine is within normal. urinalysis showing no signs of infection. head ct read by staff has no significant intracranial pathology. no mass shift, bleed or fracture per dr. x. a 12-lead ekg reviewed preliminarily by myself noting normal sinus rhythm, normal axis rates of 90. no significant st-t wave changes. no significant change from previous 09/2007 ekg. her headache has resolved. she is feeling better. i spoke with dr. x at 0206 hours consulting nephrology regarding this patient's presentation with the plan for home. follow up with her regular doctor. blood pressures have normalized for her. she should return to emergency department on concern. they are to call the family to nephrology clinic next week for optimization of her blood pressure control with a working diagnosis of head injury, hypertension, and syncope.

history of present illness: , in short, the patient is a 55-year-old gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with bmi of 69.7 with comorbidities of hypertension, atrial fibrillation, hyperlipidemia, possible sleep apnea, and also osteoarthritis of the lower extremities. he is also an ex-smoker. he is currently smoking and he is planning to quit and at least he should do this six to eight days before for multiple reasons including decreasing the dvt, pe rates and marginal ulcer problems after surgery, which will be discussed later on. ,physical examination: , on physical examination today, he weighs 514.8 pounds, he has gained 21 pounds since the last visit with us. his pulse is 78, temperature is 97.5, blood pressure is 132/74. lungs are clear. he is a pleasant gentleman with stigmata of supermorbid obesity expected of his size. abdomen is soft, nontender. no incisions. no umbilical hernia, no groin hernia, has a large abdominal pannus. no hepatosplenomegaly. lower extremities; no pedal edema. no calf tenderness. deep tendon reflexes are normal. lungs are clear. s1, s2 is heard. regular rate and rhythm. ,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 him complications including rare cases of death secondary to dvt, pe, leak, peritonitis, sepsis shock, multisystem organ failure, need for reoperations, need for endoscopy for bleeding or leak, operations which could be diagnostic laparoscopy, exploratory laparotomy, drainage procedure, gastrostomy, jejunostomy for feeding, bleeding requiring blood transfusion, myocardial infarction, pneumonia, atelectasis, respiratory failure requiring mechanical ventilation, rarely tracheostomy, rare cases of renal failure requiring dialysis, etc., were all discussed. ,all these are going to be at high risk for this patient secondary to his supermorbid obese condition. ,i also explained to him specific gastric bypass related complications including gastrojejunal stricture requiring endoscopic dilatation, marginal ulcer secondary to smoking or antiinflammatory drug intake, which can progress on to perforation or bleeding, small bowel obstruction secondary to internal hernia or adhesions, signs and symptoms of which are described, so the patient could alert us for earlier intervention, symptomatic gallstone formation during rapid weight loss, how to avoid it by taking ursodiol, which will be prescribed in the postoperative period. ,long-term complication of gastric bypass including hair loss, excess skin, multivitamin and mineral deficiencies, protein-calorie malnutrition, weight regain, weight plateauing, psychosocial and marital issues, addiction transfer, etc., were all discussed with the patient. the patient is at higher risk than usual set of patients secondary to his supermorbid obesity of bmi nearing 70 and also major cardiopulmonary and metabolic comorbidities. smoking of course does not help and increase the risk for cardiopulmonary complications and is at increased risk for cardiac risk. he will be seen by cardiologist, pulmonologist. he will also undergo long medifast dieting under our guidance, which is a very low-calorie diet to decrease the size of the liver and also to optimize his cardiopulmonary and metabolic comorbidities. he will also see a psychologist, nutritionist, and exercise physiologist in preparation for surgery for a multidisciplinary approach for short and long-term success. ,especially for him in view of his restricted mobility, supermorbid obesity status, and possibility of a pulmonary hypertension secondary to sleep apnea, he has been advised to have retrievable ivc filter and also will go home on lovenox. he also needs to start exercising to increase his flexibility and muscle tone before surgery and also to start getting the habit of doing so. all these were discussed with the patient. the patient understands. he wants to go to surgery. all questions were answered. i will see him in few weeks before the planned date of surgery.

preprocedure diagnosis:, left leg claudication.,postprocedure diagnosis: , left leg claudication.,operation performed: , aortogram with bilateral, segmental lower extremity run off.,anesthesia: , conscious sedation.,indication for procedure: ,the patient presents with lower extremity claudication. she is a 68-year-old woman, who is very fearful of the aforementioned procedures. risks and benefits of the procedure were explained to her to include bleeding, infection, arterial trauma requiring surgery, access issues and recurrence. she appears to understand and agrees to proceed.,description of procedure: , the patient was taken to the angio suite, placed in a supine position. after adequate conscious sedation, both groins were prepped with chloraseptic prep. cloth towels and paper drapes were placed. local anesthesia was administered in the common femoral artery and using ultrasound guidance, the common femoral artery was accessed. guidewire was threaded followed by a ,4-french sheath. through the 4-french sheath a 4-french omni flush catheter was placed. the glidewire was removed and contrast administered to identify the level of the renal artery. using power injector an aortogram proceeded.,the catheter was then pulled down to the aortic bifurcation. a timed run-off view of both legs was performed and due to a very abnormal and delayed run-off in the left, i opted to perform an angiogram of the left lower extremity with an isolated approach. the catheter was pulled down to the aortic bifurcation and using a glidewire, i obtained access to the contralateral left external iliac artery. the omni flush catheter was advanced to the left distal external iliac artery. the glidewire rather exchanged for an amplatz stiff wire. this was left in place and the 4-french sheath removed and replaced with a 6-french destination 45-cm sheath. this was advanced into the proximal superficial femoral artery and an angiogram performed. i identified a functionally occluded distal superficial femoral artery and after obtaining views of the run off made plans for angioplasty.,the patient was given 5000 units of heparin and this was allowed to circulate. a glidewire was carefully advanced using roadmapping techniques through the functionally occluded blood vessels. a 4-mm x 4-cm angioplasty balloon was used to dilate the area in question.,final views after dilatation revealed a dissection. a search for a 5-mm stent was performed, but none of this was available. for this reason, i used a 6-mm x 80-mm marked stent and placed this at the distal superficial femoral artery. post dilatation was performed with a 4-mm angioplasty balloon. further views of the left lower extremity showed irregular change in the popliteal artery. no significant stenosis could be identified in the left popliteal artery and noninvasive scan. for this reason, i chose not to treat any further areas in the left leg.,i then performed closure of the right femoral artery with a 6-french angio-seal device. attention was turned to the left femoral artery and local anesthesia administered. access was obtained with the ultrasound and the femoral artery identified. guidewire was threaded followed by a 4-french sheath. this was immediately exchanged for the 6-french destination sheath after the glidewire was used to access the distal external iliac artery. the glidewire was exchanged for the amplatz stiff wire to place the destination sheath. the destination was placed in the proximal superficial femoral artery and angiogram obtained. initial views had been obtained from the right femoral sheath before removal.,views of the right superficial femoral artery demonstrated significant stenosis with accelerated velocities in the popliteal and superficial femoral artery. for this reason, i performed the angioplasty of the superficial femoral artery using the 4-mm balloon. a minimal dissection plane measuring less than 1 cm was identified at the proximal area of dilatation. no further significant abnormality was identified. to avoid placing a stent in the small vessel i left it alone and approached the popliteal artery. a 3-mm balloon was chosen to dilate a 50 to 79% popliteal artery stenosis. reasonable use were obtained and possibly a 4-mm balloon could have been used. however, due to her propensity for dissection i opted not to. i then exchanged the glidewire for an o1 for thruway guidewire using an exchange length. this was placed into the left posterior tibial artery. a 2-mm balloon was used to dilate the orifice of the posterior tibial artery. i then moved the wire to the perineal artery and dilated the proximal aspect of this vessel. final images showed improved run-off to the right calf. the destination sheath was pulled back into the left external iliac artery and an angio-seal deployed.,findings: , aortogram demonstrates a dual right renal artery with the inferior renal artery supplying the lower one third of the right renal parenchyma. no evidence of renal artery stenosis is noted bilaterally. there is a single left renal artery. the infrarenal aorta, both common iliac and the external iliac arteries are normal. on the right, a superficial femoral artery is widely patent and normal proximally. at the distal third of the thigh there is diffuse disease with moderate stenosis noted. moderate stenosis is also noted in the popliteal artery and single vessel run-off through the posterior tibial artery is noted. the perineal artery is functionally occluded at the midcalf. the dorsal pedal artery filled by collateral at the high ankle level.,on the left, the proximal superficial femoral artery is patent. again, at the distal third of the thigh, there is a functional occlusion of the superficial femoral artery with poor collateralization to the high popliteal artery. this was successfully treated with angioplasty and a stent placement. the popliteal artery is diffusely diseased without focal stenosis. the tibioperoneal trunk is patent and the anterior tibial artery occluded at its orifice.,impression,1. normal bilateral renal arteries with a small accessory right renal artery.,2. normal infrarenal aorta as well as normal bilateral common and external iliac arteries.,3. the proximal right renal artery is normal with moderately severe stenosis in the superficial femoral popliteal and tibial arteries. successful angioplasty with reasonable results in the distal superficial femoral, popliteal and proximal posterior tibial artery as described.,4. normal proximal left superficial femoral artery with functional occlusion of the distal left superficial femoral artery successfully treated with angioplasty and stent placement. run-off to the left lower extremity is via a patent perineal and posterior tibial artery.

clinical history: , patient is a 37-year-old female with a history of colectomy for adenoma. during her preop evaluation it was noted that she had a lesion on her chest x-ray. ct scan of the chest confirmed a left lower mass.,specimen: , lung, left lower lobe resection.,immunohistochemical studies:, tumor cells show no reactivity with cytokeratin ae1/ae3. no significant reactivity with cam5.2 and no reactivity with cytokeratin-20 are seen. tumor cells show partial reactivity with cytokeratin-7. pas with diastase demonstrates no convincing intracytoplasmic mucin. no neuroendocrine differentiation is demonstrated with synaptophysin and chromogranin stains. tumor cells show cytoplasmic and nuclear reactivity with s100 antibody. no significant reactivity is demonstrated with melanoma marker hmb-45 or melan-a. tumor cell nuclei (spindle cell and pleomorphic/giant cell carcinoma components) show nuclear reactivity with thyroid transcription factor marker (ttf-1). the immunohistochemical studies are consistent with primary lung sarcomatoid carcinoma with pleomorphic/giant cell carcinoma and spindle cell carcinoma components.,final diagnosis:,histologic tumor type: sarcomatoid carcinoma with areas of pleomorphic/giant cell carcinoma and spindle cell carcinoma.,tumor size: 2.7 x 2.0 x 1.4 cm.,visceral pleura involvement: the tumor closely approaches the pleural surface but does not invade the pleura.,vascular invasion: present.,margins: bronchial resection margins and vascular margins are free of tumor.,lymph nodes: metastatic sarcomatoid carcinoma into one of four hilar lymph nodes.,pathologic stage: pt1n1mx.

chief complaint:, achilles ruptured tendon.,history:, mr. xyz is 41 years of age, who works for chevron and lives in angola. he was playing basketball in angola back last wednesday, month dd, yyyy, when he was driving toward the basket and felt a pop in his posterior leg. he was seen locally and diagnosed with an achilles tendon rupture. he has been on crutches and has been nonweightbearing since that time. he had no pain prior to his injury. he has had some swelling that is mild. he has just been on aspirin a day due to his traveling time. pain currently is minimal.,past medical history:, denies diabetes, cardiovascular disease, or pulmonary disease.,current medications:, malarone, which is an anti-malarial.,allergies:, nkda,social history:, he is a petroleum engineer for chevron. drinks socially. does not use tobacco.,physical exam:, pleasant gentleman in no acute distress. he has some mild swelling on the right ankle and hindfoot. he has motion that is increased into dorsiflexion. he has good plantarflexion. good subtalar, chopart and forefoot motion. his motor function is intact although weak into plantarflexion. sensation is intact. pulses are strong. in the prone position, he has diminished tension on the affected side. there is some bruising around the posterior heel. he has a palpable defect about 6-8 cm proximal to the insertion site that is tender for him. squeezing the calf causes no plantarflexion of the foot.,radiographs:, of his right ankle today show a preserved joint space. i don't see any evidence of fracture noted. radiographs of the heel show no fracture noted with good alignment.,impression:, right achilles tendon rupture.,plan:, i have gone over with mr. xyz the options available. we have discussed the risks, benefits and alternatives to operative versus nonoperative treatment. based on his age and his activity level, i think his best option is for operative fixation. we went over the risks of bleeding, infection, damage to nerves and blood vessels, rerupture of the tendon, weakness and the need for future surgery. we have discussed doing this as an outpatient procedure. he would be nonweightbearing in a splint for 10 days, nonweightbearing in a dynamic brace for 4 weeks, and then a walking boot for another six weeks with a lift until three months postop when we can get him into a shoe with a ¼" lift. he understands a 6-9 month return to sports overall. he will also need to be on some lovenox for a week after surgery and then on an aspirin as he is going to travel back to angola. today we will put him in a high tide boot that he will need at six weeks, and we will put him in a 1" lift also. he can weight bear until surgery and we will have it set up this week. his questions were all answered today.

preoperative diagnosis: , right hand dupuytren disease to the little finger.,postoperative diagnosis: ,right hand dupuytren disease to the little finger.,procedure performed: ,excision of dupuytren disease of the right hand extending out to the proximal interphalangeal joint of the little finger.,complications: ,none.,blood loss: , minimal.,anesthesia: , bier block.,indications: ,the patient is a 51-year-old male with left dupuytren disease, which is causing contractions both at the metacarpophalangeal and the pip joint as well as significant discomfort.,description of procedure: ,the patient was taken to the operating room, laid supine, administered a bier block, and prepped and draped in the sterile fashion. a zig-zag incision was made down the palmar surface of the little finger and under the palm up to the mid palm region. skin flaps were elevated carefully, dissecting dupuytren contracture off the undersurface of the flaps. both neurovascular bundles were identified proximally in the hand and the dupuytren disease fibrous band was divided proximally, which essentially returned to normal-appearing tissue. the neurovascular bundles were then dissected distally resecting everything medial to the 2 neurovascular bundles and above the flexor tendon sheath all the way out to the pip joint of the finger where the dupuytren disease stopped. the wound was irrigated. the neurovascular bundles rechecked with no evidence of any injury and the neurovascular bundles were not significantly involved in the dupuytren disease. the incisions were closed with 5-0 nylon interrupted sutures.,the patient tolerated the procedure well and was taken to the pacu in good condition.

reason for consultation:, pneumothorax and subcutaneous emphysema.,history of present illness: , the patient is a 48-year-old male who was initially seen in the emergency room on monday with complaints of scapular pain. the patient presented the following day with subcutaneous emphysema and continued complaints of pain as well as change in his voice. the patient was evaluated with a ct scan of the chest and neck which demonstrated significant subcutaneous emphysema, a small right-sided pneumothorax, but no other findings. the patient was admitted for observation.,past surgical history: , hernia repair and tonsillectomy.,allergies: , penicillin.,medications: , please see chart.,review of systems:, not contributory.,physical examination:,general: well developed, well nourished, lying on hospital bed in minimal distress.,heent: normocephalic and atraumatic. pupils are equal, round, and reactive to light. extraocular muscles are intact.,neck: supple. trachea is midline.,chest: clear to auscultation bilaterally.,cardiovascular: regular rate and rhythm.,abdomen: soft, nontender, and nondistended. normoactive bowel sounds.,extremities: no clubbing, edema, or cyanosis.,skin: the patient has significant subcutaneous emphysema of the upper chest and anterior neck area although he states that the subcutaneous emphysema has improved significantly since yesterday.,diagnostic studies:, as above.,impression: , the patient is a 48-year-old male with subcutaneous emphysema and a small right-sided pneumothorax secondary to trauma. these are likely a result of either a parenchymal lung tear versus a small tracheobronchial tree rend.,recommendations:, at this time, the ct surgery service has been consulted and has left recommendations. the patient also is awaiting bronchoscopy per the pulmonary service. at this time, there are no general surgery issues.

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

preoperative diagnosis:, sterilization candidate.,postoperative diagnosis:, sterilization candidate.,procedure performed:,1. cervical dilatation.,2. laparoscopic bilateral partial salpingectomy.,anesthesia: , general endotracheal.,complications: , none.,estimated blood loss: ,less than 50 cc.,specimen: , portions of bilateral fallopian tubes.,indications:, this is a 30-year-old female gravida 4, para-3-0-1-3 who desires permanent sterilization.,findings: , on bimanual exam, the uterus is small, anteverted, and freely mobile. there are no adnexal masses appreciated. on laparoscopic exam, the uterus, bilateral tubes and ovaries appeared normal. the liver margin and bowel appeared normal.,procedure: , after consent was obtained, the patient was taken to the operating room where general anesthetic was administered. the patient was placed in dorsal lithotomy position and prepped and draped in the normal sterile fashion. a sterile speculum was placed in the patient's vagina and the anterior lip of the cervix was grasped with a vulsellum tenaculum. the uterus was then sounded to 7 cm.,the cervix was serially dilated with hank dilators. a #20 hank dilator was left in place. the sterile speculum was then removed. gloves were changed. attention was then turned to the abdomen where approximately a 10 mm transverse infraumbilical incision was made through the patient's previous scar. the veress needle was placed and gas was turned on. when good flow and low abdominal pressures were noted, the gas was turned up and the abdomen was allowed to insufflate. a 11 mm trocar was then placed through this incision and the camera was placed with the above findings noted. two 5 mm step trocars were placed, one 2 cm superior to the pubic bone along the midline and the other approximately 7 cm to 8 cm to the left at the level of the umbilicus. the endoloop was placed through the left-sided port. a grasper was placed in the suprapubic port and put through the endoloop and then a portion of the left tube was identified and grasped with a grasper. a knuckle of tube was brought up with the grasper and a #0 vicryl endoloop synched down across this knuckle of tube. the suture was then cut using the endoscopic shears. the portion of tube that was tied off was removed using a harmonic scalpel. this was then removed from the abdomen and sent to pathology. the right tube was then identified and in a similar fashion, the grasper was placed through the loop of the #0 vicryl endoloop and the right tube was grasped with the grasper and the knuckle of tube was brought up into the loop. the loop was then synched down. the endoshears were used to cut the suture. the harmonic scalpel was then used to remove that portion of tube. the portion of the tube that was removed from the abdomen was sent to pathology. both tubes were examined and found to have excellent hemostasis. all instruments were then removed. the 5 mm ports were removed with good hemostasis noted. the camera was removed and the abdomen was allowed to desufflate. the 11 mm trocar introducer was replaced and the trocar was removed. the fascia of the infraumbilical incision was reapproximated with an interrupted suture of #3-0 vicryl. the skin was then closed with #4-0 undyed vicryl in a subcuticular fashion. approximately 10 cc of marcaine was injected at the incision site. the vulsellum tenaculum and cervical dilator were then removed from the patient's cervix with excellent hemostasis noted. the patient tolerated the procedure well. sponge, lap, and needle counts were correct at the end of the procedure. the patient was taken to the recovery room in satisfactory condition. she will be discharged home with a prescription for vicodin for pain and was instructed to follow up in the office in two weeks.

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

cc:, intermittent binocular horizontal, vertical, and torsional diplopia.,hx: ,70y/o rhm referred by neuro-ophthalmology for evaluation of neuromuscular disease. in 7/91, he began experiencing intermittent binocular horizontal, vertical and torsional diplopia which was worse and frequent at the end of the day, and was eliminated when closing one either eye. an mri brain scan at that time was unremarkable. he was seen at uihc strabismus clinic in 5/93 for these symptoms. on exam, he was found to have intermittent right hypertropia in primary gaze, and consistent diplopia in downward and rightward gaze. this was felt to possibly represent grave's disease. thyroid function studies were unremarkable, but orbital echography suggested graves orbitopathy. the patient was then seen in the neuro-ophthalmology clinic on 12/23/92. his exam remained unchanged. he underwent tensilon testing which was unremarkable. on 1/13/93, he was seen again in neuro-ophthalmology. his exam remained relatively unchanged and repeat tensilon testing was unremarkable. he then underwent a partial superior rectus resection, od, with only mild improvement of his diplopia. during his 8/27/96 neuro-ophthalmology clinic visit he was noted to have hypertropia od with left pseudogaze palsy and a right ptosis. the ptosis improved upon administration of tensilon and he was placed on mestinon 30mg tid. his diplopia subsequently improved, but did not resolve. the dosage was increased to 60mg tid and his diplopia worsened and the dose decreased back to 30mg tid. at present he denied any fatigue on repetitive movement. he denied dysphagia, sob, dysarthria, facial weakness, fevers, chills, night sweats, weight loss or muscle atrophy.,meds: , viokase, probenecid, mestinon 30mg tid.,pmh:, 1) gastric ulcer 30 years ago, 2) cholecystectomy, 3) pancreatic insufficiency, 4) gout, 5) diplopia.,fhx:, mother died age 89 of "old age." father died age 89 of stroke. brother, age 74 with cad, sister died age 30 of cancer.,shx:, retired insurance salesman and denies history of tobacco or illicit drug us. he has no h/o etoh abuse and does not drink at present.,exam: ,bp 155/104. hr 92. rr 12. temp 34.6c. wt 76.2kg.,ms: unremarkable. normal speech with no dysarthria.,cn: right hypertropia (worse on rightward gaze and less on leftward gaze). minimal to no ptosis, od. no ptosis, os. vfftc. no complaint of diplopia. the rest of the cn exam was unremarkable.,motor: 5/5 strength throughout with normal muscle bulk and tone.,sensory: no deficits appreciated on pp/vib/lt/prop/temp testing.,coordination/station/gait: unremarkable.,reflexes: 2/2 throughout. plantar responses were flexor on the right and withdrawal on the left.,heent and gen exam: unremarkable.,course:, emg/ncv, 9/26/96: repetitive stimulation studies of the median, facial, and spinal accessory nerves showed no evidence of decrement at baseline, and at intervals up to 3 minutes following exercise. the patient had been off mestinon for 8 hours prior to testing. chest ct with contrast, 9/26/96, revealed a 4x2.5x4cm centrally calcified soft tissue anterior mediastinal mass adjacent to the aortic arch. this was highly suggestive of a thymoma. there were diffuse emphysematous disease with scarring in the lung bases. a few nodules suggestive of granulomas and few calcified perihilar lymph nodes. he underwent thoracotomy and resection of the mass. pathologic analysis was consistent with a thymoma, lymphocyte predominant type, with capsular and pleural invasion, and extension to the phrenic nerve resection margin. acetylcholine receptor-binding antibody titer 12.8nmol/l (normal<0.7), acetylcholine receptor blocking antibody <10% (normal), acetylcholine receptor modulating antibody 42% (normal<19), striated muscle antibody 1:320 (normal<1:10). striated muscle antibody titers tend to be elevated in myasthenia gravis associated with thymoma. he was subsequently treated with xrt and continued to complain of fatigue at his 4/18/97 oncology visit.

past medical history:, unremarkable, except for diabetes and atherosclerotic vascular disease.,allergies:, penicillin.,current medications:, include glucovance, seroquel, flomax, and nexium.,past surgical history: , appendectomy and exploratory laparotomy.,family history: , noncontributory.,social history: ,the patient is a non-smoker. no alcohol abuse. the patient is married with no children.,review of systems:, significant for an old cva.,physical examination:, the patient is an elderly male alert and cooperative. blood pressure 96/60 mmhg. respirations were 20. pulse 94. afebrile. o2 was 94% on room air. heent: normocephalic and atraumatic. pupils are reactive. oral mucosa is grossly normal. neck is supple. lungs: decreased breath sounds. disturbed breath sounds with poor exchange. heart: regular rhythm. abdomen: soft and nontender. no organomegaly or masses. extremities: no cyanosis, clubbing, or edema.,laboratory data: , oropharyngeal evaluation done on 11/02/2006 revealed mild oropharyngeal dysphagia with no evidence of laryngeal penetration or aspiration with food or liquid. slight reduction in tongue retraction resulting in mild residual remaining in the palatal sinuses, which clear with liquid swallow and double-saliva swallow.,assessment:,1. cough probably multifactorial combination of gastroesophageal reflux and recurrent aspiration.,2. old cva with left hemiparesis.,3. oropharyngeal dysphagia.,4. diabetes.,plan:, at the present time, the patient is recommended to continue on a regular diet, continue speech pathology evaluation as well as perform double-swallow during meals with bolus sensation. he may use italian lemon ice during meals to help clear sinuses as well. the patient will follow up with you. if you need any further assistance, do not hesitate to call me.

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 diagnoses:, menorrhagia and dysmenorrhea.,postoperative diagnoses: , menorrhagia and dysmenorrhea.,procedure: , laparoscopic supracervical hysterectomy.,anesthesia: , general endotracheal.,estimated blood loss: , 100 ml.,findings: , an 8-10 cm anteverted uterus, right ovary with a 2 cm x 2 cm x 2 cm simple cyst containing straw colored fluid, a normal-appearing left ovary, and normal-appearing tubes bilaterally.,specimens: ,uterine fragments.,complications:, none.,procedure in detail: , the patient was brought to the or where general endotracheal anesthesia was obtained without difficulty. the patient was placed in dorsal lithotomy position. examination under anesthesia revealed an anteverted uterus and no adnexal masses. the patient was prepped and draped in normal sterile fashion. a foley catheter was placed in the patient's bladder. the patient's cervix was visualized with speculum. a single-tooth tenaculum was placed on the anterior lip of the cervix. a humi uterine manipulator was placed through the internal os of the cervix and the balloon was inflated. the tenaculum and speculum were then removed from the vagina. attention was then turned to the patient's abdomen where a small infraumbilical incision was made with scalpel. veress needle was placed through this incision and the patient's abdomen was inflated to a pressure of 15 mmhg. veress needle was removed and then 5-mm trocar was placed through the umbilical incision. laparoscope was placed through this incision and the patient's abdominal contents were visualized. a 2nd trocar incision was placed in the midline 2 cm above the symphysis pubis and a 5-mm trocar was placed through this incision on direct visualization for laparoscope. a trocar incision was made in the right lower quadrant. a 10-mm trocar was placed through this incision under direct visualization with the laparoscope. a ___ trocar incision was made in the left lower quadrant and a 2nd 10-mm trocar was placed through this incision under direct visualization with the laparoscope. the patient's abdominal and pelvic anatomy were again visualized with the assistance of a blunt probe. the gyrus cautery was used to cauterize and cut the right and left round ligaments. the anterior leaf of the broad ligament was bluntly dissected and cauterized and cut in an inferior fashion towards lower uterine segment. the right uteroovarian ligament was cauterized and cut using the gyrus. the uterine vessels were then bluntly dissected. the gyrus was then used to cauterize the right uterine vessels. gyrus was then used on the left side to cauterize and cut the left round ligament. the anterior leaf of the broad ligament on the left side was bluntly dissected, cauterized, and cut. using the gyrus, the left uteroovarian ligament was cauterized and cut and the left uterine vessels were then bluntly dissected. the left uterine vessels were then cauterized and cut using the gyrus. at this point, as the uterine vessels had been cauterized on both sides, the uterine body exhibited blanching. at this point, the harmonic scalpel hook was used to amputate the uterine body from the cervix at the level just below the uterine vessels. the humi manipulator was removed prior to amputation of the uterine body. after the uterine body was detached from the cervical stump, morcellation of the uterine body was performed using the uterine morcellator. the uterus was removed in a piecemeal fashion through the right lower quadrant trocar incision. once, all fragments of the uterus were removed from the abdominal cavity, the pelvis was irrigated. the harmonic scalpel was used to cauterize the remaining endocervical canal. the cervical stump was also cauterized with the harmonic scalpel and good hemostasis was noted at the cervical stump and also at the sites of all pedicles. the harmonic scalpel was then used to incise the right ovarian simple cyst. the right ovarian cyst was then drained yielding straw-colored fluid. the site of right ovarian cystotomy was noted to be hemostatic. the pelvis was again inspected and noted to be hemostatic. the ureters were identified on both sides and noted to be intact throughout the visualized course. all instruments were then removed from the patient's abdomen and the abdomen was deflated. the fascial defects at the 10-mm trocar sites were closed using figure-of-8 sutures of 0-vicryl and skin incisions were closed with a 4-0 vicryl in subcuticular fashion. the cervix was then visualized with the speculum. good hemostasis at the site of tenaculum insertion was obtained using silver nitrate sticks. all instruments were removed from the patient's vagina and the patient was placed in normal supine position.,sponge, lap, needle, and instrument counts were correct x2. the patient was awoken from anesthesia and then transferred to the recovery room in stable condition.