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preoperative diagnoses:, om, chronic, serous, simple or unspecified. adenoid hyperplasia. hypertrophy of tonsils.,postoperative diagnosis: , same as preoperative diagnosis.,operation: , bilateral myringotomies with armstrong grommet tubes, adenoidectomy, and tonsillectomy.,anesthesia:, general.,complications:, none.,estimated blood loss: , minimal.,drains: , none.,consent:, the procedure, benefits, and risks were discussed in detail preoperatively. the parentsagreed to proceed after all questions were answered.,technique: , the patient was brought to the operating room and placed in the supine position. after general mask anesthesia was adequately obtained, the right external auditory canal was cleaned out under the microscope. serous fluid was aspirated from the middle ear space. an armstrong grommet tube was placed down through the incision and rotated into place. the opposite ear was then cleaned out under the microscope. serous fluid was aspirated from the middle ear space. an armstrong grommet tube was placed down through the incision and rotated into place. cortisporin suspension was placed in both ear canals.,then the patient was intubated. a crowe-davis mouth gag was placed into the mouth and extended and hung on the mayo stand. the red rubber catheter was placed down through the nose and brought out through the mouth to retract the palate. the adenoid fossa was visualized with the mirror. the adenoids were removed using the microdebrider. two adenoid packs were placed. the packs were removed one by one. using mirror and suction bovie, adequate hemostasis was achieved.,the tonsils were quite large and cryptic. the tenaculum was placed on the superior pole of the right tonsil. cheesy material came out from the crypts. the tonsils were retracted medially. the bovie electrocautery was used to make an incision in the right anterior tonsillar pillar, and the plane was developed between the tonsil and the musculature. the tonsil was completely dissected out of this plane, preserving both the anterior and posterior tonsillar pillars. all bleeders were cauterized as they were encountered. the tenaculum was then placed on the superior pole of the left tonsil. cheesy material came out from the crypts. the tonsils were retracted medially. the bovie electrocautery was used to make an incision in the left anterior tonsillar pillar, and the plane was developed between the tonsil and the musculature. the tonsil was completely dissected out of this plane, preserving both the anterior and posterior tonsillar pillars. all bleeders were cauterized as they were encountered. both tonsil beds were then re-cauterized, paying particular attention to the inferior and superior poles.,the stomach was evacuated with the nasogastric tube. the patient was then awakened in the operating room, extubated and taken to the recovery room in satisfactory condition.

exam:, nuclear medicine lymphatic scan.,reason for exam: , left breast cancer.,technique: , 1.0 mci of technetium-99m sulfur colloid was injected within the dermis surrounding the left breast biopsy site at four locations. a 16-hour left anterior oblique imaging was performed with and without shielding of the original injection site.,findings: ,there are two small foci of increased activity in the left axilla. this is consistent with the sentinel lymph node. no other areas of activity are visualized outside of the injection site and two axillary lymph nodes.,impression: ,technically successful lymph node injection with two areas of increased activity in the left axilla consistent with sentinel lymph node.

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: , term pregnancy at 40 and 3/7th weeks.,procedure performed: , spontaneous vaginal delivery.,history of present illness: ,the patient is a 36-year-old african-american female who is a g-2, p-2-0-0-2 with an edc of 08/30/2003. she is blood type ab -ve with antibody screen negative and is also rubella immune, vdrl nonreactive, hepatitis b surface antigen negative, and hiv nonreactive. she does have a history of sickle cell trait. she presented to labor and delivery triage at 40 and 3/7th weeks gestation with complaint of contractions every ten minutes. she also stated that she has lost her mucous plug. she did have fetal movement, noted no leak of fluid, did have some spotting. on evaluation of triage, she was noted to be contracting approximately every five minutes and did have discomfort with her contractions. she was evaluated by sterile vaginal exam and was noted to be 4 cm dilated, 70% effaced, and -3 station. this was a change from her last office exam, at which she was 1 cm to 2 cm dilated.,procedure details:, the patient was admitted to labor and delivery for expected management of labor and arom was performed and the amniotic fluid was noted to be meconium stained. after her membranes were ruptured, contractions did increase to every two to three minutes as well as the intensity increased. she was given nubain for discomfort with good result.,she had a spontaneous vaginal delivery of a live born female at 11:37 with meconium stained fluid as noted from roa position. after controlled delivery of the head, tight nuchal cord was noted, which was quickly double clamped and cut and the shoulders and body were delivered without difficulty. the infant was taken to the awaiting pediatrician. weight was 2870 gm, length was 51 cm. the apgars were 6 at 1 minute and 9 at 5 minutes. there was initial neonatal depression, which was treated by positive pressure ventilation and the administration of narcan.,spontaneous delivery of an intact placenta with a three-vessel cord was noted at 11:45. on examination, there were no noted perineal abrasions or lacerations. on vaginal exam, there were no noted cervical or vaginal sidewall lacerations. estimated blood loss was less than 250 cc. mother and infant are in recovery doing well at this time.

preoperative diagnosis:, posterior mediastinal mass with possible neural foraminal involvement.,postoperative diagnosis: , posterior mediastinal mass with possible neural foraminal involvement (benign nerve sheath tumor by frozen section).,operation performed:, left thoracotomy with resection of posterior mediastinal mass.,indications for procedure: ,the patient is a 23-year-old woman who recently presented with a posterior mediastinal mass and on ct and mri there were some evidence of potential widening of one of the neural foramina. for this reason, dr. x and i agreed to operate on this patient together. please note that two surgeons were required for this case due to the complexity of it. the indications and risks of the procedure were explained and the patient gave her informed consent.,description of procedure: , the patient was brought to the operating suite and placed in the supine position. general endotracheal anesthesia was given with a double lumen tube. the patient was positioned for a left thoracotomy. all pressure points were carefully padded. the patient was prepped and draped in usual sterile fashion. a muscle sparing incision was created several centimeters anterior to the tip of the scapula. the serratus and latissimus muscles were retracted. the intercostal space was opened. we then created a thoracoscopy port inferiorly through which we placed a camera for lighting and for visualization. through our small anterior thoracotomy and with the video-assisted scope placed inferiorly we had good visualization of the posterior mediastinum mass. this was in the upper portion of the mediastinum just posterior to the subclavian artery and aorta. the lung was deflated and allowed to retract anteriorly. with a combination of blunt and sharp dissection and with attention paid to hemostasis, we were able to completely resect the posterior mediastinal mass. we began by opening the tumor and taking a very wide large biopsy. this was sent for frozen section, which revealed a benign nerve sheath tumor. then, using the occluder device dr. x was able to _____ the inferior portions of the mass. this left the external surface of the mass much more malleable and easier to retract. using a bipolar cautery and endoscopic scissors we were then able to completely resect it. once the tumor was resected, it was then sent for permanent sections. the entire hemithorax was copiously irrigated and hemostasis was complete. in order to prevent any lymph leak, we used 2 cc of evicel and sprayed this directly on to the raw surface of the pleural space. a single chest tube was inserted through our thoracoscopy port and tunneled up one interspace. the wounds were then closed in multiple layers. a #2 vicryl was used to approximate the ribs. the muscles of the chest wall were allowed to return to their normal anatomic position. a 19 blake was placed in the subcutaneous tissues. subcutaneous tissues and skin were closed with running absorbable sutures. the patient was then rolled in the supine position where she was awakened from general endotracheal anesthesia and taken to the recovery room in stable condition.

procedure:, left cardiac catheterization, left ventriculography, coronary angiography and stent placement.,indications: , atherosclerotic coronary artery disease.,patient history: , this is a 55-year-old male. he presented with 3 hours of unstable angina.,past cardiac history: , history of previous arteriosclerotic cardiovascular disease. previous st elevation mi.,review of systems., the creatinine value is 1.3 mg/dl mg/dl.,procedure medications:,1. visipaque 361 ml total dose.,2. clopidogrel bisulphate (plavix) 225 mg po,3. promethazine (phenergan) 12.5 mg total dose.,4. abciximab (reopro) 10 mg iv bolus,5. abciximab (reopro) 0.125 mcg/kg/minute, 4.5 ml/250 ml d5w x 17 ml,6. nitroglycerin 300 mcg ic total dose.,description of procedure:,approach: , left heart catheterization via right femoral artery approach.,access method: , percutaneous needle puncture.,devices used:,1. balloon catheter utilized: manufacturer: boston sci quantum maverick rx 2.75mm x 20mm.,2. cordis vista brite tip 6fr jr 4.0,3. acs/guidant sport .014" (190cm) wire,4. stent utilized: boston sci taxus rx stent 3.0mm x 32mm.,findings/interventions:,left ventriculography:, the overall left ventricular systolic function is mildly reduced. left ventricular ejection fraction is 40% by left ventriculogram. mild hypokinesis of the anterior wall of the left ventricle. there was no transaortic gradient. mitral valve regurgitation is not seen.,left main coronary artery: , there were no obstructing lesions in the left main coronary artery. blood flow appeared normal.,left anterior descending artery: , there was a 95%, discrete stenosis in the mid left anterior descending artery. a drug eluting, boston sci taxus rx stent 3.0mm x 32mm stent was placed in the mid left anterior descending artery and post-dilated to 3.5 mm. post-procedure stenosis was 0%. there was no dissection and no perforation.,left circumflex artery: , there was a 50%, diffuse stenosis in the left circumflex artery.,right coronary artery:, the right coronary artery is dominant to the posterior circulation. there were no obstructing lesions in the right coronary artery. blood flow appeared normal.,complications:,there were no complications during the procedure., ,impression:,1. severe two-vessel coronary artery disease.,2. severe left anterior descending coronary artery disease. there was a 95% mid left anterior descending artery stenosis. the lesion was successfully stented.,3. moderate left circumflex artery disease. there was a 50% left circumflex artery stenosis. intervention not warranted.,4. the overall left ventricular systolic function is mildly reduced with ejection fraction of 40%. mild hypokinesis of the anterior wall of the left ventricle.,recommendation:,1. clopidogrel (plavix) 75 mg po daily for 1 year.

preoperative diagnoses:,1. hallux abductovalgus, right foot.,2. hammer toe, right foot, second, third, fourth and fifth toes.,3. tailor's bunionette, right foot.,4. degenerative joint disease, right first metatarsophalangeal joint.,5. rheumatoid arthritis.,6. contracted fourth right metatarsophalangeal joint.,postoperative diagnoses:,1. hallux abductovalgus, right foot.,2. hammer toe, right foot, second, third, fourth and fifth toes.,3. tailor's bunionette, right foot.,4. degenerative joint disease, right first metatarsophalangeal joint.,5. rheumatoid arthritis.,6. contracted fourth right metatarsophalangeal joint.,procedures performed:,1. bunionectomy, right foot with biopro hemi implant, right first metatarsophalangeal joint.,2. arthrodesis, right second, third, and fourth toes with external rod fixation.,3. hammertoe repair, right fifth toe.,4. extensor tenotomy and capsulotomy, right fourth metatarsophalangeal joint.,5. modified tailor's bunionectomy, right fifth metatarsal.,anesthesia:, tiva/local.,history:, this 51-year-old female presented to abcd preoperative holding area after keeping herself npo since mid night for surgery on her painful right foot bunion, hammer toes, and tailor's bunion. the patient has a long history of crippling severe rheumatoid arthritis. she has pain with shoe gear and pain with every step. she has tried multiple conservative measures under dr. x's supervision consisting of wide shoe's and accommodative padding all which have provided inadequate relief. at this time, she desires attempted surgical reconstruction/correction. the consent is available on the chart for review and the risks versus benefits of this procedure have been discussed with patient in detail by dr. x.,procedure in detail: , after iv was established by the department of anesthesia, the patient was taken to the operating room via cart and placed on the operating table in a supine position and a safety strap was placed across her waist for her protection. next, copious amounts of webril were applied about the right ankle and a pneumatic ankle tourniquet was applied over the webril. next, after adequate iv sedation was administered by the department of anesthesia, a total of 20 cc of 1:1 mixture of 0.5% marcaine plain and 1% lidocaine were instilled into the right foot using a standard ankle block technique. next, the foot was prepped and draped in the usual aseptic fashion. an esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 230 mmhg. the foot was lowered in the operative field. the sterile stockinette was reflected and attention was directed to the right first metatarsophalangeal joint. the joint was found to be severely contracted with lateral deviation of the hallux with a slightly overlapping contracted second toe. in addition, the range of motion was less than 5 degrees of the first ray. there was medial pinch callus and callus on the plantar right second metatarsal. using a #10 blade, a linear incision over the first metatarsophalangeal joint was then created approximately 4 cm in length. next, a #15 blade was used to deepen the incision to the subcutaneous tissue all which was found to be very thin taking care to protect the medial neurovascular bundle and the lateral extensor hallucis longus tendon. any small vein traversing the operative site were clamped with hemostat and ligated with electrocautery. next, the medial and lateral wound margins were undermined with sharp dissection. the joint capsule was then visualized. two apparent soft tissue masses probably consistent with rheumatoid nodules were found at the distal medial aspect of the first metatarsal capsule. a dorsal linear incision to the capsular tissue down to bone was performed with a #15 blade. the capsule and periosteal tissues were elevated sharply off the metatarsal head and the base of proximal phalanx.,a large amount of hypertrophic synovium was encountered over the metatarsophalangeal joint. in addition, multiple hypertrophic exostosis were found dorsally, medially, and laterally over the metatarsal. upon entering the joint, the base of the proximal phalanx was grossly deformed and the medial and lateral aspect were widely flared and encompassing the metatarsal head. a sagittal saw was used to carefully remove the base of the proximal phalanx just distal to the metaphyseal flare. next, the bone was passed out as specimen. the head of the metatarsal had evidence of erosion and eburnation. the tibial sesamoid was practically absent, but was found to be a conglomeration of hypertrophic synovium and poorly differentiated appearing exostosis and bony tissue. this was hindering the range of motion of the joint and was removed. the fibular sesamoid was in the interspace. a lateral release was performed in addition. next, the mcglamry elevators were inserted into the first metatarsal head and all of the plantar adhesions were freed. the metatarsal head was remodeled with a sagittal saw and all of the medial eminence the dorsal and lateral hypertropic bone was removed and the metatarsal head was shaped into more acceptable contoured structure. next, the biopro sizer was used and it was found that a median large implant would be the best fit for this patient's joint. a small drill hole was made in the central aspect at the base of the proximal phalanx. the trial sizer median large was placed in the joint and an excellent fit and increased range of motion was observed.,next, the joint was flushed with copious amounts of saline. a median large porous biopro implant was inserted using the standard technique and was tapped with the mallet into position. it had an excellent fit and the range of motion again was markedly increased from the preoperative level. next, the wound was again flushed with copious amounts of saline. the flexor tendon was inspected and was found to be intact plantarly. a #3-0 vicryl was used to close the capsule in a running fashion. a medial capsulorrhaphy performed and the toe assumed to more rectus position and the joint was more congruous. next, the subcutaneous layer was closed with #4-0 vicryl in a simple interrupted technique. next, the skin was closed with #5-0 monocryl in a running subcuticular fashion.,attention was directed to the right second toe, which was found to be markedly contracted and rigid in nature. there was a clavus in the dorsal aspect of the head of the proximal phalanx noted. a linear incision was made over the proximal phalanx approximately 2 cm in length. the incision was deepened with #15 blade down to the subcutaneous tissue. next, the medial and lateral aspects of the wound were undermined with sharp dissection taking care to protect the neurovascular structures.,next, after identifying the extensor expansion and long extensor tendon, a #15 blade was used to transect the tendon at the level of the joint. the tendon was peeled off sharply, proximally, and distally. the medial and lateral collateral ligaments were released and the head of the proximal phalanx was delivered into the wound. the bone was found to be extremely soft in the toe joints and the head of the proximal phalanx was oddly shaped and the cartilage was eroded. the base of the middle phalanx, however, had a normal-appearing cartilage. a sagittal saw was used to transect the head of the proximal phalanx just proximal to metaphyseal flare. next, the base of the middle phalanx was also resected. a 0.045 inch kirschner wire was retrograded out at the end of the toe and then back through the residual proximal phalanx shaft. the toe assumed a straight and markedly increased straight position. an extensor hood resection was performed to assist in keeping the proximal phalanx plantar flexed. the joint was flushed with copious amounts of saline. a #3-0 vicryl was used to reapproximate the tendon after arthrodesis. a #4-0 nylon was used to close the skin with a combination of simple interrupted and horizontal mattress suture technique. the wire was cut, capped, and bent in the usual fashion.,attention was directed to the right third toe where an exact same procedure as performed in the second digit was repeated. the same suture material was used and the same 0.045 kirschner wire was used for external wire fixation.,attention was directed to the right fourth toe with exact same procedure was repeated. the same suture material was used. however, a 0.062 kirschner wire was used to fixate the arthrodesis site as the bone was very soft and a 0.045 kirschner wire was attempted but was found to be slipping in the soft bone and was inadequately holding the arthrodesis site tight. next, attention was directed to the fifth digit, which was found to be contracted as well. a linear incision was made over the proximal phalanx with a #10 blade approximately 2 cm in length. a #15 blade was used to deepen the incision to the subcutaneous tissue down to the level of the long extensor tendon, which was identified and transected. the medial and lateral collateral ligaments were transected and the head of the proximal phalanx was delivered into the wound. a sagittal saw was used to resect the head of the proximal phalanx just proximal to metaphyseal flare. the toe assumed to more rectus position. the reciprocating rasp was used to smooth the all bony surfaces. the joint was again flushed with saline. next, the long extensor tendon was reapproximated with #3-0 vicryl in a simple interrupted technique. the skin was closed with #4-0 nylon in a simple interrupted technique.,next, attention was directed to the fifth metatarsal head, which was found to have a lateral exostosis and bursa under the skin. a #10 blade was used to make a 2.5 cm dorsal incision over the fifth metatarsal head. the incision was deepened with a #15 blade to the subcutaneous tissue. any small vein traversing subcutaneous layer were ligated with electrocautery. care was taken to avoid abductor digiti minimi tendon and extensor digitorum longus tendon respectively. next, the dorsal linear capsular incision was made down to the bone with a #15 blade. the capsular and periosteal tissues were elevated off the bone with a #15 blade and the metatarsal head was delivered into the wound. hypertrophic bone was noted to be found dorsally and laterally as well as plantarly. a sagittal saw was used to resect all hypertrophic bone. a reciprocating rasp was used to smooth all bony surfaces. next, the wound was flushed with copious amounts of saline. the capsular and periosteal tissues wee closed with #3-0 vicryl in a simple interrupted technique. next, the subcutaneous layer was closed with #4-0 vicryl in a simple interrupted technique. a bursa which was found consisting of a white glistening hypertrophic synovium was removed and sent as specimen as was also found in two of the second and third digit in the above procedures. the skin was closed with #5-0 monocryl in a running subcuticular fashion. the ______ was reinforced with horizontal mattress sutures with #5-0 monocryl. attention was directed to the fourth metatarsophalangeal joint where the joint was found to be contracted and the proximal phalanx was still found to be elevated. therefore, a #15 blade was used to make a stab incision over the joint lateral to the extensor digitorum longus tendon. the tendon was transected. next, a blade was inserted in the dorsal, medial, and lateral aspects of the metatarsophalangeal joint and tenotomy was performed. next, the proximal phalanx residual bone was plantar flexed and found to assume a more rectus position. one #4-0 nylon suture was placed in the skin.,mastisol tape was applied to the first metatarsal and fifth metatarsal postoperative wounds. betadine-soaked owen silk was applied to all wounds. betadine-soaked 4 x 4 splints were applied to all toes. the pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all digits. all the wires have previously been bent and cut and all were capped. a standard postoperative consisting of 4x4s, kling, kerlix, and coban were applied. the patient tolerated the above anesthesia and procedure without complications. she was transported via cart to the postanesthesia care unit with vital signs stable and vascular status intact. she was given prescription for tylenol #3, #40 one to two p.o. q.4-6h. p.r.n. pain and naprosyn 375 mg p.o. b.i.d. p.c. she is to continue her rheumatoid arthritis drugs preoperatively prescribed by the rheumatologist.,she is to follow up with dr. x in the office. she was given emergency contact numbers and standard postoperative instructions. she was given darco orthowedge shoe and a pair of crutches. she was discharged in stable condition.

procedure: , direct current cardioversion.,reason for procedure: , atrial fibrillation.,procedure in detail: ,the procedure was explained to the patient with risks and benefits including risk of stroke. the patient understands as well as her husband. the patient had already a transesophageal echocardiogram showing no left atrial appendage thrombus or thrombus in the left atrium. there was spontaneous echocardiogram contrast noticed. the patient was on anticoagulation with lovenox, received already 3 mg of versed and 25 mcg of fentanyl for the tee followed by next 2 mg of versed for total of 5 mg of versed. the pads applied in the anterior and posterior approach. with synchronized biphasic waveform at 150 j, one shock was successful in restoring sinus rhythm. the patient had some occasional pacs noticed with occasional sinus tachycardia. the patient had no immediate post-procedure complications. the rhythm was maintained and 12-lead ekg was requested.,impression: ,successful direct current cardioversion with restoration of sinus rhythm from atrial fibrillation with no immediate complication.

preoperative diagnosis:, residual stone, status post right percutaneous nephrolithotomy.,postoperative diagnoses: , residual stone status post right percutaneous nephrolithotomy, attempted second-look nephrolithotomy, cysto with insertion of 6-french variable length double-j stent.,anesthesia:, general via endotracheal tube.,blood loss:, minimal.,drains: , 16-french foley, 6-french variable length double-j stent.,intraoperative complications: , unable to re-access the collecting system.,description of procedure: ,the patient was brought to the operating room and laid supine. general anesthesia was accomplished. a 16-french foley was placed using aseptic technique. the patient was then placed on the operating table prone. his right flank was prepped and draped in a sterile fashion. at this point, contrast was injected through his existing nephrostomy tube and there was no continuity with the collecting system and it was removed. the 5-french pollack catheter was used to pass a 0.38 super-stiff amplatz wire. the wire would not go down the ureter. multiple attempts were made using pollack catheters and cobra catheters and attempts were made to dilate the track, both with rigid dilator and the balloon dilator and access could not be obtained. after multiple attempts, access was lost. at this point, the tubes were left out of the kidney and sterile dressings were applied. the patient was then placed on another operating table supine. his genitalia were prepped and draped after removing his foley catheter. flexible cystoscopy was performed and the right orifice identified, which was edematous and erythematous. the wire was passed up to kidney and a 5-french pollack catheter was then passed over to after the removing the scope. the wire was removed. contrast injection with good placement in the collecting system. the wire was replaced. the pollack catheter removed and 6-french variable length double-j stent was inserted using fluoroscopic guidance. the wire was removed leaving the double-j stent in good position. _______ 16-french foley was reinserted and connected to close drains.,procedure was terminated at this point and had been well tolerated. the patient was awakened and taken to recovery room in satisfactory condition having tolerated the procedure well.

comparison:, none.,medications:, lopressor 5mg iv at 0920 hours.,heart rate: ,recorded heart rate 55 to 57bpm.,exam:,initial unenhanced axial ct imaging of the heart was obtained with ecg gating for the purpose of coronary artery calcium scoring (agatston method) and calcium volume determination.,18 gauge iv intracath was inserted into the right antecubital vein.,a 20cc saline bolus was injected intravenously to confirm vein patency and adequacy of venous access.,multi-detector ct imaging was performed with a 64 slice mdct scanner with images obtained from the mid ascending aorta to the diaphragm at 0.5mm slice thickness during breath-holding.,95 cc of isovue was administered followed by a 90cc saline “bolus chaser”. image reconstruction was performed using retrospective cardiac gating. calcium scoring analysis (agatston method and volume determination) was performed.,findings:,calcium score: the patient's total agatston calcium score is: 115. the agatston score for the individual vessels are: lm: 49. rca: 1. lad: 2. cx: 2. other: 62. the agatston calcium score places the patient in the 90th percentile, which means 10 percent of the male population in this age group would have a higher calcium score.,quality assessment:, examination is of good quality with good bolus timing and good demonstration of coronary arteries.,left main coronary artery:, the left main coronary artery has a posteriorly positioned take-off from the valve cusp, with a patent ostium, and it has an extramural (non-malignant) course. the vessel is of moderate size. there is an apparent second ostium, in a more normal anatomic location, but quite small. this has an extramural (non-malignant) course. there is mixed calcific/atheromatous plaque within the distal vessel, as well as positive remodeling. there is no high grade stenosis but a flow-limiting lesion can not be excluded. the vessel trifurcates into a left anterior descending artery, a ramus intermedius and a left circumflex artery.,left anterior descending coronary artery:, the left anterior descending artery is a moderate-size vessel, with ostial calcific plaque and soft plaque without a high-grade stenosis, but there may be a flow-limiting lesion here. there is a moderate size bifurcating first diagonal branch with ostial calcification, but no flow-limiting lesion. lad continues as a moderate-size vessel to the posterior apex of the left ventricle.,ramus intermedius branch is a moderate to large-size vessel with extensive calcific plaque, but no ostial stenosis. the dense calcific plaque limits evaluation of the vessel lumen, and a flow-limiting lesion within the proximal vessel cannot be excluded. the vessel continues as a small vessel on the left lateral ventricular wall.,left circumflex coronary artery:, the left circumflex artery is a moderate-size vessel with a normal ostium giving rise to a small om1 branch and a large om2 branch supplying much of the posterolateral wall of the left ventricular. the av-groove branch tapers at the base of the heart. there is minimal calcific plaque within the mid vessel, but there is no flow-limiting stenosis.,right coronary artery:, the right coronary artery is a large vessel with a normal ostium giving rise to a moderate-size acute marginal branch and continuing as a large vessel to the crux of the heart supplying a left posterior descending artery and small posterolateral ventricular branches. there is minimal calcific plaque within the mid vessel, but there is no flow-limiting lesion.,coronary circulation is right dominant.,functional analysis:, end diastolic volume: 106ml end systolic volume: 44ml ejection fraction: 58 percent,anatomic analysis:,normal heart size with no demonstrated ventricular wall abnormalities. there are no demonstrated myocardial,bridges. normal left atrial appendage with no evidence of thrombosis.,cardiac valves are normal.,the aortic diameter measures 33mm just distal to the sino-tubular junction. the visualized thoracic aorta appears normal in size.,normal pericardium without pericardial thickening or effusion.,there is no demonstrated mediastinal or hilar adenopathy. the visualized lung parenchyma is unremarkable.,there are two left and two right pulmonary veins.,impression:,ventricular function: normal.,single vessel coronary artery analysis:,lm: there is a posterior origin from the valve cusp. there is mixed calcific/atheromatous plaque and positive remodeling plaque within the lm, and although there is no high grade stenosis, a flow-limiting lesion can not be excluded. in addition, there is an apparent second ostium of indeterminate significance, but both ostia have extramural (non-malignant) courses.,lad: dense calcific plaque within the proximal vessel with ostial calcification and possible flow-limiting proximal lesion. there is a ramus branch with dense calcific plaque limiting evaluation of the vessel lumen, but a flow-limiting lesion cannot be excluded here.,cx: minimal calcific plaque with no flow-limiting lesion.,rca: minimal calcific plaque with no flow-limiting lesion.,coronary artery dominance: right.

preoperative diagnosis: , morton's neuroma, third interspace, left foot.,postoperative diagnosis:, morton's neuroma, third interspace, left foot.,operation performed: , excision of neuroma, third interspace, left foot.,anesthesia: , general (local was confirmed by surgeon).,hemostasis: , ankle pneumatic tourniquet 225 mmhg.,tourniquet time: , 18 minutes. electrocautery was necessary.,injectables: , 50:50 mixture of 0.5% marcaine and 1% xylocaine, both plain. also, 0.5 ml dexamethasone phosphate (4 mg/ml).,indications: , please see dictated h&p for specifics.,procedure: ,after proper identification was made, the patient was brought to the operating room and placed on the table in supine position. the patient was then placed under general anesthesia. a local block was then injected into the third ray of the left foot. the left foot was then prepped with chlorhexidine gluconate and then draped in the usual sterile technique. the left foot was then exsanguinated with an esmarch bandage and elevated and an ankle pneumatic tourniquet was then inflated. attention was then directed to the third interspace where a longitudinal incision was placed just proximal to the webspace. the incision was deepened via sharp and blunt dissection with care taken to protect all vital structures. identification of the neuroma was made following plantar flexion of the digits. it was grasped with a hemostat and it was dissected in toto and removed. it was then sent to pathology. the area was then flushed with copious amounts of sterile saline. closure was with 4-0 vicryl in the subcutaneous tissue and then running subcuticular 4-0 nylon suture in the skin. steri-strips were then placed over that area. a sterile compressive dressing consisting of saline-soaked gauze, abd, kling, coban was placed over the foot. the tourniquet was then released. good flow was noted to return to all digits. the patient did tolerate the procedure well. he left the operating room with all vital signs stable and neurovascular status intact. the patient went to the recovery. the patient previously had been given both oral and written preoperative as well as postoperative instructions and a prescription for pain. the patient will follow up with me in approximately 4 days for dressing change.

diagnosis: , chronic laryngitis, hoarseness.,history: ,the patient is a 68-year-old male, was referred to medical center's outpatient rehabilitation department for skilled speech therapy secondary to voicing difficulties. the patient attended initial evaluation plus 3 outpatient speech therapy sessions, which focused on training the patient to complete resonant voice activities and to improve his vocal hygiene. the patient attended therapy one time a week and was given numerous home activities to do in between therapy sessions. the patient made great progress and he came in to discuss with an appointment on 12/23/08 stating that his voice had finally returned to "normal".,short-term goals:,1. to be independent with relaxation and stretching exercises and lessac-madsen resonant voice therapy protocol.,2. he also met short-term goal therapy 3 and he is independent with resonant voice therapy tasks.,3. we did not complete his __________ ratio during his last session; so, i am unsure if he had met his short-term goal number 2.,4. to be referred for a videostroboscopy, but at this time, the patient is not in need of this evaluation. however, in the future if hoarseness returns, it is strongly recommended that he be referred for a videostroboscopy prior to returning to additional outpatient therapy.,long-term goals:,1. the patient did reach his long-term goal of improved vocal quality to return to prior level of function and to utilize his voice in all settings without vocal hoarseness or difficulty.,2. the patient appears very pleased with his return of his normal voice and feels that he no longer needs outpatient skilled speech therapy.,the patient is discharged from my services at this time with a home program to continue to promote normal voicing.

preoperative diagnoses:,1. intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.,2. protein s low.,3. oligohydramnios.,postoperative:,1. intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.,2. protein s low.,3. oligohydramnios.,4. delivery of a viable female, weight 5 pound, 14 ounces. apgars of 9 and 9 at 1 and 5 minutes respectively and cord ph is 7.314.,operation performed:, low transverse c-section.,estimated blood loss: , 500 ml.,drains: , foley.,anesthesia: , spinal with duramorph.,history of present illness: ,this is a 21-year-old white female gravida 1, para 0, who had presented to the hospital at 37-3/7 weeks for induction. the patient had oligohydramnios and also when placed on the monitor had nonreassuring fetal heart rate with late deceleration. due to the iugr as well a decision for a c-section was made.,procedure: , the patient was taken to the operating room and placed in a seated position with standard spinal form of anesthesia administered by the anesthesia department. the patient was then repositioned, prepped and draped in a slight left lateral tilt. once this was completed first knife was used to make a low transverse skin incision approximately two fingerbreadths above the pubic symphysis. this was extended down to the level of the fascia. the fascia was nicked in the center and extended in transverse fashion. edges of the fascia were grasped with kocher and both blunt and sharp dissection both caudally and cephalic was completed consistent with the pfannenstiel technique. the abdominal rectus muscle was divided in the center, extended in vertical fashion and the peritoneum was entered at a high point and extended in vertical fashion. bladder blade was put in place and a bladder flap was created with the use of metzenbaum and pickups and then bluntly dissected via cautery and reincorporated in the bladder blade. second knife was used to make a low transverse uterine incision with care being taken to avoid the presenting part of fetus. presenting part was vertex, the head was delivered, followed by the remaining portion of the body. the mouth and nose were suctioned through bulb syringe and the cord was doubly clamped and cut and then the newborn handed off to waiting nursing personnel. cord ph blood and cord blood was obtained. the placenta was delivered manually and the uterus was externalized and the lining was cleaned off any remaining placental fragments and blood and the incisional edges were reapproximated with 0-chromic and a continuous locking stitch with a second layer used to imbricate the first. the bladder flap was re-peritonized with gelfoam underneath and abdomen was irrigated with copious amounts of saline and the uterus was placed back in its anatomical position. the gutters were wiped clean of any remaining blood and fluid and the edges of the perineum grasped with hemostats and continuous locking stitches of 2-0 vicryl was used to reapproximate the abdominal rectus muscle as well as the perineum. this area was then irrigated. cautery was used for adequate hemostasis, corners of the fascia grasped with hemostats and continuous locking stitch of 1-vicryl was started at both corners and overlapped in the center. subcutaneous tissue was irrigated with saline and reapproximated with 3-0 vicryl. skin edges reapproximated with sterile staples. sterile dressing was applied. the uterus was evacuated of any remaining clots vaginally. the patient was taken to recovery room in stable condition. instrument count, needle count, and sponge counts were all correct.

problem list:,1. acquired hypothyroidism.,2. papillary carcinoma of the thyroid gland, status post total thyroidectomy in 1992.,3. diabetes mellitus.,4. insomnia with sleep apnea.,history of present illness: , this is a return visit to the endocrine clinic for the patient with history as noted above. she is 45 years old. her last visit was about 6 months ago. since that time, the patient states her health has remained unchanged. currently, primary complaint is one of fatigue that she feels throughout the day. she states, however, she is doing well with cpap and wakes up feeling refreshed but tends to tire out later in the day. in terms of her thyroid issues, the patient states that she is not having signs or symptoms of thyroid excess or hypothyroidism. she is not reporting temperature intolerance, palpitations, muscle weakness, tremors, nausea, vomiting, constipation, hyperdefecation or diarrhea. her weight has been stable. she is not reporting proximal muscle weakness.,current medications:,1. levothyroxine 125 micrograms p.o. once daily.,2. cpap.,3. glucotrol.,4. avandamet.,5. synthroid.,6. byetta injected twice daily.,review of systems: , as stated in the hpi. she is not reporting polyuria, polydipsia or polyphagia. she is not reporting fevers, chills, sweats, visual acuity changes, nausea, vomiting, constipation or diarrhea. she is not having any lightheadedness, weakness, chest pain, shortness of breath, difficulty breathing, orthopnea or dyspnea on exertion.,physical examination:,general: she is an overweight, very pleasant woman, in no acute distress. vital signs: temperature 96.9, pulse 85, respirations not counted, blood pressure 135/65, and weight 85.7 kg. neck: reveals well healed surgical scar in the anteroinferior aspect of the neck. there is no palpable thyroid tissue noted on this examination today. there is no lymphadenopathy. thorax: reveals lungs that are clear, pa and lateral, without adventitious sounds. cardiovascular: demonstrated regular rate and rhythm. s1 and s2 without murmur. no s3, no s4 is auscultated. extremities: deep tendon reflexes 2+/4 without a delayed relaxation phase. no fine resting tremor of the outstretched upper extremity. skin, hair, and nails: all are unremarkable.,laboratory database: , lab data on 08/29/07 showed the following: thyroglobulin quantitative less than 0.5 and thyroglobulin antibody less than 20, free t4 1.35, and tsh suppressed at 0.121.,assessment and plan:,this is a 45-year-old woman with history as noted above.,1. acquired hypothyroidism, status post total thyroidectomy for papillary carcinoma in 1992.,2. plan to continue following thyroglobulin levels.,3. plan to obtain a free t4, tsh, and thyroglobulin levels today.,4. have the patient call the clinic next week for followup and continued management of her hypothyroid state.,5. plan today is to repeat her thyroid function studies. this case was discussed with dr. x and the recommendation. we are giving the patient today is for us to taper her medication to get her tsh somewhere between 0.41 or less. therefore, labs have been drawn. we plan to see the patient back in approximately 6 months or sooner. a repeat body scan will not been done, the one in 03/06 was negative.

preoperative diagnoses:,1. cervical intraepithelial neoplasia grade-iii status post conization with poor margins.,2. recurrent dysplasia.,3. unable to follow in office.,4. uterine procidentia grade ii-iii.,postoperative diagnoses:,1. cervical intraepithelial neoplasia grade-iii postconization.,2. poor margins.,3. recurrent dysplasia.,4. uterine procidentia grade ii-iii.,5. mild vaginal vault prolapse.,procedures performed:,1. total abdominal hysterectomy (tah) with bilateral salpingooophorectomy.,2. uterosacral ligament vault suspension.,anesthesia: , general and spinal with astramorph for postoperative pain.,estimated blood loss: , less than 100 cc.,fluids: ,2400 cc.,urine: , 200 cc of clear urine output.,indications: ,this patient is a 57-year-old nulliparous female who desires definitive hysterectomy for history of cervical intraepithelial neoplasia after conization and found to have poor margins.,findings: ,on bimanual examination, the uterus was found to be small. there were no adnexal masses appreciated. intraabdominal findings revealed a small uterus approximately 2 cm in size. the ovaries were atrophic consistent with menopause. the liver margins and stomach were palpated and found to be normal.,procedure in detail: , after informed consent was obtained, the patient was taken back to the operating suite and administered a spinal anesthesia for postoperative pain control. she was then placed in the dorsal lithotomy position and administered general anesthesia. she was then prepped and draped in the sterile fashion and an indwelling foley catheter was placed in her bladder. at this point, the patient was evaluated for a possible vaginal hysterectomy. she was nulliparous and the pelvis was narrow. after the anesthesia was administered, the patient was repeatedly stooling and therefore because of these two reasons, the decision was made to do an abdominal hysterectomy. after the patient was prepped and draped, a pfannenstiel skin incision was made approximately 2 cm above the pubic symphysis. the second scalpel was used to dissect out to the underlying layer of fascia. the fascia was incised in the midline and extended laterally using the mayo scissors. the superior aspect of the rectus fascia was grasped with ochsners, tented up and underlying layer of rectus muscle was dissected off bluntly as well as with mayo scissors. in a similar fashion, the inferior portion of the rectus fascia was tented up, dissected off bluntly as well as with mayo scissors. the rectus muscle was then separated bluntly in the midline and the peritoneum was identified and entered with the metzenbaum. the peritoneal incision was extended superiorly and inferiorly with good visualization of the bladder. at this point, the above findings were noted and the gyn balfour retractor was placed. moist laparotomy sponges were used to pack the bowel out of the operative field. the bladder blade and the extension for the retractor were then placed. an allis was used on the uterus for retraction. the round ligaments were then identified, clamped with two hemostats and transected and then suture ligated. the anterior portion of the broad ligament was dissected along vesicouterine resection. the bladder was then dissected off the anterior cervix and vagina without difficulty. the infundibulopelvic ligaments on both sides were then doubly clamped using hemostats, transected and suture ligated with #0 vicryl suture. the uterine vessels on both sides were skeletonized and clamped with two hemostats and transected and suture ligated with #0 vicryl. good hemostasis was assured. the cardinal ligaments on both sides were clamped using a curved hemostat, transected and suture ligated with #0 vicryl. good hemostasis was obtained. two hemostats were then placed just under the cervix meeting in the midline. the uterus and cervix were then _______ off using a scalpel. this was handed and sent to pathology for evaluation. using #0 vicryl suture, the right vaginal cuff angle was closed and affixed to the ipsilateral cardinal ligament. a baseball stitch was then used to close the cuff to the midline. the same was done to the left vaginal cuff angle, which was affixed to the ipsilateral and cardinal ligaments. the baseball stitch was used to close the cuff to the midline. the hemostats were removed and the cuff was closed and good hemostasis was noted. the uterosacral ligaments were also transfixed to the cuff and brought out for good support by using a #0 vicryl suture through each uterosacral ligament and incorporating this into the vaginal cuff. the pelvis was then copiously irrigated with warm normal saline. good support and hemostasis was noted. the bowel packing was then removed and the gyn balfour retractor was moved. the peritoneum was then repaired with #0 vicryl in a running fashion. the fascia was then closed using #0 vicryl in a running fashion, marking the first stitch and first last stitch in a lateral to medial fashion. the skin was then closed with #4-0 undyed vicryl in a subcuticular closure and an op-site was placed over this. the patient was then brought out of general anesthesia and extubated. the patient tolerated the procedure well. sponge, lap, and needle counts were correct x2. she will follow up postoperatively as an inpatient.

preoperative diagnosis:, vitreous hemorrhage, right eye.,postoperative diagnosis: , vitreous hemorrhage, right eye.,procedure: ,vitrectomy, right eye.,procedure in detail: ,the patient was prepared and draped in the usual manner for a vitrectomy procedure under local anesthesia. initially, a 5 cc retrobulbar injection was performed with 2% xylocaine during monitored anesthesia control. a lancaster lid speculum was applied and the conjunctiva was opened 4 mm posterior to the limbus. mvr incisions were made 4 mm posterior to the limbus in the *** and *** o'clock meridians following which the infusion apparatus was positioned in the *** o'clock site and secured with a 5-0 vicryl suture. then, under indirect ophthalmoscopic control, the vitrector was introduced through the *** o'clock site and a complete vitrectomy was performed. all strands of significance were removed. tractional detachment foci were apparent posteriorly along the temporal arcades. next, endolaser coagulation was applied to ischemic sites and to neovascular foci under indirect ophthalmoscopic control. finally, an air exchange procedure was performed, also under indirect ophthalmoscopic control. the intraocular pressure was within the normal range. the globe was irrigated with a topical antibiotic. the mvr incisions were closed with 7-0 vicryl. no further manipulations were necessary. the conjunctiva was closed with 6-0 plain catgut. an eye patch was applied and the patient was sent to the recovery area in good condition.

exam: , cta chest pulmonary angio.,reason for exam: , evaluate for pulmonary embolism.,technique: , postcontrast ct chest pulmonary embolism protocol, 100 ml of isovue-300 contrast is utilized.,findings: , there are no filling defects in the main or main right or left pulmonary arteries. no central embolism. the proximal subsegmental pulmonary arteries are free of embolus, but the distal subsegmental and segmental arteries especially on the right are limited by extensive pulmonary parenchymal, findings would be discussed in more detail below. there is no evidence of a central embolism.,as seen on the prior examination, there is a very large heterogeneous right chest wall mass, which measures at least 10 x 12 cm based on axial image #35. just superior to the mass is a second heterogeneous focus of neoplasm measuring about 5 x 3.3 cm. given the short interval time course from the prior exam, dated 01/23/09, this finding has not significantly changed. however, there is considerable change in the appearance of the lung fields. there are now bilateral pleural effusions, small on the right and moderate on the left with associated atelectasis. there are also extensive right lung consolidations, all new or increased significantly from the prior examination. again identified is a somewhat spiculated region of increased density at the right lung apex, which may indicate fibrosis or scarring, but the possibility of primary or metastatic disease cannot be excluded. there is no pneumothorax in the interval.,on the mediastinal windows, there is presumed subcarinal adenopathy, with one lymph node measuring roughly 12 mm suggestive of metastatic disease here. there is aortic root and arch and descending thoracic aortic calcification. there are scattered regions of soft plaque intermixed with this. the heart is not enlarged. the left axilla is intact in regards to adenopathy. the inferior thyroid appears unremarkable.,limited assessment of the upper abdomen discloses a region of lower density within the right hepatic lobe, this finding is indeterminate, and if there is need for additional imaging in regards to hepatic metastatic disease, follow up ultrasound. spleen, adrenal glands, and upper kidneys appear unremarkable. visualized portions of the pancreas are unremarkable.,there is extensive rib destruction in the region of the chest wall mass. there are changes suggesting prior trauma to the right clavicle.,impression:,1. again demonstrated is a large right chest wall mass.,2. no central embolus, distal subsegmental and segmental pulmonary artery branches are in part obscured by the pulmonary parenchymal findings, are not well assessed.,3. new bilateral pleural effusions and extensive increasing consolidations and infiltrates in the right lung.,4. see above regarding other findings.

preoperative diagnosis: , left adrenal mass, 5.5 cm.,postoperative diagnoses:,1. left adrenal mass, 5.5 cm.,2. intraabdominal adhesions.,procedure performed:,1. laparoscopic lysis of adhesions.,2. laparoscopic left adrenalectomy.,anesthesia: , general.,estimated blood loss:, less than 100 cc.,fluids: , 3500 cc crystalloids.,drains:, none.,disposition:, the patient was taken to recovery room in stable condition. sponge, needle, and instrument counts were correct per or staff.,history:, this is a 57-year-old female who was found to have a large left adrenal mass, approximately 5.5 cm in size. she had undergone workup previously with my associate, dr. x as well as by endocrinology, and showed this to be a nonfunctioning mass. due to the size, the patient was advised to undergo an adrenalectomy and she chose the laparoscopic approach due to her multiple pulmonary comorbidities.,intraoperative findings: , showed multiple intraabdominal adhesions in the anterior abdominal wall. the spleen and liver were unremarkable. the gallbladder was surgically absent.,there was large amount of omentum and bowel in the pelvis, therefore the gynecological organs were not visualized. there was no evidence of peritoneal studding or masses. the stomach was well decompressed as well as the bladder.,procedure details: , after informed consent was obtained from the patient, she was taken to the operating room and given general anesthesia. she was placed on a bean bag and secured to the table. the table was rotated to the right to allow gravity to aid in our retraction of the bowel.,prep was performed. sterile drapes were applied. using the hassan technique, we placed a primary laparoscopy port approximately 3 cm lateral to the umbilicus on the left. laparoscopy was performed with ___________. at this point, we had a second trocar, which was 10 mm to 11 mm port. using the non-cutting trocar in the anterior axillary line and using harmonic scalpel, we did massive lysis of adhesions from the anterior abdominal wall from the length of the prior abdominal incision, the entire length of the abdominal incision from the xiphoid process to the umbilicus. the adhesions were taken down off the entire anterior abdominal wall.,at this point, secondary and tertiary ports were placed. we had one near the midline in the subcostal region and to the left midline and one at the midclavicular line, which were also 10 and 11 ports using a non-cutting blade.,at this point, using the harmonic scalpel, we opened the white line of toldt on the left and reflected the colon medially, off the anterior aspect of the gerota's fascia. blunt and sharp dissection was used to isolate the upper pole of the kidney, taking down some adhesions from the spleen. the colon was further mobilized medially again using gravity to aid in our retraction. after isolating the upper pole of the kidney using blunt and sharp dissection as well as the harmonic scalpel, we were able to dissect the plane between the upper pole of the kidney and lower aspect of the adrenal gland. we were able to isolate the adrenal vein, dumping into the renal vein, this was doubly clipped and transected. there was also noted to be vascular structure of the upper pole, which was also doubly clipped and transected. using the harmonic scalpel, we were able to continue free the remainder of the adrenal glands from its attachments medially, posteriorly, cephalad, and laterally.,at this point, using the endocatch bag, we removed the adrenal gland through the primary port in the periumbilical region and sent the flap for analysis. repeat laparoscopy showed no additional findings. the bowel was unremarkable, no evidence of bowel injury, no evidence of any bleeding from the operative site.,the operative site was irrigated copiously with saline and reinspected and again there was no evidence of bleeding. the abdominal cavity was desufflated and was reinspected. there was no evidence of bleeding.,at this point, the camera was switched to one of the subcostal ports and the primary port in the periumbilical region was closed under direct vision using #0 vicryl suture. at this point, each of the other ports were removed and then with palpation of each of these ports, this indicated that the non-cutting ports did close and there was no evidence of fascial defects.,at this point, the procedure was terminated. the abdominal cavity was desufflated as stated. the patient was sent to recovery in stable condition. postoperative orders were written. the procedure was discussed with the patient's family at length.

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

preoperative diagnosis: , cataract, left eye.,postoperative diagnosis: ,cataract, left eye.,procedure performed: ,extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens, left eye.,anesthesia: , topical.,complications: , none.,procedure: , after the induction of topical anesthesia with 4% xylocaine drops, the left eye was prepped and draped in the usual fashion. a speculum was inserted, and the microscope was moved into position.,a 3.2-mm incision was made in clear cornea at the limbus with a diamond keratome at the 3 o'clock position, and 0.1 cc of 1% xylocaine without preservative was instilled into the anterior chamber. it was then filled with viscoelastic. a stab incision was made into the anterior chamber at the limbus at 5 o'clock position with a microblade.,a cystitome was used to make a capsulotomy, and the capsulorrhexis forceps were used to complete a circular capsulorrhexis. the nucleus was hydrodelineated and hydrodissected with balanced salt solution on a 26-gauge cannula, and the phacoemulsifier was used to phacoemulsify the nucleus using a bimanual technique with the nucleus rotator inserted through the keratotomy incision. the irrigation-aspiration handpiece was used to systematically aspirate cortex 360 degrees. the posterior capsule was vacuumed; it was clear and intact.,the capsular bag and the anterior chamber were filled with viscoelastic. a model ma30ac lens, power 21.5 diopters, serial number 864414.095, was folded, grasped with the lens insertion forceps and inserted into the capsular bag. the trailing loop was placed inside the bag. the viscoelastic was removed with the irrigation-aspiration handpiece. the lens centered well. a single 10-0 nylon suture was placed to close the wound. it was checked and ascertained to be watertight. decadron 0.25 cc, 0.25 cc of antibiotic and 0.25 cc of xylocaine were injected subconjunctivally. dexacidin ointment was placed in the eye, and the procedure was terminated.,the procedure was well tolerated by the patient who was returned to the recovery room in good condition.

preoperative diagnosis:, airway stenosis with self-expanding metallic stent complication.,postoperative diagnosis:, airway stenosis with self-expanding metallic stent complication.,procedures:,1. rigid bronchoscopy with removal of foreign body, prolonged procedure taking two hours to remove the stent piecemeal in a very difficult and trying situation.,2. excision of granulation tissue tumor.,3. bronchial dilation with a balloon bronchoplasty, right main bronchus.,4. argon plasma coagulation to control bleeding in the trachea.,5. placement of a tracheal and bilateral bronchial stents with a silicon wire stent.,endoscopic findings:,1. normal true vocal cords.,2. proximal trachea with high-grade occlusion blocking approximately 90% of the trachea due to granulation tissue tumor and break down of metallic stent.,3. multiple stent fractures in the mid portion of the trachea with granulation tissue.,4. high-grade obstruction of the right main bronchus by stent and granulation tissue.,5. left main bronchus was covered by the distal portion of the stent and was only being ventilated through the struts of the stent.,6. all in all a high-grade terrible airway obstruction with involvement of the carina, left and right main stem bronchus, mid, distal, and proximal trachea.,technique in detail: , after informed consent was obtained from the patient, he was brought into the operating field. a rapid sequence induction was done. he was intubated with a rigid scope. jet ventilation technique was carried out using a rigid and flexible scope. a thorough airway inspection was carried out with findings as described above.,dr. d was present in the operating room and we conferred on operative strategy and agreed that the best of strategy would be to first dilate the right main bronchus, cauterize it to control bleeding and then piecemeal removed the stent from distal to proximal. this is the technique that was carried out in a painstaking fashion removing bits of the stent piecemeal with finally getting all of the visible stent out of the airway. it should be noted that dr. donovan and i felt that two of the metallic stents were probably in place but we cannot be sure because of the terrible anatomy and the fact that the stent pieces were coming out twisted metal in fragments. nevertheless, all the visible stent was removed, and the airway was much better after with the dilation of balloon and the rigid scope. we took measurements and decided to place stents in the trachea, left and right main bronchus using a dumon y-stent. it was measured 18 mm in tracheal diameter and 14 mm in bronchial diameter. the right main stem stent was 2.25 cm in length, the left main stem stent was 3 cm in length and the tracheal portion was 9 cm in length. after it was placed, excellent placement was achieved with the proximal end of the stent 3 cm below the true vocal cords. the patient tolerated the procedure well and was brought to the recovery room extubated.

procedure: , placement of left ventriculostomy via twist drill.,preoperative diagnosis:, massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,postoperative diagnosis: , massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,indications for procedure: ,the patient is a man with a history of massive intracranial hemorrhage and hydrocephalus with intraventricular hemorrhage. his condition is felt to be critical. in a desperate attempt to relieve increased intracranial pressure, we have proposed placing a ventriculostomy. i have discussed this with patient's wife who agrees and asked that we proceed emergently.,after a sterile prep, drape, and shaving of the hair over the left frontal area, this area is infiltrated with local anesthetic. subsequently a 1 cm incision was made over kocher's point. hemostasis was obtained. then a twist drill was made over this area. bones strips were irrigated away. the dura was perforated with a spinal needle.,a camino monitor was connected and zeroed. this was then passed into the left lateral ventricle on the first pass. excellent aggressive very bloody csf under pressure was noted. this stopped, slowed, and some clots were noted. this was irrigated and then csf continued. initial opening pressures were 30, but soon arose to 80 or a 100.,the patient tolerated the procedure well. the wound was stitched shut and the ventricular drain was then connected to a drainage bag.,platelets and ffp as well as vitamin k have been administered and ordered simultaneously with the placement of this device to help prevent further clotting or bleeding.

title of operation: , phacoemulsification with posterior chamber intraocular lens implant in the right eye.,indication for surgery: , the patient is a 27-year-old male who sustained an open globe injury as a child. he subsequently developed a retinal detachment in 2005 and now has silicone oil in the anterior chamber of the right eye as well as a dense cataract. he is undergoing silicone oil removal as well as concurrent cataract extraction with lens implant in the right eye.,preop diagnosis:,1. history of open globe to the right eye.,2. history of retinal detachment status post repair in the right eye.,3. silicone oil in anterior chamber.,4. dense silicone oil cataract in the right eye obscuring the view of the posterior pole.,postop diagnosis:,1. history of open globe to the right eye.,2. history of retinal detachment status post repair in the right eye.,3. silicone oil in anterior chamber.,4. dense silicone oil cataract in the right eye obscuring the view of the posterior pole.,anesthesia: , general.,pros dev implant: , abc laboratories posterior chamber intraocular lens, 21.0 diopters, serial number 123456.,narrative: , informed consent was obtained. all questions were answered. the patient was brought to preoperative holding area where the operative right eye was marked. he was brought to the operating room and placed in the supine position. ekg leads were placed. general anesthesia was induced by the anesthesia service. a time-out was called to confirm the procedure and operative eye. the right operative eye was disinfected and draped in a standard fashion for eye surgery. a lid speculum was placed. the vitreoretinal team placed the infusion cannula after performing a peritomy. at this point in the case, the patient was turned over to the cornea service with mrs. jun. a paracentesis was made at the approximately 3 o'clock position. healon was placed into the anterior chamber. the diamond keratome was used to make a vertical groove incision just inside the limbus at the 108-degree axis. this incision was then shelved anteriorly and used to enter the anterior chamber. the utrata forceps were used to complete a continuous circular capsulorrhexis after incision of the capsule with the cystotome. hydrodissection was performed. the lens nucleus was removed using phacoemulsification and irrigation and aspiration. lens cortex also was removed using irrigation and aspiration. viscoelastic was placed to inflate the capsular remnant. the diamond knife was used to enlarge the phaco incision. intraocular lens was selected from preoperative calculations, placed in the injector system, and inserted into the capsule without difficulty. the trailing haptic was placed using the sheets forceps and the barraquer sweep to push the iol optic posteriorly as the trailing haptic was placed. the anterior cornea wound was sutured along with the paracentesis after irrigation and aspiration was performed to remove remaining viscoelastic from the anterior chamber. this was done without difficulty. the anterior chamber was secured and watertight at the end of the procedure. intraocular pressure was satisfactory. the patient tolerated the procedure well and then was turned over to the retina service in good condition. they will dictate a separate note.

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

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

reason for consultation:, regarding weakness and a history of polymyositis.,history of present illness:, the patient is an 87-year-old white female who gives a history of polymyositis diagnosed in 1993. the patient did have biopsy of the quadriceps muscle performed at that time which, per her account, did show an abnormality. she was previously followed by dr. c, neurology, over several years but was last followed up in the last three to four years. she is also seeing dr. r at rheumatology in the past. initially, she was treated with steroids but apparently was intolerant of that. she was given other therapy but she is unclear of the details of that. she has had persistent weakness of the bilateral lower extremities and has ambulated with the assistance of a walker for many years. she has also had a history of spine disease though the process there is not known to me at this time.,she presented on february 1, 2006 with productive cough, fevers and chills, left flank rash and pain there as well as profound weakness. since admission, she has been diagnosed with a left lower lobe pneumonic process as well as shingles and is on therapy for both. she reports that strength in the proximal upper extremities has remained good. however, she has no grip strength. apparently, this has been progressive over the last several years as well. she also presently has virtually no strength in the lower extremities and that is worse within the last few days. prior to admission, she has had cough with mild shortness of breath. phlegm has been dark in color. she has had reflux and occasional dysphagia. she has also had constipation but no other gi issues. she has no history of seizure or stroke like symptoms. she occasionally has headaches. no vision changes. other than the left flank skin changes, she has had no other skin issues. she does have a history of dvt but this was 30 to 40 years ago. no history of dry eyes or dry mouth. she denies chest pain at present.,past medical and surgical history:, hysterectomy, cholecystectomy, congestive heart failure, hypertension, history of dvt, previous colonoscopy that was normal, renal artery stenosis.,medications:, medications prior to admission: os-cal, zyrtec, potassium, plavix, bumex, diovan.,current medications:, acyclovir, azithromycin, ceftriaxone, diovan, albuterol, robitussin, hydralazine, atrovent.,allergies:, no known drug allergies.,social history:, she is a widow. she has 8 children that are healthy with the exception of one who has coronary artery disease and has had bypass. she also has a son with lumbar spine disease. no tobacco, alcohol or iv drug abuse.,family history:, no history of neurologic or rheumatologic issues.,review of systems:, as above.,physical examination:,vital signs: she is afebrile. current temperature 98. respirations 16, heart rate 80 to 90. blood pressure 114/55.,general appearance: she is alert and oriented and in no acute distress. she is pleasant. she is reclining in the bed.,heent: pupils are reactive. sclera are clear. oropharynx is clear.,neck: no thyromegaly. no lymphadenopathy.,cardiovascular: heart is regular rate and rhythm.,respiratory: lungs have a few rales only.,abdomen: positive bowel sounds. soft, nontender, nondistended. no hepatosplenomegaly.,extremities: no edema.,skin: left flank dermatome with vesicular rash that is red and raised consistent with zoster.,joints: no synovitis anywhere. strength is 5/5 in the proximal upper extremities. proximal lower extremities are 0 out of 5. she has no grip strength at present.,neurological: cranial nerves ii through xii grossly intact. reflexes 2/4 at the biceps, brachial radialis, triceps. nil out of four at the patella and achilles bilaterally. sensation seems normal. chest x-ray shows copd, left basilar infiltrate, cardiomegaly, atherosclerotic changes.,laboratory data:, white blood cell count 6.1, hemoglobin 11.9, platelets 314,000. sed rate 29 and 30. electrolytes: sodium 134, potassium 4.9, creatinine 1.2, normal liver enzymes. tsh is slightly elevated at 5.38. cpk 36, bnp 645. troponin less than 0.04.,impression:,1. the patient has a history of polymyositis, apparently biopsy proven with a long standing history of bilateral lower extremity weakness. she has experienced dramatic worsening in the last 24 hours of the lower extremity weakness. this in the setting of an acute illness, presumably a pneumonic process.,2. she also gives a history of spine disease though the details of that process are not available either.,the question raised at this time is of recurrence in inflammatory myopathy which would need to include not only polymyositis but also inclusion body myositis versus progressive spine disease versus weakness secondary to acute illness versus neuropathic process versus other.,3. zoster of the left flank.,4. left lower lobe pneumonic process.,5. elevation of the thyroid stimulating hormone.,recommendations:,1. i have asked dr. c to see the patient and he has done so tonight. he is planning for emg nerve conduction study in the morning.,2. i would consider further spine evaluation pending review of the emg nerve conduction study.,3. agree with supportive care being administered thus far and will follow along with you.

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

preoperative diagnosis:, cervical myelopathy secondary to very large disc herniations at c4-c5 and c5-c6.,postoperative diagnosis: , cervical myelopathy secondary to very large disc herniations at c4-c5 and c5-c6.,procedure performed:,1. anterior cervical discectomy, c4-c5 and c5-c6.,2. arthrodesis, c4-c5 and c5-c6.,3. partial corpectomy, c5.,4. machine bone allograft, c4-c5 and c5-c6.,5. placement of anterior cervical plate with a zephyr c4 to c6.,6. fluoroscopic guidance.,7. microscopic dissection.,anesthesia:, general.,estimated blood loss: , 60 ml.,complications: , none.,indications:, this is a patient who presents with progressive weakness in the left upper extremity as well as imbalance. he has also noted to have cord signal at the c4-c5 level secondary to a very large disc herniation that came behind the body at c5 as well and as well as a large disc herniation at c5-c6. risks and benefits of the surgery including bleeding, infection, neurologic deficit, nonunion, progressive spondylosis, and lack of improvement were all discussed. he understood and wished to proceed.,description of procedure: , the patient was brought to the operating room and placed in the supine position. preoperative antibiotics were given. the patient was placed in the supine position with all pressure points noted and well padded. the patient was prepped and draped in standard fashion. an incision was made approximately above the level of the cricoid. blunt dissection was used to expose the anterior portion of the spine with carotid moved laterally and trachea and esophagus moved medially. we then placed needle into the disc spaces and was found to be at c5-c6. distracting pins were placed in the body of c4 and in to the body of c6. the disc was then completely removed at c4-c5. there was very significant compression of the cord. this was carefully removed to avoid any type of pressure on the cord. this was very severe and multiple free fragments were noted. this was taken down to the level of ligamentum. both foramen were then also opened. other free fragments were also found behind the body of c5, part of the body of c5 was taken down to assure that all of these were removed. the exact same procedure was done at c5-c6; however, if there were again free fragments noted, there was less not as severe compression at the c4-c5 area. again part of the body at c5 was removed to make sure that there was no additional constriction. both nerve roots were then widely decompressed. machine bone allograft was placed into the c4-c5 as well as c5-c6 and then a zephyr plate was placed in the body of c4 and to the body of c6 with a metal pin placed into the body at c5. excellent purchase was obtained. fluoroscopy showed good placement and meticulous hemostasis was obtained. fascia was closed with 3-0 vicryl, subcuticular 3-0 dermabond for skin. the patient tolerated the procedure well and went to recovery in good condition.

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 suppurative appendicitis.,procedure performed: , laparoscopic appendectomy.,anesthesia: , general endotracheal and marcaine 0.25% local.,indications:, this 29-year-old female presents to abcd general hospital emergency department on 08/30/2003 with history of acute abdominal pain. on evaluation, it was noted that the patient has clinical findings consistent with acute appendicitis. however, the patient with additional history of loose stools for several days prior to event. therefore, a cat scan of the abdomen and pelvis was obtained revealing findings consistent with acute appendicitis. there was no evidence of colitis on the cat scan. with this in mind and the patient's continued pain at present, the patient was explained the risks and benefits of appendectomy. she agreed to procedure and informed consent was obtained.,gross findings: , the appendix was removed without difficulty with laparoscopic approach. the appendix itself noted to have a significant inflammation about it. there was no evidence of perforation of the appendix.,procedure details:, the patient was placed in supine position. after appropriate anesthesia was obtained and sterile prep and drape completed, a #10 blade scalpel was used to make a curvilinear infraumbilical incision. through this incision, a veress needle was utilized to create a co2 pneumoperitoneum of 15 mmhg. the veress needle was then removed. a 10 mm trocar was then introduced through this incision into the abdomen. a video laparoscope was then inserted and the above noted gross findings were appreciated upon evaluation. initially, bilateral ovarian cysts were appreciated, however, there was no evidence of acute disease on evaluation. photodocumentation was obtained.,a 5 mm port was then placed in the right upper quadrant. this was done under direct visualization and a blunt grasper was utilized to mobilize the appendix. next, a 12 mm port was placed in the left lower quadrant lateral to the rectus musculature under direct visualization. through this port, the dissector was utilized to create a small window in the mesoappendix. next, an endogia with gi staples was utilized to fire across the base of the appendix, which was done noting it to be at the base of the appendix. next, staples were changed to vascular staples and the mesoappendix was then cut and vessels were then ligated with vascular staples. two 6 x-loupe wires with endogia were utilized in this prior portion of the procedure. next, an endocatch was placed through the 12 mm port and the appendix was placed within it. the appendix was then removed from the 12 mm port site and taken off the surgical site. the 12 mm port was then placed back into the abdomen and co2 pneumoperitoneum was recreated. the base of the appendix was reevaluated and noted to be hemostatic. aspiration of warm saline irrigant then done and noted to be clear. there was a small adhesion appreciated in the region of the surgical site. this was taken down with blunt dissection without difficulty. there was no evidence of other areas of disease. upon re-exploration with a video laparoscope in the abdomen and after this noting the appendix base to be hemostatic and intact. the instruments were removed from the patient and the port sites were then taken off under direct visualization. the co2 pneumoperitoneum was released into the air and the fascia was approximated in the 10 mm and 12 mm port sites with #0 vicryl ligature x2. marcaine 0.25% was then utilized in all three incision sites and #4-0 vicryl suture was used to approximate the skin and all three incision sites. steri-strips and sterile dressings were applied. the patient tolerated the procedure well and taken to postoperative care unit in stable condition and monitored under general medical floor on iv antibiotics, pain medications, and return to diet.

procedure:, colonoscopy.,preoperative diagnosis: , follow up adenomas.,postoperative diagnoses:,1. two colon polyps, removed.,2. small internal hemorrhoids.,3. otherwise normal examination of cecum.,medications: , fentanyl 150 mcg and versed 7 mg slow iv push.,indications: , this is a 60-year-old white female with a history of adenomas. she does have irregular bowel habits.,findings: , the patient was placed in the left lateral decubitus position and the above medications were administered. the colonoscope was advanced to the cecum as identified by the ileocecal valve, appendiceal orifice, and blind pouch. the colonoscope was slowly withdrawn and a careful examination of the colonic mucosa was made, including a retroflexed view of the rectum. there was a 4 mm descending colon polyp, which was removed with jumbo forceps, and sent for histology in bottle one. there was a 10 mm pale, flat polyp in the distal rectum, which was removed with jumbo forceps, and sent for histology in bottle 2. there were small internal hemorrhoids. the remainder of the examination was normal to the cecum. the patient tolerated the procedure well without complication.,impression:,1. two colon polyps, removed.,2. small internal hemorrhoids.,3. otherwise normal examination to cecum.,plan: , i will await the results of the colon polyp histology. the patient was told the importance of daily fiber.

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

history of present illness: , the patient returns for followup evaluation 21 months after undergoing prostate fossa irradiation for recurrent gleason 8 adenocarcinoma. his urinary function had been stable until 2 days ago. over the past couple of days he has been waking every 1 to 1-1/2 hours and has had associated abdominal cramping, as well as a bit of sore throat (his wife has had a cold for about 2 weeks). his libido remains intact (but he has not been sexually functional), but his erections have been dysfunctional. the bowel function is stable with occasional irritative hemorrhoidal symptoms. he has had no hematochezia. the psa has been slowly rising in recent months. this month it reached 1.2.,pain assessment: , abdominal cramping in the past 2 days. no more than 1 to 2 of 10 in intensity.,performance status: , karnofsky score 100. he continues to work full-time.,nutritional status: , appetite has been depressed over the past couple of days, and he has lost about 5 pounds. (per him, mostly this week.),psychiatric: , some stress regarding upcoming irs audits of clients.,review of systems: , otherwise noncontributory.,medications,1. nyquil.,2. timolol eye drops.,3. aspirin.,4. advil.,5. zinc.,physical examination,general: pleasant, well-developed, gentleman in no acute distress. weight is 197 pounds.,heent: sclerae and conjunctivae are clear. extraocular movement are intact. hearing is grossly intact. the oral cavity is without thrush. there is minor pharyngitis.,lymph nodes: no palpable lymphadenopathy.,skeletal: no focal skeletal tenderness.,lungs: clear to auscultation bilaterally.,cardiovascular: regular rate and rhythm.,abdomen: soft, nontender without palpable mass or organomegaly.,digital rectal examination: there are external hemorrhoids. the prostate fossa is flat without suspicious nodularity. there is no blood on the examining glove.,extremities: without clubbing, cyanosis, or edema.,neurologic: without focal deficit.,impression:, concerning slow ongoing rise in psa.,plan: , discussed significance of this in detail with the patient. he understands the probability that there may be residual cancer although the location is unknown. for now there is no good evidence that early management affects the ultimate prognosis. accordingly, he is comfortable with careful monitoring, and i have asked him to return here in 3 months with an updated psa. i also suggested that he reestablish contact with dr. x at his convenience.

exam: , ct stone protocol.,reason for exam:, history of stones, rule out stones.,technique: , noncontrast ct abdomen and pelvis per renal stone protocol.,findings: , correlation is made with a prior examination dated 01/20/09.,again identified are small intrarenal stones bilaterally. these are unchanged. there is no hydronephrosis or significant ureteral dilatation. there is no stone along the expected course of the ureters or within the bladder. there is a calcification in the low left pelvis not in line with ureter, this finding is stable and is compatible with a phlebolith. there is no asymmetric renal enlargement or perinephric stranding.,the appendix is normal. there is no evidence of a pericolonic inflammatory process or small bowel obstruction.,scans through the pelvis disclose no free fluid or adenopathy.,lung bases aside from very mild dependent atelectasis appear clear.,given the lack of contrast, liver, spleen, adrenal glands, and the pancreas are grossly unremarkable. the gallbladder is present. there is no abdominal free fluid or pathologic adenopathy.,impression:,1. bilateral intrarenal stones, no obstruction.,2. normal appendix.

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

preoperative diagnoses:,1. gastroesophageal reflux disease.,2. chronic dyspepsia.,postoperative diagnoses:,1. gastroesophageal reflux disease.,2. chronic dyspepsia.,3. alkaline reflux gastritis.,4. gastroparesis.,5. probable billroth ii anastomosis.,6. status post whipple's pancreaticoduodenectomy.,procedure performed:, esophagogastroduodenoscopy with biopsies.,indications for procedure: , this is a 55-year-old african-american female who had undergone whipple's procedure approximately five to six years ago for a benign pancreatic mass. the patient has pancreatic insufficiency and is already on replacement. she is currently using nexium. she has continued postprandial dyspepsia and reflux symptoms. to evaluate this, the patient was boarded for egd. the patient gave informed consent for the procedure.,gross findings: , at the time of egd, the patient was found to have alkaline reflux gastritis. there was no evidence of distal esophagitis. gastroparesis was seen as there was retained fluid in the small intestine. the patient had no evidence of anastomotic obstruction and appeared to have a billroth ii reconstruction by gastric jejunostomy. biopsies were taken and further recommendations will follow.,procedure: ,the patient was taken to the endoscopy suite. the heart and lungs examination were unremarkable. the vital signs were monitored and found to be stable throughout the procedure. the patient's oropharynx was anesthetized with cetacaine spray. she was placed in left lateral position. the patient had the video olympus gif gastroscope model inserted per os and was advanced without difficulty through the hypopharynx. ge junction was in normal position. there was no evidence of any hiatal hernia. there was no evidence of distal esophagitis. the gastric remnant was entered. it was noted to be inflamed with alkaline reflux gastritis. the anastomosis was open and patent. the small intestine was entered. there was retained fluid material in the stomach and small intestine and _______ gastroparesis. biopsies were performed. insufflated air was removed with withdrawal of the scope. the patient's diet will be adjusted to postgastrectomy-type diet. biopsies performed. diet will be reviewed. the patient will have an upper gi series performed to rule out more distal type obstruction explaining the retained fluid versus gastroparesis. reglan will also be added. further recommendations will follow.

summary: ,this patient is one-day postop open parathyroid exploration with subtotal parathyroidectomy and intraoperative pth monitoring for parathyroid hyperplasia. she has had an uneventful postoperative night. she put out 1175 ml of urine since surgery. her incision looks good. iv site and extremities are unremarkable.,laboratory data: ,her calcium level was 7.5 this morning. she has been on three tums orally b.i.d. and i am increasing three tums orally q.i.d. before meals and at bedtime.,plan:, i will heparin lock her iv, advance her diet, and ambulate her. i have asked her to increase her prednisone when she goes home. she will double her regular dose for the next five days. i will advance her diet. i will continue to monitor her calcium levels throughout the day. if they stabilize, i am hopeful that she will be ready for discharge either later today or tomorrow. she will be given lortab elixir 2 to 4 teaspoons orally every four hours p.r.n. pain, dispensed #240 ml with one refill. her final calcium dosage will be determined prior to discharge. i will plan to see her back in the office on the 12/30/08, and she has been instructed to call or return sooner for any problems.

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

procedure performed: , bassini inguinal herniorrhaphy.,anesthesia: , local with mac anesthesia.,procedure: , after informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table. the patient was sedated and an adequate local anesthetic was administered using 1% lidocaine without epinephrine. the patient was prepped and draped in the usual sterile manner.,a standard inguinal incision was made, and dissection was carried down to the external oblique aponeurosis using a combination of metzenbaum scissors and bovie electrocautery. the external oblique aponeurosis was cleared of overlying adherent tissue, and the external ring was delineated. the external oblique was then incised with a scalpel and this incision was carried out to the external ring using metzenbaum scissors. care was taken not to injure the ilioinguinal nerve. having exposed the inguinal canal, the cord structures were separated from the canal using blunt dissection, and a penrose drain was then used to retract the cord structures as needed. adherent cremasteric muscle was dissected free from the cord using bovie electrocautery.,the cord was then explored using a combination of sharp and blunt dissection, and the sac was found anteromedially to the cord structures. the sac was dissected free from the cord structures using a combination of blunt dissection and bovie electrocautery.,once preperitoneal fat was encountered, the dissection stopped and the sac was suture ligated at the level of the preperitoneal fat using a 2-0 silk suture ligature. the sac was excised and sent to pathology. the stump was examined and no bleeding was noted. the ends of the suture were then cut, and the stump retracted back into the abdomen.,the floor of the inguinal canal was then strengthened by suturing the shelving edge of poupart's ligament to the conjoined tendon using a 2-0 prolene, starting at the pubic tubercle and running towards the internal ring. in this manner, an internal ring was created that admitted just the tip of my smallest finger.,the penrose drain was removed. the wound was then irrigated using sterile saline, and hemostasis was obtained using bovie electrocautery. the incision in the external oblique was approximated using a 2-0 vicryl in a running fashion, thus reforming the external ring. marcaine 0.5% was injected 1 fingerbreadth anterior to the anterior and superior iliac spine and around the wound for postanesthetic pain control. the skin incision was approximated with skin staples. a dressing was then applied. all surgical counts were reported as correct.,having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.

chief complaint:, low back pain and right lower extremity pain. the encounter reason for today's consultation is for a second opinion regarding evaluation and treatment of the aforementioned symptoms.,hpi - lumbar spine:, the patient is a male and 39 years old. the current problem began on or about 3 months ago. the symptoms were sudden in onset. according to the patient, the current problem is a result of a fall. the date of injury was 3 months ago. there is no significant history of previous spine problems. medical attention has been obtained through the referral source. medical testing for the current problem includes the following: no recent tests. treatment for the current problem includes the following: activity modification, bracing, medications and work modification. the following types of medications are currently being used for the present spine problem: narcotics, non-steroidal anti-inflammatories and muscle relaxants. the following types of medications have been used in the past: steroids. in general, the current spine problem is much worse since its onset.,past spine history:, unremarkable.,present lumbar symptoms:, pain location: lower lumbar. the patient describes the pain as sharp. the pain ranges from none to severe. the pain is severe frequently. it is present intermittently and most of the time daily. the pain is made worse by flexion, lifting, twisting, activity, riding in a car and sitting. the pain is made better by laying in the supine position, medications, bracing and rest. sleep alteration because of pain: wakes up after getting to sleep frequently and difficulty getting to sleep frequently. pain distribution: the lower extremity pain is greater than the low back pain. the patient's low back pain appears to be discogenic in origin. the pain is much worse since its onset.,present right leg symptoms:, pain location: s1 dermatome (see the pain diagram). the patient describes the pain as sharp. the severity of the pain ranges from none to severe. the pain is severe frequently. it is present intermittently and most of the time daily. the pain is made worse by the same things that make the low back pain worse. the pain is made better by the same things that make the low back pain better. sleep alteration because of pain: wakes up after getting to sleep frequently and difficulty getting to sleep frequently. the patient's symptoms appear to be radicular in origin. the pain is much worse since its onset.,present left leg symptoms:, none.,neurologic signs/symptoms:, the patient denies any neurologic signs/symptoms. bowel and bladder function are reported as normal.

preoperative diagnosis: , chronic hypertrophic adenotonsillitis.,postoperative diagnosis: , chronic hypertrophic adenotonsillitis.,operative procedure:, adenotonsillectomy, primary, patient under age 12.,anesthesia: , general endotracheal anesthesia.,procedure in detail: , this patient was brought from the holding area and did receive preoperative antibiotics of cleocin as well as iv decadron. she was placed supine on the operating room table. general endotracheal anesthesia was induced without difficulty. in the holding area, her allergies were reviewed. it is unclear whether she is actually allergic to penicillin. codeine caused her to be excitable, but she did not actually have an allergic reaction to codeine. she might be allergic to bactrim and sulfa. after positioning a small shoulder roll and draping sterilely, mcivor mouthgag, #3 blade was inserted and suspended from the mayo stand. there was no bifid uvula or submucous cleft. she had 3+ cryptic tonsils with significant debris in the tonsillar crypts. injection at each peritonsillar area with 0.25% with marcaine with 1:200,000 epinephrine, approximately 1.5 ml total volume. the left superior tonsillar pole was then grasped with curved allis forceps. _______ incision and dissection in the tonsillar capsule and hemostasis and removal of the tonsil was obtained with coblation evac xtra wand on 7/3. mouthgag was released, reopened, no bleeding was seen. the right tonsil was then removed in the same fashion. the mouthgag released, reopened, and no bleeding was seen. small red rubber catheter in the nasal passage was used to retract the soft palate. she had mild-to-moderate adenoidal tissue residual. it was removed with coblation evac xtra gently curved wand on 9/5. red rubber catheter was then removed. mouthgag was again released, reopened, no bleeding was seen. orogastric suction carried out with only scant clear stomach contents. mouthgag was then removed. teeth and lips were inspected and were in their preoperative condition. the patient then awakened, extubated, and taken to recovery room in good condition.,total blood loss from tonsillectomy: , less than 2 ml.,total blood loss from adenoidectomy: , less than 2 ml.,complications: , no intraoperative events or complications occurred.,plan:, family will be counseled postoperatively. postoperatively, the patient will be on zithromax oral suspension 500 mg daily for 5 to 7 days, lortab elixir for pain. _______ and promethazine if needed for nausea and vomiting.

preoperative diagnosis: , large left adnexal mass, 8 cm in diameter.,postoperative diagnosis: , pelvic adhesions, 6 cm ovarian cyst.,procedures performed: ,1. pelvic laparotomy.,2. lysis of pelvic adhesions.,3. left salpingooophorectomy with insertion of pain-buster pain management system by dr. x.,gross findings: ,there was a transabdominal mass palpable in the lower left quadrant. an ultrasound suggestive with a mass of 8 cm, did not respond to suppression with norethindrone acetate and on repeat ultrasound following the medical treatment, the ovarian neoplasm persisted and did not decreased in size.,procedure: ,under general anesthesia, the patient was placed in lithotomy position, prepped and draped. a low transverse incision was made down to and through to the rectus sheath. the rectus sheath was put laterally. the inferior epigastric arteries were identified bilaterally, doubly clamped and tied with #0 vicryl sutures. the rectus muscle was then split transversally and the peritoneum was split transversally as well. the left adnexal mass was identified and large bowel was attached to the mass and dr. zuba from general surgery dissected the large bowel adhesions and separated them from the adnexal mass. the ureter was then traced and found to be free of the mass and free of the infundibulopelvic ligament. the infundibulopelvic ligament was isolated, entered via blunt dissection. a #0 vicryl suture was put into place, doubly clamped with curved heaney clamps, cut with curved mayo scissors and #0 vicryl fixation suture put into place. curved heaney clamps were then used to remove the remaining portion of the ovary from its attachment to the uterus and then #0 vicryl suture was put into place. pathology was called to evaluate the mass for potential malignancy and the pathology's verbal report at the time of surgery was that this was a benign lesion. irrigation was used. minimal blood loss at the time of surgery was noted. sigmoid colon was inspected in place in physiologic position of the cul-de-sac as well as small bowel omentum. instrument, needle, and sponge counts were called for and found to be correct. the peritoneum was closed with #0 vicryl continuous running locking suture. the rectus sheath was closed with #0 vicryl continuous running locking suture. a donjoy pain-buster pain management system was placed through the skin into the subcutaneous space and the skin was closed with staples. final instrument needle counts were called for and found to be correct. the patient tolerated the procedure well with minimal blood loss and transferred to recovery area in satisfactory condition.

chief complaint: , blood in urine.,history of present illness: ,this is a 78-year-old male who has prostate cancer with metastatic disease to his bladder and in several locations throughout the skeletal system including the spine and shoulder. the patient has had problems with hematuria in the past, but the patient noted that this episode began yesterday, and today he has been passing principally blood with very little urine. the patient states that there is no change in his chronic lower back pain and denies any incontinence of urine or stool. the patient has not had any fever. there is no abdominal pain and the patient is still able to pass urine. the patient has not had any melena or hematochezia. there is no nausea or vomiting. the patient has already completed chemotherapy and is beyond treatment for his cancer at this time. the patient is receiving radiation therapy, but it is targeted to the bones and intended to give symptomatic relief of his skeletal pain and not intended to treat and cure the cancer. the patient is not enlisted in hospice, but the principle around the patient's current treatment management is focusing on comfort care measures.,review of systems: , constitutional: no fever or chills. the patient does report generalized fatigue and weakness over the past several days. heent: no headache, no neck pain, no rhinorrhea, no sore throat. cardiovascular: no chest pain. respirations: no shortness of breath or cough, although the patient does get easily winded with exertion over these past few days. gastrointestinal: the patient denies any abdominal pain. no nausea or vomiting. no changes in the bowel movement. no melena or hematochezia. genitourinary: a gross hematuria since yesterday as previously described. the patient is still able to pass urine without difficulty. the patient denies any groin pain. the patient denies any other changes to the genital region. musculoskeletal: the chronic lower back pain which has not changed over these past few days. the patient does have multiple other joints, which cause him discomfort, but there have been no recent changes in these either. skin: no rashes or lesions. no easy bruising. neurologic: no focal weakness or numbness. no incontinence of urine or stool. no saddle paresthesia. no dizziness, syncope or near-syncope. endocrine: no polyuria or polydipsia. no heat or cold intolerance. hematologic/lymphatic: the patient does not have a history of easy bruising or bleeding, but the patient has had previous episodes of hematuria.,past medical history: , prostate cancer with metastatic disease as previously described.,past surgical history: , turp.,current medications:, morphine, darvocet, flomax, avodart and ibuprofen.,allergies: , vicodin.,social history: , the patient is a nonsmoker. denies any alcohol or illicit drug use. the patient does live with his family.,physical examination: , vital signs: temperature is 98.8 oral, blood pressure is 108/65, pulse is 109, respirations 16, oxygen saturation is 97% on room air and interpreted as normal. constitutional: the patient is well nourished, well developed. the patient appears to be pale, but otherwise looks well. the patient is calm, comfortable. the patient is pleasant and cooperative. heent: eyes normal with clear conjunctivae and corneas. nose is normal without rhinorrhea or audible congestion. mouth and oropharynx normal without any sign of infection. mucous membranes are moist. neck: supple. full range of motion. no jvd. cardiovascular: heart is mildly tachycardic with regular rhythm without murmur, rub or gallop. peripheral pulses are +2. respirations: clear to auscultation bilaterally. no shortness of breath. no wheezes, rales or rhonchi. good air movement bilaterally. gastrointestinal: abdomen is soft, nontender, nondistended. no rebound or guarding. no hepatosplenomegaly. normal bowel sounds. no bruit. no masses or pulsatile masses. genitourinary: the patient has normal male genitalia, uncircumcised. there is no active bleeding from the penis at this time. there is no swelling of the testicles. there are no masses palpated to the testicles, scrotum or the penis. there are no lesions or rashes noted. there is no inguinal lymphadenopathy. normal male exam. musculoskeletal: back is normal and nontender. there are no abnormalities noted to the arms or legs. the patient has normal use of the extremities. skin: the patient appears to be pale, but otherwise the skin is normal. there are no rashes or lesions. neurologic: motor and sensory are intact to the extremities. the patient has normal speech. psychiatric: the patient is alert and oriented x4. normal mood and affect. hematologic/lymphatic: there is no evidence of bruising noted to the body. no lymphadenitis is palpated.,emergency department testing:, cbc was done, which had a hemoglobin of 7.7 and hematocrit of 22.6. neutrophils were 81%. the rdw was 18.5, and the rest of the values were all within normal limits and unremarkable. chemistry had a sodium of 134, a glucose of 132, calcium is 8.2, and rest of the values are unremarkable. alkaline phosphatase was 770 and albumin was 2.4. rest of the values all are within normal limits of the lfts. urinalysis was grossly bloody with a large amount of blood and greater than 50 rbc's. the patient also had greater than 300 of the protein reading, moderate leukocytes, 30-50 white blood cells, but no bacteria were seen. coagulation profile study had a pt of 15.9, ptt of 43 and inr of 1.3.,emergency department course: , the patient was given normal saline 2 liters over 1 hour without any adverse effect. the patient was given multiple doses of morphine to maintain his comfort while here in the emergency room without any adverse effect. the patient was given levaquin 500 mg by mouth as well as 2 doses of phenergan over the course of his stay here in the emergency department. the patient did not have an adverse reaction to these medicines either. phenergan resolved his nausea and morphine did relieve his pain and make him pain free. i spoke with dr. x, the patient's urologist, about most appropriate step for the patient, and dr. x said he would be happy to care for the patient in the hospital and do urologic scopes if necessary and surgery if necessary and blood transfusion. it was all a matter of what the patient wished to do given the advanced stage of his cancer. dr. x was willing to assist in any way the patient wished him to. i spoke with the patient and his son about what he would like to do and what the options were from doing nothing from keeping him comfortable with pain medicines to admitting him to the hospital with the possibility of scopes and even surgery being done as well as the blood transfusion. the patient decided to choose a middle ground in which he would be transfused with 2 units of blood here in the emergency room and go home tonight. the patient's son felt comfortable with his father's choice. this was done. the patient was transfused 2 units of packed red blood cells after appropriately typed and match. the patient did not have any adverse reaction at any point with his transfusion. there was no fever, no shortness of breath, and at the time of disposition, the patient stated he felt a little better and felt like he had a little more strength. over the course of the patient's several-hour stay in the emergency room, the patient did end up developing enough problems with clotted blood in his bladder that he had a urinary obstruction. foley catheter was placed, which produced bloody urine and relieved the developing discomfort of a full bladder. the patient was given a leg bag and the foley catheter was left in place.,diagnoses,1. hematuria.,2. prostate cancer with bone and bladder metastatic disease.,3. significant anemia.,4. urinary obstruction.,condition on disposition: ,fair, but improved.,disposition: , to home with his son.,plan: , we will have the patient follow up with dr. x in his office in 2 days for reevaluation. the patient was given a prescription for levaquin and phenergan tablets to take home with him tonight. the patient was encouraged to drink extra water. the patient was given discharge instructions on hematuria and asked to return to the emergency room should he have any worsening of his condition or develop any other problems or symptoms of concern.

history and physical: ,the patient is a 13-year-old, who has a history of shone complex and has a complete heart block. he is on the pacemaker. he had a coarctation of the aorta and that was repaired when he was an infant. he was followed in our cardiology clinic here and has been doing well. however last night, he was sleeping, and he states he felt as if he has having a dream, and there was thunder in this dream, which woke him up. he then felt that his defibrillator was going off and this has continued and feels like his heart rate is not normal. thus, his dad put him in the car and transported him here. he has been evaluated here. he had some scar tissue at one point when the internal pacemaker was not working properly and had to have that replaced. it was 2 a.m. when he woke, and again, he was brought here by private vehicle. he was well prior to going to bed. no cough, cold, runny nose, fever. no trauma has been noted.,past medical history:, shone complex, pacemaker dependent.,medications: , he is on no medications at this time.,allergies:, he has no allergies.,immunizations:, up to date.,social history: , he lives with his parents.,family history: , negative.,review of system: , twelve asked, all negative, except as noted above.,physical examination:,general: this is an awake, alert male, who appears to be in mild distress.,heent: pupils are equal, round, and reactive to light. extraocular movements are intact. his tms are clear. his nares are clear. the mucous membranes are pink and moist. throat is clear.,neck: supple without lymphadenopathy or masses. trachea is midline.,lungs: clear.,heart: shows bradycardia at 53. he has good distal pulses.,abdomen: soft, nontender. positive bowel sounds. no guarding, no rebound. no rashes are seen.,hospital course:, initial blood pressure is 164/90. he was moved in room 1. he was placed on nasal cannula. pulse ox was 100%, which is normal. we placed him on a monitor. we did an ekg; it has not appear to be capturing his pacemaker at this time. shortly after the patient's arrival, the medtronic technician came and worked out his pacemaker. medtronic representative informed me that the lead that he has in place has been recalled because it has been prone to microfractures, oversensing, and automatic defibrillation. as noted, he was transferred to room 1, placed on a monitor, pulse ox. an iv was placed. a standard blood work was sent. a chest x-ray was done showing normal heart size, lead appeared to be in placed. there was no evidence of pulmonary edema. his pacemaker did not appear to be capturing. we placed him on transthoracic leads. however, it is difficult to get good placement with these because of the area where his pacemaker was placed. the medtronic technician initially turned off his defibrillation mode and turned down his sensor. however, we could not get our transthoracic pacer to capture his heart. when the medtronic representative turned off the pacemaker, the heart rate seemed to drop into the 40s. the patient appeared to be in pain. we placed it back on a rate of 60 at that time. he has remained in sinus bradycardia, but no evidence of ectopic beats. no widening of his qrs complex. i spoke with cardiology. cardiology service has come in, has evaluated him at bedside with me. again, we turned up the transthoracic pacer, but it is again not seem to be picking up, and his heart rate is still going with the medtronic's internal pacemaker. so with the icu physician on call, dr. x, he has agreed with taking this young man to the icu.,an hour after presentation here, the icu was ready for bed. i accompanied the patient up to the icu. he remained awake and alert. initially, he was complaining of a lot of chest pain. once the defibrillator was turned off, he had no more pain. he was transported to the pediatrics picu and delivered in stable condition.,laboratory data: , cbc was normal. chem-20 was normal as well.,impression: ,complete heart block with pacemaker malfunction.,plan: ,he is admitted to the icu.,time seen: , critical care time outside billable procedures was 45 minutes with this patient. i should note that a 12-lead ekg was done here showing sinus bradycardia, normal intervals otherwise.

reason for referral:, evaluation for right l4 selective nerve root block.,chief complaint:,

preop diagnoses:,1. left pilon fracture.,2. left great toe proximal phalanx fracture.,postop diagnoses:,1. left pilon fracture.,2. left great toe proximal phalanx fracture.,operation performed:,1. external fixation of left pilon fracture.,2. closed reduction of left great toe, t1 fracture.,anesthesia: ,general.,blood loss: ,less than 10 ml.,needle, instrument, and sponge counts were done and correct.,drains and tubes: , none.,specimens:, none.,indication for operation: ,the patient is a 58-year-old female who was involved in an auto versus a tree accident on 6/15/2009. the patient suffered a fracture of a distal tibia and fibula as well as her great toe on the left side at that time. the patient was evaluated by the emergency room and did undergo further evaluation due to loss of consciousness. she underwent a provisional reduction and splinting in the emergency room followed by further evaluation for her heart and brain by the medicine service following this and she was appropriate for surgical intervention. due to the comminuted nature of her tibia fracture as well as soft tissue swelling, the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fixation. the patient had swollen lower extremities, however, compartments were soft and she had no sign of compartment syndrome. risks and benefits of procedure were discussed in detail with the patient and her husband. all questions were answered, and consent was obtained. the risks including damage to blood vessels and nerves with painful neuroma or numbness, limb altered function, loss of range of motion, need for further surgery, infection, complex regional pain syndrome and deep vein thrombosis were all discussed as potential risks of the surgery.,findings:,1. there was a comminuted distal tibia fracture with a fibular shaft fracture. following traction, there was adequate coronal and sagittal alignment of the fracture fragments and based on the length of the fibula, the fracture fragments were out to length.,2. the base of her proximal phalanx fracture was assessed and reduced with essentially no articular step-off and approximately 1-mm displacement. as the reduction was stable with buddy taping, no pinning was performed.,3. her compartments were full, but not firm nor did she have any sign of compartment syndrome and no compartment releases were performed.,operative report in detail: ,the patient was identified in the preoperative holding area. the left leg was identified and marked at the surgical site of the patient. she was then taken to the operating room where she was transferred to the operating room in the supine position, placed under general anesthesia by the anesthesiology team. she received ancef for antibiotic prophylaxis. a time-out was then undertaken verifying the correct patient, extremity, visibility of preoperative markings, availability of equipment, and administration of preoperative antibiotics. when all was verified by the surgeon, anesthesia and circulating personnel left lower extremity was prepped and draped in the usual fashion. at this point, intraoperative fluoroscopy was used to identify the fracture site as well as the appropriate starting point both in the calcaneus for a transcalcaneal cross stent and in the proximal tibia with care taken to leave enough room for later plate fixation without contaminating the future operative site. a single centrally threaded calcaneal cross tunnel was then placed across the calcaneus parallel to the joint surface followed by placement of 2 schantz pins in the tibia and a frame type external fixator was then applied in traction with attempts to get the fracture fragments out to length, but not overly distract the fracture and restore coronal and sagittal alignment as much as able. when this was adequate, the fixator apparatus was locked in place, and x-ray images were taken verifying correct placement of the hardware and adequate alignment of the fracture. attention was then turned to the left great toe, where a reduction of the proximal phalanx fracture was performed and buddy taping as this provided good stability and was least invasive. x-rays were taken showing good reduction of the base of the proximal phalanx of the great toe fracture. at this point, the pins were cut short and capped to protect the sharp ends. the stab wounds for the schantz pin and cross pin were covered with gauze with betadine followed by dry gauze, and the patient was then awakened from anesthesia and transferred to the progressive care unit in stable condition. please note there was no break in sterile technique throughout the case.,plan: ,the patient will require definitive surgical treatment in approximately 2 weeks when the soft tissues are amenable to plate and screw fixation with decreased risk of wound complication. she will maintain her buddy taping in regards to her great toe fracture.

description of procedure:, after appropriate operative consent was obtained the patient was brought supine to the operating room and placed on the operating room table. after intravenous sedation was administered a retrobulbar block consisting of 2% xylocaine with 0.75% marcaine and wydase was administered to the right eye without difficulty. the patient's right eye was prepped and draped in sterile ophthalmic fashion and the procedure begun. a wire lid speculum was inserted into the right eye and a limited conjunctival peritomy performed at the limbus temporally and superonasally. infusion line was set up in the inferotemporal quadrant and two additional sclerotomies were made in the superonasal and superotemporal quadrants. a lens ring was secured to the eye using 7-0 vicryl suture.

principal diagnosis: , buttock abscess, icd code 682.5.,procedure performed:, incision and drainage (i&d) of buttock abscess.,cpt code: , 10061.,description of procedure: ,under general anesthesia, skin was prepped and draped in usual fashion. two incisions were made along the right buttock approximately 5 mm diameter. purulent material was drained and irrigated with copious amounts of saline flush. a penrose drain was placed. penrose drain was ultimately sutured forming a circular drain. the patient's drain will be kept in place for a period of 1 week and to be taken as an outpatient basis. anesthesia, general endotracheal anesthesia. estimated blood loss approximately 5 ml. intravenous fluids 100 ml. tissue collected. purulent material from buttock abscess sent for usual cultures and chemistries. culture and sensitivity gram stain. a single penrose drain was placed and left in the patient. dr. x attending surgeon was present throughout the entire procedure.

reason for consultation:, acute renal failure.,history: , limited data is available; i have reviewed his admission notes. apparently this man was found down by a family member, was taken to medical center, and subsequently flown here. he has got respiratory failure, multi-organ system failure syndrome, and has renal insufficiency, as well. markers of renal function have been fairly stable. i do not presently see indicators that he historically has been oliguric. the bun and creatinine have been fairly stable. it is not clear whether he was taking his lisinopril up until the time of his demise, and it is also not clear whether he was taking his diuretic. earlier thoughts had been that he could have had rhabdomyolysis, but the highest cpk i find recorded is 1500, the phosphorus is not elevated, though i acknowledge the serum calcium is low. i see no markers of myoglobinuria nor serum level of myoglobin. he has received iv fluid resuscitation, good broad-spectrum antibiotic coverage, continues mechanically ventilated, and is on parenteral nutrition.,past medical history:, not obtained from the patient, but is reviewed in other physician's notes and seems notable for probably atherosclerotic cardiovascular disease wherein he was taking imdur and digoxin, reportedly. a suggestion of hypertensive disease versus bph, he was on terazosin. suggestion of chf versus hypertension versus volume overload, treated with lasix. he was iron, i presume for anemia. he was on potassium, lisinopril and aspirin.,allergies:, other physician's notes indicate no known allergies.,family history:, not available.,social history:, not available.,review of systems:, not available.,physical examination:,general: an older white male who is intubated, edematous, and appears uncomfortable.,heent: male pattern baldness. pupils equally round, no icterus. intubated. og tube in place.,neck: not tested for suppleness, no carotid bruits are heard. neck vein distention is not seen.,lungs: he has diffuse expiratory wheezing anteriorly, laterally and posteriorly. i would describe the wheezes as coarse. i hear no present rales. breath sounds otherwise are symmetrical.,heart: heart tones regular to auscultation, currently without audible rub or gallop sounds.,breasts: not enlarged.,abdomen: on plane. bowel sounds presently are normal. abdomen, i believe, is soft on plane, normal bowel sounds, no bruits, no liver edge felt, no hjr, no spleen tip, no suprapubic fullness.,gu: catheter draining a dark yellow urine.,extremities: very edematous. pulses not palpable. cyanosis not observed. fungal changes are not observed.,neurological: not otherwise assessed.,laboratory data:, reviewed.,impression:,1. acute renal failure, suspected. likely due to multi-organ system failure syndrome, with antecedent lisinopril use at home and at time of demise. he also reportedly was on lasix prior to hospitalization, ? hypovolemia as a consequence.,2. multi-organ system failure/systemic inflammatory response syndrome, with septic shock.,3. i am under-whelmed presently with the diagnosis of rhabdomyolysis, if the maximum ck recorded is 1500.,4. antecedent hypoxemia, with renal hypoperfusion.,5. diffuse aspiration pneumonitis suggested.,discussion/plan: ,i think the renal function will follow the patient. supportive care, attention to stability of a euvolemic state, will be important at this time. he is currently nonoliguric, has apparently stable, diffuse, bilateral wheezing, with adequate gas exchange. he is on tpn, antimicrobials, and has been on vasopressive agents. blood pressures are close to acceptable, he may now be wearing off his lisinopril, assuming he was taking it prior to admission.,i would use diuretics to maintain central euvolemia. recorded i's are substantially o's during the course of the hospitalization, i presume as part of his resuscitation effort. no central pressures or monitoring of same is currently available. i will follow with you. no present indication for hemodialysis. antimicrobials are being handled by others.

final diagnoses,1. morbid obesity, status post laparoscopic roux-en-y gastric bypass. ,2. hypertension. ,3. obstructive sleep apnea, on cpap.,operation and procedure: , laparoscopic roux-en-y gastric bypass.,brief hospital course summary: ,this is a 30-year-old male, who presented recently to the bariatric center for evaluation and treatment of longstanding morbid obesity and associated comorbidities. underwent standard bariatric evaluation, consults, diagnostics, and preop medifast induced weight loss in anticipation of elective bariatric surgery. ,taken to the or via same day surgery process for elective gastric bypass, tolerated well, recovered in the pacu, and sent to the floor for routine postoperative care. there, dvt prophylaxis was continued with subcu heparin, early and frequent mobilization, and scds. pca was utilized for pain control, efficaciously, he utilized the cpap, was monitored, and had no new cardiopulmonary complaints. postop day #1, labs within normal limits, able to clinically start bariatric clear liquids at 2 ounces per hour, this was tolerated well. he was ambulatory, had no cardiopulmonary complaints, no unusual fever or concerning symptoms. by the second postoperative day, was able to advance to four ounces per hour, tolerated this well, and is able to discharge in stable and improved condition today. he had his drains removed today as well.,discharge instructions: , include re-appointment in the office in the next week, call in the interim if any significant concerning complaints. scripts left in the chart for omeprazole and lortab. med rec sheet completed (on no meds). he will maintain bariatric clear liquids at home, goal 64 ounces per day, maintain activity at home, but no heavy lifting or straining. can shower starting tomorrow, drain site care and wound care reviewed. he will re-appoint in the office in the next week, certainly call in the interim if any significant concerning complaints.

history: , the patient is a 71-year-old female, who was referred for an outpatient modified barium swallow study to objectively evaluate her swallowing function and safety. the patient complained of globus sensation high in her throat particularly with solid foods and with pills. she denied history of coughing and chocking with meals. the patient's complete medical history is unknown to me at this time. the patient was cooperative and compliant throughout this evaluation.,study:, modified barium swallow study was performed in the radiology suite in cooperation with dr. x. the patient was seated upright at a 90-degree angle in a video imaging chair. to evaluate her swallowing function and safety, she was administered graduated amounts of food and liquid mixed with barium in the form of thin liquids (teaspoon x3. cup sip x4); thickened liquid (cup sip x3); puree consistency (teaspoon x3); and solid consistency (1/4 cracker x1). the patient was given 2 additional cup sips of thin liquid following the puree and solid food presentation.,oral stage: ,the patient had no difficulty with bolus control and transport. no spillage out lips. the patient appears to have pocketing __________ particularly with puree and solid food between her right faucial pillars. the patient did state that she had her tonsil taken out as a child and appears to be a diverticulum located in this state. further evaluation by an ent is highly recommended based on the residual and pooling that occurred during this evaluation. we were not able to clear out the residual with alternating cup sips and thin liquid.,pharyngeal stage: ,no aspiration or penetration occurred during this evaluation. the patient's hyolaryngeal elevation and anterior movements are within the functional limits. epiglottic inversion is within functional limits. she had no residual or pooling in the pharynx after the swallow.,cervical esophageal stage: ,the patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus.,diagnostic impression: ,the patient had no aspiration or penetration occurred during this evaluation. she does appear to have a diverticulum in the area between her right faucial pillars. additional evaluation is needed by an ent physician.,plan: ,based on this evaluation, the following is recommended:,1. the patient's diet should consist regular consistency food with thin liquids. she needs to take small bites and small sips to help decrease her risk of aspiration and penetration as well as reflux.,2. the patient should be referred to an otolaryngologist for further evaluation of her oral cavity particularly the area between her faucial pillars.,the above recommendations and results of the evaluation were discussed with the patient as well as her daughter and both responded appropriately.,thank you for the opportunity to be required the patient's medical care. she is not in need of skilled speech therapy and is discharged from my services.

history of present illness: ,this 59-year-old white male is seen for comprehensive annual health maintenance examination on 02/19/08, although this patient is in excellent overall health. medical problems include chronic tinnitus in the left ear with moderate hearing loss for many years without any recent change, dyslipidemia well controlled with niacin, history of hemorrhoids with occasional external bleeding, although no problems in the last 6 months, and also history of concha bullosa of the left nostril, followed by ent associated with slight septal deviation. there are no other medical problems. he has no symptoms at this time and remains in excellent health.,past medical history: , otherwise noncontributory. there is no operation, serious illness or injury other than as noted above.,allergies: , there are no known allergies.,family history: , father died of an mi at age 67 with copd and was a heavy smoker. his mother is 88, living and well, status post lung cancer resection. two brothers, living and well. one sister died at age 20 months of pneumonia.,social history:, the patient is married. wife is living and well. he jogs or does cross country track 5 times a week, and weight training twice weekly. no smoking or significant alcohol intake. he is a physician in allergy/immunology.,review of systems:, otherwise noncontributory. he has no gastrointestinal, cardiopulmonary, genitourinary or musculoskeletal symptomatology. no symptoms other than as described above.,physical examination:,general: he appears alert, oriented, and in no acute distress with excellent cognitive function. vital signs: his height is 6 feet 2 inches, weight is 181.2, blood pressure is 126/80 in the right arm, 122/78 in the left arm, pulse rate is 68 and regular, and respirations are 16. skin: warm and dry. there is no pallor, cyanosis or icterus. heent: tympanic membranes benign. the pharynx is benign. nasal mucosa is intact. pupils are round, regular, and equal, reacting equally to light and accommodation. eom intact. fundi reveal flat discs with clear margins. normal vasculature. no hemorrhages, exudates or microaneurysms. no thyroid enlargement. there is no lymphadenopathy. lungs: clear to percussion and auscultation. normal sinus rhythm. no premature beat, murmur, s3 or s4. heart sounds are of good quality and intensity. the carotids, femorals, dorsalis pedis, and posterior tibial pulsations are brisk, equal, and active bilaterally. abdomen: benign without guarding, rigidity, tenderness, mass or organomegaly. neurologic: grossly intact. extremities: normal. gu: genitalia normal. there are no inguinal hernias. there are mild hemorrhoids in the anal canal. the prostate is small, if any normal to mildly enlarged with discrete margins, symmetrical without significant palpable abnormality. there is no rectal mass. the stool is hemoccult negative.,impression:,1. comprehensive annual health maintenance examination.,2. dyslipidemia.,3. tinnitus, left ear.,4. hemorrhoids.,plan:, at this time, continue niacin 1000 mg in the morning, 500 mg at noon, and 1000 mg in the evening; aspirin 81 mg daily; multivitamins; vitamin e 400 units daily; and vitamin c 500 mg daily. consider adding lycopene, selenium, and flaxseed to his regimen. all appropriate labs will be obtained today. followup fasting lipid profile and alt in 6 months.

preoperative diagnosis:, posterior mediastinal mass with possible neural foraminal involvement.,postoperative diagnosis: , posterior mediastinal mass with possible neural foraminal involvement (benign nerve sheath tumor by frozen section).,operation performed:, left thoracotomy with resection of posterior mediastinal mass.,indications for procedure: ,the patient is a 23-year-old woman who recently presented with a posterior mediastinal mass and on ct and mri there were some evidence of potential widening of one of the neural foramina. for this reason, dr. x and i agreed to operate on this patient together. please note that two surgeons were required for this case due to the complexity of it. the indications and risks of the procedure were explained and the patient gave her informed consent.,description of procedure: , the patient was brought to the operating suite and placed in the supine position. general endotracheal anesthesia was given with a double lumen tube. the patient was positioned for a left thoracotomy. all pressure points were carefully padded. the patient was prepped and draped in usual sterile fashion. a muscle sparing incision was created several centimeters anterior to the tip of the scapula. the serratus and latissimus muscles were retracted. the intercostal space was opened. we then created a thoracoscopy port inferiorly through which we placed a camera for lighting and for visualization. through our small anterior thoracotomy and with the video-assisted scope placed inferiorly we had good visualization of the posterior mediastinum mass. this was in the upper portion of the mediastinum just posterior to the subclavian artery and aorta. the lung was deflated and allowed to retract anteriorly. with a combination of blunt and sharp dissection and with attention paid to hemostasis, we were able to completely resect the posterior mediastinal mass. we began by opening the tumor and taking a very wide large biopsy. this was sent for frozen section, which revealed a benign nerve sheath tumor. then, using the occluder device dr. x was able to _____ the inferior portions of the mass. this left the external surface of the mass much more malleable and easier to retract. using a bipolar cautery and endoscopic scissors we were then able to completely resect it. once the tumor was resected, it was then sent for permanent sections. the entire hemithorax was copiously irrigated and hemostasis was complete. in order to prevent any lymph leak, we used 2 cc of evicel and sprayed this directly on to the raw surface of the pleural space. a single chest tube was inserted through our thoracoscopy port and tunneled up one interspace. the wounds were then closed in multiple layers. a #2 vicryl was used to approximate the ribs. the muscles of the chest wall were allowed to return to their normal anatomic position. a 19 blake was placed in the subcutaneous tissues. subcutaneous tissues and skin were closed with running absorbable sutures. the patient was then rolled in the supine position where she was awakened from general endotracheal anesthesia and taken to the recovery room in stable condition.

preoperative diagnosis: , acquired nasal septal deformity.,postoperative diagnosis: , acquired nasal septal deformity.,procedures:,1. open septorhinoplasty with placement of bilateral spreader grafts.,2. placement of a radiated rib tip graft.,3. placement of a morcellized autogenous cartilage dorsal onlay graft.,4. placement of endogen, radiated collagen dorsal onlay graft.,5. placement of autogenous cartilage columellar strut graft.,6. bilateral lateral osteotomies.,7. takedown of the dorsal hump with repair of the bony and cartilaginous open roof deformities.,8. fracture of right upper lateral cartilage.,anesthesia: ,general endotracheal tube anesthesia.,complications: , none.,estimated blood loss: ,100 ml.,urine output:, not recorded.,specimens:, none.,drains: , none.,findings: ,1. the patient had a marked dorsal hump, which was both bony and cartilaginous in nature.,2. the patient had marked hypertrophy of his nasalis muscle bilaterally contributing to the soft tissue dorsal hump.,3. the patient had a c-shaped deformity to the left before he had tip ptosis.,indications for procedure: , the patient is a 22-year-old hispanic male who is status post blunt trauma to the nose approximately 9 months with the second episode 2 weeks following and suffered a marked dorsal deformity. the patient was evaluated, but did not complain of nasal obstruction, and his main complaint was his cosmetic deformity. he was found to have a c-shaped deformity to the left as well as some tip ptosis. the patient was recommended to undergo an open septorhinoplasty to repair of this cosmetic defect.,operation in detail: , after obtaining a full consent from the patient, identified the patient, prepped with betadine, brought to the operating room and placed in the supine position on the operating table. the appropriate esmarch was placed; and after adequate sedation, the patient was subsequently intubated without difficulty. the endotracheal tube was then secured, and the table was then turned clockwise to 90 degrees. three afrin-soaked cottonoids were then placed in nasal cavity bilaterally. the septum was then injected with 3 ml of 1% lidocaine with 1:100,000 epinephrine in the subperichondrial plane bilaterally. then, 50 additional ml of 1% lidocaine with 1:100,000 epinephrine was then injected into the nose in preparation for an open rhinoplasty.,procedure was begun by first marking a columellar incision. this incision was made using a #15 blade. a lateral transfixion incision was then made bilaterally using a #15 blade, and then, the columellar incision was completed using iris scissors with care not to injure the medial crura. however, there was a dissection injury to the left medial crura. dissection was then taken in the subperichondrial plane over the lower lateral cartilages and then on to the upper lateral cartilage. once we reached the nasal bone, a freer was used to elevate the tissue overlying the nasal bone in a subperiosteal fashion. once we had completed exposure of the bony cartilaginous structures, we appreciated a very large dorsal hump, which was made up of both a cartilaginous and bony portions. there was also an obvious fracture of the right upper lateral cartilage. there was also marked hypertrophy what appeared to be in the nasalis muscle in the area of the dorsal hump. the skin was contributing to the patient's cosmetic deformity. in addition, we noted what appeared to be a small mucocele coming from the area of the fractured cartilage on the right upper lateral cartilage. this mucocele was attempted to be dissected free, most of which was removed via dissection. we then proceeded to remove takedown of the dorsal hump using a rubin osteotome. the dorsal hump was taken down and passed off the table. examination of the specimen revealed the marking amount of scar tissue at the junction of the bone and cartilage. this was passed off to use later for possible onlay grafts. there was now a marked open roof deformity of the cartilage and bony sprue. a septoplasty was then performed throughout and a kelly incision on the right side. subperichondrial planes were elevated on the right side, and then, a cartilage was incised using a caudal and subperichondrial plane elevated on the left side. a 2 x 3-cm piece of the cardinal cartilage was then removed with care to leave at least 1 cm dorsal and caudal septal strut. this cartilage was passed down the table and then 2 columellar strut grafts measuring approximately 15 mm in length were then used and placed to close the bony and cartilaginous open roof deformities. the spreader grafts were sewn in place using three interrupted 5-0 pds sutures placed in the horizontal fashion bilaterally. once these were placed, we then proceeded to work on the bony open roof. lateral osteotomies were made with 2-mm osteotomes bilaterally. the nasal bones were then fashioned medially to close the open roof deformity, and this reduced the width of the bony nasal dorsum. we then proceeded to the tip. a cartilaginous strut was then fashioned from the cartilaginous septum. it was approximately 15 mm long. this was placed, and a pocket was just formed between the medial crura. this pocket was taken down to the nasal spine, and then, the strut graft was placed. the intradermal sutures were then placed using interrupted 5-0 pds suture to help to provide more tip projection and definition. the intradermal sutures were then placed to help to align the nasal tip. the cartilage strut was then sutured in place to the medial crura after elevating the vestibular skin off the medial crura in the area of the plane suturing. prior to the intradermal suturing, the vestibular skin was also taken off in the area of the dome.,the columellar strut was then sutured in place using interrupted 5-0 pds suture placed in a horizontal mattress fashion with care to help repair the left medial crural foot. the patient had good tip support after this maneuver. we then proceeded to repair the septal deformity created by taking down the dorsal hump with the rubin osteotome. this was done by crushing the remaining cartilage in the morcellizer and then wrapping this crushed cartilage in endogen, which is a radiated collagen. the autogenous cartilage was wrapped in endogen in a sandwich fashion, and then, a 4-0 chromic suture was placed through this to help with placement of the dorsal onlay graft.,the dorsal onlay was then sewn into position, and then, the 4-0 chromic suture was brought out through this externally to help the superior placement of the dorsal onlay graft. once we were happy with the position of the dorsal onlay graft, the graft was then sutured in place using two interrupted 4-0 fast-absorbing sutures inferiorly just above the superior edge of the lower lateral cartilages. once we were happy with the placement of this, we did need to take down some of the bony dorsal hump laterally, and this was done using a #6 and then followed with a #3 push grafts. this wrapping was performed prior to placement of the dorsal onlay graft.,i went through content with the dorsal onlay graft and the closure of the roof deformities as well as placement of the columellar strut, we then felt the patient could use a bit more tip projection; and therefore, we fashioned a radiated rib into a small octagon; and this was sutured in place over the tip using two interrupted 5-0 pds sutures.,at this point, we were happy with the test results, although the patient did have significant amount of fullness in the dorsal hump area due to soft tissue thick and fullness. there do not appear to be any other pathology causing the patient dorsal hump and therefore, we felt we have achieved the best cosmetic result at this point. the septum was reapproximated using a fast-absorbing 4-0 suture and a keith needle placed in the mattress fashion. the kelly incision was closed using two interrupted 4-0 fast-absorbing gut suture. doyle splints were then placed within the nasal cavity and secured to the inferior septum using a 3-0 monofilament suture. the columellar skin was reapproximated using interrupted 6-0 nylon sutures, and the marginal incision of the vestibular skin was closed using interrupted 4-0 chromic sutures.,at the end of the procedure, all sponge, needle, and instrument counts were correct. a denver external splint was then applied. the patient was awakened, extubated, and transported to anesthesia care unit in good condition.

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

preoperative diagnoses: , 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.

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

preoperative diagnosis:, right undescended testicle.,postoperative diagnosis:, right undescended testicle.,operations:,1. right orchiopexy.,2. right herniorrhaphy.,anesthesia: , lma.,estimated blood loss: , minimal.,specimen: , sac.,brief history: , this is a 10-year-old male who presented to us with his mom with consultation from craig connor at cottonwood with right undescended testis. the patient and mother had seen the testicle in the right hemiscrotum in the past, but the testicle seemed to be sliding. the testis was identified right at the external inguinal ring. the testis was unable to be brought down into the scrotal sac. the patient could have had sliding testicle in the past and now the testis has become undescended as the child has grown. options such as watchful waiting and wait for puberty to stimulate the descent of the testicle, hcg stimulation, orchiopexy were discussed. risk of anesthesia, bleeding, infection, pain, hernia, etc. were discussed. the patient and parents understood and wanted to proceed with right orchiopexy and herniorrhaphy.,procedure in detail: , the patient was brought to the or, anesthesia was applied. the patient was placed in supine position. the patient was prepped and draped in the inguinal and scrotal area. after the patient was prepped and draped, an inguinal incision was made on the right side about 1 cm away for the anterior superior iliac spine going towards the external ring over the inguinal canal. the incision came through the subcutaneous tissue and external oblique fascia was identified. the external oblique fascia was opened sharply and was taken all the way down towards the external ring. the ilioinguinal nerve was identified right underneath the external oblique fascia, which was preserved and attention was drawn throughout the entire case to ensure that it was not under any tension or pinched or got hooked in the suture. after dissecting proximally, the testis was identified in the distal end of the inguinal canal. the testis was pulled up. the cremasteric muscle was divided and dissection was carried all the way up to the internal inguinal ring. there was very small hernia, which was removed and was tied at the base. pds suture was used to tie this hernia sac all the way up to the base. there was a y right at the vas and cord indicating there was enough length into the scrotal sac. the testis was easily brought down into the scrotal sac. one centimeter superior scrotal incision was made and a dartos pouch was created. the testicle was brought down into the pouch and was placed into the pouch. careful attention was done to ensure that there was no torsion of the cord. the vas was medial all the way throughout and the cord was lateral all the way throughout. the epididymis was in the posterolateral location. the testicle was pexed using 4-0 vicryl into the scrotal sac. skin was closed using 5-0 monocryl. the external oblique fascia was closed using 2-0 pds. attention was drawn to re-create the external inguinal ring. a small finger was easily placed in the external inguinal ring to ensure that there was no tightening of the cord. marcaine 0.25% was applied, about 15 ml worth of this was applied for local anesthesia. after closing the external oblique fascia, the scarpa was brought together using 4-0 vicryl and the skin was closed using 5-0 monocryl in subcuticular fashion. dermabond and steri-strips were applied.,the patient was brought to recovery room in stable condition at the end of the procedure.,please note that the testicle was viable. it was smaller than the other side, probably by 50%. there were no palpable testicular masses. plan was for the patient to follow up with us in about 1 month. the patient was told not to do any heavy lifting for at least 3 months, okay to shower in 48 hours. no tub bath for 2 months. the patient and family understood all the instructions.

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.

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

preprocedure diagnosis:, chest pain secondary to fractured ribs, unmanageable with narcotics.,postprocedure diagnosis:, chest pain secondary to fractured ribs, unmanageable with narcotics.,procedure: , intercostal block from fourth to tenth intercostal spaces, left.,indications: , i was requested by dr. x to do an intercostal block on this lady who fell and has fractured ribs, whose chest pain is paralyzing and not responding well to increasing doses of narcotics.,procedure detail:, after obtaining an informed consent with the patient on her bedside, she was placed in the right decubitus position with the left side up. the posterior left chest wall was prepped and draped in the usual fashion and then a mixture of 1% xylocaine 20 ml and marcaine 0.25% 20 ml were mixed together and the intercostal spaces from the fourth to the tenth ribs were anesthetized. a total of 30 ml worth of solution was used. i also injected some local anesthetic subcutaneously into an area of contusion in the left lumbar area.,the patient tolerated the procedure well. she had no respiratory distress. immediately, the patient felt some relief from the pain. chest x-ray was ordered for the following day.

preoperative diagnoses: , left cubital tunnel syndrome and ulnar nerve entrapment.,postoperative diagnoses: , left cubital tunnel syndrome and ulnar nerve entrapment.,procedure performed: , decompression of the ulnar nerve, left elbow.,anesthesia: , general.,findings of the operation:, the ulnar nerve appeared to be significantly constricted as it passed through the cubital tunnel. there was presence of hourglass constriction of the ulnar nerve.,procedure: , the patient was brought to the operating room and once an adequate general anesthesia was achieved, his left upper extremity was prepped and draped in standard sterile fashion. a sterile tourniquet was positioned and tourniquet was inflated at 250 mmhg. perioperative antibiotics were infused. time-out procedure was called. the medial epicondyle and the olecranon tip were well palpated. the incision was initiated at equidistant between the olecranon and the medial epicondyle extending 3-4 cm proximally and 6-8 cm distally. the ulnar nerve was identified proximally. it was mobilized with a blunt and a sharp dissection proximally to the arcade of struthers, which was released sharply. the roof of the cubital tunnel was then incised and the nerve was mobilized distally to its motor branches. the ulnar nerve was well-isolated before it entered the cubital tunnel. the arch of the fcu was well defined. the fascia was elevated from the nerve and both the fcu fascia and the osborne fascia were divided protecting the nerve under direct visualization. distally, the dissection was carried between the 2 heads of the fcu. decompression of the nerve was performed between the heads of the fcu. the muscular branches were well protected. similarly, the cutaneous branches in the arm and forearm were well protected. the venous plexus proximally and distally were well protected. the nerve was well mobilized from the cubital tunnel preserving the small longitudinal vessels accompanying it. proximally, multiple vascular leashes were defined near the incision of the septum into the medial epicondyle, which were also protected. once the in situ decompression of the ulnar nerve was performed proximally and distally, the elbow was flexed and extended. there was no evidence of any subluxation. satisfactory decompression was performed. tourniquet was released. hemostasis was achieved. subcutaneous layer was closed with 2-0 vicryl and skin was approximated with staples. a well-padded dressing was applied. the patient was then extubated and transferred to the recovery room in stable condition. there were no intraoperative complications noted. the patient tolerated the procedure very well.

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.

sample address,re: sample patient,wife's name: sample name,dear sample doctor:,mr. sample patient was seen on month dd, yyyy, describing a vasectomy 10 years ago and a failed vasectomy reversal done almost two years ago at the university of michigan. he has remained azoospermic postoperatively. the operative note suggests the presence of some sperm and sperm head on the right side at the time of the vasectomy reversal.,he states that he is interested in sperm harvesting and cryopreservation prior to the next attempted ovulation induction for his wife. apparently, several attempts at induction have been tried and due to some anatomic abnormality, they have been unsuccessful.,at the time that he left the office, he was asking for cryopreservation. at the time of sperm harvesting, i recently received a phone call suggesting that he does not want to do this at all unless his wife's ovulation has been confirmed and it appears then that he may be interested in a fresh specimen harvest. i look forward to hearing from you regarding the actual plan so that we can arrange our procedure appropriately. at his initial request, month dd, yyyy was picked as the date for scheduled harvesting, although this may change if you require fresh specimen.,thank you very much for the opportunity to have seen him.,sample doctor, m.d.

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

preoperative diagnoses:,1. entropion, left upper lid.,2. entropion and some blepharon, right lower lid.,title of operation:,1. repair of entropion, left upper lid, with excision of anterior lamella and cryotherapy.,2. repairs of blepharon, entropion, right lower lid with mucous membrane graft.,procedure in detail: ,the patient was brought to the operating room and prepped and draped in the usual fashion. the left upper lid and right lower lid were all infiltrated with 2% xylocaine with epinephrine.,the lid was then everted with special clips and the mucotome was then used to cut a large mucous membrane graft from the lower lid measuring 0.5 mm in thickness. the graft was placed in saline and a 4 x 4 was placed over the lower lid.,attention was then drawn to the left upper lid and the operating microscope was found to place. an incision was made in the gray line nasally in the area of trichiasis and entropion, and the dissection was carried anterior to the tarsal plate and an elliptical piece of the anterior lamella was excised. bleeding was controlled with the wet-field cautery and the cryoprobe was then used with a temperature of -8 degree centigrade in the freeze-thaw-refreeze technique to treat the bed of the excised area.,attention was then drawn to the right lower lid with the operating microscope and a large elliptical area of the internal aspect of the lid margin was excised with a super blade. some of the blepharon were dissected from the globe and bleeding was controlled with the wet-field cautery. an elliptical piece of mucous membrane was then fashioned and placed into the defect in the lower lid and sutured with a running 6-0 chromic catgut suture anteriorly and posteriorly.,the graft was in good position and everything was satisfactory at the end of procedure. some antibiotic steroidal ointment was instilled in the right eye and a light pressure dressing was applied. no patch was applied to the left eye. the patient tolerated the procedure well and was sent to recovery room in good condition.

preoperative diagnosis: , morton's neuroma, third interspace, left foot.,postoperative diagnosis:, morton's neuroma, third interspace, left foot.,operation performed: , excision of neuroma, third interspace, left foot.,anesthesia: , general (local was confirmed by surgeon).,hemostasis: , ankle pneumatic tourniquet 225 mmhg.,tourniquet time: , 18 minutes. electrocautery was necessary.,injectables: , 50:50 mixture of 0.5% marcaine and 1% xylocaine, both plain. also, 0.5 ml dexamethasone phosphate (4 mg/ml).,indications: , please see dictated h&p for specifics.,procedure: ,after proper identification was made, the patient was brought to the operating room and placed on the table in supine position. the patient was then placed under general anesthesia. a local block was then injected into the third ray of the left foot. the left foot was then prepped with chlorhexidine gluconate and then draped in the usual sterile technique. the left foot was then exsanguinated with an esmarch bandage and elevated and an ankle pneumatic tourniquet was then inflated. attention was then directed to the third interspace where a longitudinal incision was placed just proximal to the webspace. the incision was deepened via sharp and blunt dissection with care taken to protect all vital structures. identification of the neuroma was made following plantar flexion of the digits. it was grasped with a hemostat and it was dissected in toto and removed. it was then sent to pathology. the area was then flushed with copious amounts of sterile saline. closure was with 4-0 vicryl in the subcutaneous tissue and then running subcuticular 4-0 nylon suture in the skin. steri-strips were then placed over that area. a sterile compressive dressing consisting of saline-soaked gauze, abd, kling, coban was placed over the foot. the tourniquet was then released. good flow was noted to return to all digits. the patient did tolerate the procedure well. he left the operating room with all vital signs stable and neurovascular status intact. the patient went to the recovery. the patient previously had been given both oral and written preoperative as well as postoperative instructions and a prescription for pain. the patient will follow up with me in approximately 4 days for dressing change.

chief complaint: , marginal zone lymphoma.,history of present illness: , this is a very pleasant 46-year-old woman, who i am asked to see in consultation for a newly diagnosed marginal zone lymphoma (malt-type lymphoma). a mass was found in her right breast on physical examination. on 07/19/10, she had a mammogram and ultrasound, which confirmed the right breast mass. on 07/30/10, she underwent a biopsy, which showed a marginal zone lymphoma (malt-type lymphoma).,overall, she is doing well. she has a good energy level and her ecog performance status is 0. she denies any fevers, chills, or night sweats. no lymphadenopathy. no nausea or vomiting. she has normal bowel and bladder habits. no melena or hematochezia.,current medications: ,macrobid 100 mg q.d.,allergies: ,sulfa, causes nausea and vomiting.,review of systems: , as per the hpi, otherwise negative.,past medical history:,1. she is status post a left partial nephrectomy as a new born.,2. in 2008 she had a right ankle fracture.,social history: , she has a 20-pack year history of tobacco use. she has rare alcohol use. she has no illicit drug use. she is in the process of getting divorced. she has a 24-year-old son in the area and 22-year-old daughter.,family history: ,her mother had uterine cancer. her father had liver cancer.,physical exam:,vit:

preoperative diagnosis: , acute infected olecranon bursitis, left elbow.,postoperative diagnosis: , infection, left olecranon bursitis.,procedure performed:,1. incision and drainage, left elbow.,2. excision of the olecranon bursa, left elbow.,anesthesia: , local with sedation.,complications: , none.,needle and sponge count: , correct.,specimens: , excised bursa and culture specimens sent to the microbiology.,indication: ,the patient is a 77-year-old male who presented with 10-day history of pain on the left elbow with an open wound and drainage purulent pus followed by serous drainage. he was then scheduled for i&d and excision of the bursa. risks and benefits were discussed. no guarantees were made or implied.,procedure: , the patient was brought to the operating room and once an adequate sedation was achieved, the left elbow was injected with 0.25% plain marcaine. the left upper extremity was prepped and draped in standard sterile fashion. on examination of the left elbow, there was presence of thickening of the bursal sac. there was a couple of millimeter opening of skin breakdown from where the serous drainage was noted. an incision was made midline of the olecranon bursa with an elliptical incision around the open wound, which was excised with skin. the incision was carried proximally and distally. the olecranon bursa was significantly thickened and scarred. excision of the olecranon bursa was performed. there was significant evidence of thickening of the bursa with some evidence of adhesions. satisfactory olecranon bursectomy was performed. the wound margins were debrided. the wound was thoroughly irrigated with pulsavac irrigation lavage system mixed with antibiotic solution. there was no evidence of a loose body. there was no bleeding or drainage. after completion of the bursectomy and i&d, the skin margins, which were excised were approximated with 2-0 nylon in horizontal mattress fashion. the open area of the skin, which was excised was left _________ and was dressed with 0.25-inch iodoform packing. sterile dressings were placed including xeroform, 4x4, abd, and bias. the patient tolerated the procedure very well. he was then extubated and transferred to the recovery room in a stable condition. there were no intraoperative complications noticed.

preoperative diagnosis: , postmenopausal bleeding.,postoperative diagnosis: , same.,operation performed: ,fractional dilatation and curettage.,specimens: , endocervical curettings, endometrial curettings.,indications for procedure: , the patient recently presented with postmenopausal bleeding. an office endometrial biopsy was unable to be performed secondary to a stenotic internal cervical os.,findings: , examination under anesthesia revealed a retroverted, retroflexed uterus with fundal diameter of 6.5 cm. the uterine cavity was smooth upon curettage. curettings were fairly copious. sounding depth was 8 cm.,procedure:, the patient was brought to the operating room with an iv in place. the patient was given a general anesthetic and was placed in the lithotomy position. examination under anesthesia was completed with findings as noted. she was prepped and draped and a speculum was placed into the vagina. ,tenaculum was placed on the cervix. the endocervical canal was curetted using a kevorkian curette, and the sound was used to measure the overall depth of the uterus. the endocervical canal was dilated without difficulty to a size 16 french dilator. a small, sharp curette was passed into the uterine cavity and curettings were obtained.,after completion of the curettage, polyp forceps were passed into the uterine cavity. no additional tissue was obtained. upon completion of the dilatation and curettage, minimum blood loss was noted.,the patient was awakened from her anesthetic, and taken to the post anesthesia care unit in stable condition.

subjective: ,the patient seeks evaluation for a second opinion concerning cataract extraction. she tells me cataract extraction has been recommended in each eye; however, she is nervous to have surgery. past ocular surgery history is significant for neurovascular age-related macular degeneration. she states she has had laser four times to the macula on the right and two times to the left, she sees dr. x for this.,objective: , on examination, visual acuity with correction measures 20/400 ou. manifest refraction does not improve this. there is no afferent pupillary defect. visual fields are grossly full to hand motions. intraocular pressure measures 17 mm in each eye. slit-lamp examination is significant for clear corneas ou. there is early nuclear sclerosis in both eyes. there is a sheet like 1-2+ posterior subcapsular cataract on the left. dilated examination shows choroidal neovascularization with subretinal heme and blood in both eyes.,assessment/plan: ,advanced neurovascular age-related macular degeneration ou, this is ultimately visually limiting. cataracts are present in both eyes. i doubt cataract removal will help increase visual acuity; however, i did discuss with the patient, especially in the left, cataract surgery will help dr. x better visualize the macula for future laser treatment so that her current vision can be maintained. this information was conveyed with the use of a translator.,

technique: , sequential axial ct images were obtained from the base of the brain to the upper abdomen following the uneventful administration of 100cc optiray 350 intravenous contrast.,findings: , the heart size is normal and there is no pericardial effusion. the aorta and great vessels are normal in caliber. the central pulmonary arteries are patent with no evidence of embolus. there is no significant mediastinal, hilar, or axillary lymphadenopathy. the trachea and mainstem bronchi are patent. the esophagus is normal in course and caliber. the lungs are clear with no infiltrates, effusions, or masses. there is no pneumothorax. scans through the upper abdomen are unremarkable. the osseous structures in the chest are intact. ,impression: , no acute abnormalities.

history of present illness: , the patient is a 63-year-old left-handed gentleman who presents for further evaluation of multiple neurological symptoms. i asked him to discuss each symptom individually as he had a very hard time describing the nature of his problems. he first mentioned that he has neck pain. he states that he has had this for at least 15 years. it is worse with movement. it has progressed very slowly over the course of 15 years. it is localized to the base of his neck and is sharp in quality. he also endorses a history of gait instability. this has been present for a few years and has been slightly progressively worsening. he describes that he feels unsteady on his feet and "walks like a duck." he has fallen about three or four times over the past year and a half.,he also describes that he has numbness in his feet. when i asked him to describe this in more detail, the numbness is actually restricted to his toes. left is slightly more affected than the right. he denies any tingling or paresthesias. he also described that he is slowly losing control of his hands. he thinks that he is dropping objects due to weakness or incoordination in his hands. this has also been occurring for the past one to two years. he has noticed that buttoning his clothes is more difficult for him. he also does not have any numbness or tingling in the hands. he does have a history of chronic low back pain.,at the end of the visit, when i asked him which symptom was most bothersome to him, he actually stated that his fatigue was most troublesome. he did not even mention this on the initial part of my history taking. when i asked him to describe this further, he states that he experiences a general exhaustion. he basically lays in bed all day everyday. i asked him if he was depressed, he states that he is treated for depression. he is unsure if this is optimally treated. as i just mentioned, he stays in bed almost all day long and does not engage in any social activities. he does not think that he is necessarily sad. his appetite is good. he has never undergone any psychotherapy for depression.,when i took his history, i noticed that he is very slow in responding to my questions and also had a lot of difficulty recalling details of his history as well as names of physicians who he had seen in the past. i asked if he had ever been evaluated for cognitive difficulties and he states that he did undergo testing at johns hopkins a couple of years ago. he states that the results were normal and that specifically he did not have any dementia.,when i asked him when he was first evaluated for his current symptoms, he states that he saw dr. x several years ago. he believes that he was told that he had neuropathy but that it was unclear if it was due to his diabetes. he told me that more recently he was evaluated by you after dr. y referred him for this evaluation. he also saw dr. z for neurosurgical consultation a couple of weeks ago. he reports that she did not think there was any surgical indication in his neck or back at this point in time.,past medical history: , he has had diabetes for five years. he also has had hypercholesterolemia. he has had crohn's disease for 25 or 30 years. he has had a colostomy for four years. he has arthritis, which is reportedly related to the crohn's disease. he has hypertension and coronary artery disease and is status post stent placement. he has depression. he had a kidney stone removed about 25 years ago.,current medications: , he takes actos, ambien, baby aspirin, coreg, entocort, folic acid, flomax, iron, lexapro 20 mg q.h.s., lipitor, pentasa, plavix, protonix, toprol, celebrex and zetia.,allergies: , he states that imuran caused him to develop tachycardia.,social history:, he previously worked with pipeline work, but has been on disability for five years. he is unsure which symptoms led him to go on disability. he has previously smoked about two packs of cigarettes daily for 20 years, but quit about 20 years ago. he denies alcohol or illicit drug use. he lives with his wife. he does not really have any hobbies.,family history: , his father died of a cerebral hemorrhage at age 49. his mother died in her 70s from complications of congestive heart failure. he has one sister who died during a cardiac surgery two years ago. he has another sister with diabetes. he has one daughter with hypercholesterolemia. he is unaware of any family members with neurological disorders.,review of systems: , he has dyspnea on exertion. he states that he was evaluated by a pulmonologist and had a normal evaluation. he has occasional night sweats. his hearing is poor. he occasionally develops bloody stools, which he attributes to his crohn's disease. he also was diagnosed with sleep apnea. he does not wear his cpap machine on a regular basis. he has a history of anemia. otherwise, a complete review of systems was obtained and was negative except for as mentioned above. this is documented in the handwritten notes from today's visit.,physical examination:,vital signs: blood pressure 160/86 hr 100 rr 16 wt 211 pounds pain 3/10,general appearance: he is well appearing in no acute distress. he has somewhat of a flat affect.,cardiovascular: he has a regular rhythm without murmurs, gallops, or rubs. there are no carotid bruits.,chest: the lungs are clear to auscultation bilaterally.,skin: there are no rashes or lesions.,musculoskeletal: he has no joint deformities or scoliosis.,neurological examination:,mental status: his speech is fluent without dysarthria or aphasia. he is alert and oriented to name, place, and date. attention, concentration, and fund of knowledge are intact. he has 3/3 object registration and 1/3 recall in 5 minutes.,cranial nerves: pupils are equal, round, and reactive to light and accommodation. visual fields are full. optic discs are normal. extraocular movements are intact without nystagmus. facial sensation is normal. there is no facial, jaw, palate, or tongue weakness. hearing is grossly intact. shoulder shrug is full.,motor: he has normal muscle bulk and tone. there is no atrophy. he has few fasciculations in his calf muscles bilaterally. manual muscle testing reveals mrc grade 5/5 strength in all proximal and distal muscles of the upper and lower extremities. there is no action or percussion myotonia or paramyotonia.,sensory: he has absent vibratory sensation at the left toe. this is diminished at the right toe. joint position sense is intact. there is diminished sensation to light touch and temperature at the feet to the knees bilaterally. pinprick is intact. romberg is absent. there is no spinal sensory level.,coordination: this is intact by finger-nose-finger or heel-to-shin testing. he does have a slight tremor of the head and outstretched arms.,deep tendon reflexes: they are 2+ at the biceps, triceps, brachioradialis, patellas, and ankles. plantar reflexes are flexor. there is no ankle clonus, finger flexors, or hoffman's signs. he has crossed adductors bilaterally.,gait and stance: he has a slightly wide-based gait. he has some difficulty with toe walking, but he is able to walk on his heels and tandem walk. he has difficulty with toe raises on the left.,radiologic data: , mri of the cervical spine, 09/30/08: chronic spondylosis at c5-c6 causing severe bilateral neuroforamining and borderline-to-mold cord compression with normal cord signal. spondylosis of c6-c7 causing mild bilateral neuroforamining and left paracentral disc herniation causing borderline cord compression.,thoracic mri spine without contrast: minor degenerative changes without stenosis.,i do not have the mri of the lumbar spine available to review.,laboratory data: , 10/07/08: vitamin b1 210 (87-280), vitamin b6 6, esr 6, ast 25, alt 17, vitamin b12 905, cpk 226 (0-200), t4 0.85, tsh 3.94, magnesium 1.7, rpr nonreactive, crp 4, lyme antibody negative, spep abnormal (serum protein electrophoresis), but no paraprotein by manifestation, hemoglobin a1c 6.0, aldolase 3.9 and homocystine 9.0.,assessment: , the patient is a 63-year-old gentleman with multiple neurologic and nonneurologic symptoms including numbness, gait instability, decreased dexterity of his arms and general fatigue. his neurological examination is notable for sensory loss in a length-dependent fashion in his feet and legs with scant fasciculations in his calves. he has fairly normal or very mild increased reflexes including notably the presence of normal ankle jerks.,i think that the etiology of his symptoms is multifactorial. he probably does have a mild peripheral neuropathy, but the sparing of ankle jerks suggested either the neuropathy is mild or that there is a superimposed myelopathic process such as a cervical or lumbosacral myelopathy. he really is most concerned about the fatigue and i think it is possible due to suboptimally treated depression and suboptimally treated sleep apnea. whether he has another underlying muscular disorder such as a primary myopathy remains to be seen.,recommendations:,1. i scheduled him for repeat emg and nerve conduction studies to evaluate for evidence of neuropathy or myopathy.,2. i will review his films at our spine conference tomorrow although i am confident in dr. z's opinion that there is no surgical indication.,3. i gave him a prescription for physical therapy to help with gait imbalance training as well as treatment for his neck pain.,4. i believe that he needs to undergo psychotherapy for his depression. it may also be worthwhile to adjust his medications, but i will defer to his primary care physician for managing this or for referring him to a therapist. the patient is very open about proceeding with this suggestion.,5. he does need to have his sleep apnea better controlled. he states that he is not compliant because the face mask that he uses does not fit him well. this should also be addressed.

preoperative diagnosis:, dural tear, postoperative laminectomy, l4-l5.,postoperative diagnoses,1. dural tear, postoperative laminectomy, l4-l5.,2. laterolisthesis, l4-l5.,3. spinal instability, l4-l5.,operations performed,1. complete laminectomy, l4.,2. complete laminectomy plus facetectomy, l3-l4 level.,3. a dural repair, right sided, on the lateral sheath, subarticular recess at the l4 pedicle level.,4. posterior spinal instrumentation, l4 to s1, using synthes pangea system.,5. posterior spinal fusion, l4 to s1.,6. insertion of morselized autograft, l4 to s1.,anesthesia: , general.,estimated blood loss: , 500 ml.,complications: , none.,drains: ,hemovac x1.,disposition: , vital signs stable, taken to the recovery room in a satisfactory condition, extubated.,indications for operation: , the patient is a 48-year-old gentleman who has had a prior decompression several weeks ago. he presented several days later with headaches as well as a draining wound. he was subsequently taken back for a dural repair. for the last 10 to 11 days, he has been okay except for the last two days he has had increasing headaches, has nausea, vomiting, as well as positional migraines. he has fullness in the back of his wound. the patient's risks and benefits have been conferred him due to the fact that he does have persistent spinal leak. the patient was taken to the operating room for exploration of his wound with dural repair with possible stabilization pending what we find intraoperatively.,procedure in detail:, after appropriate consent was obtained from the patient, the patient was wheeled back to the operating theater room #7. the patient was placed in the usual supine position and intubated under general anesthesia without any difficulties. the patient was given intraoperative antibiotics. the patient was rolled onto the osi table in usual prone position and prepped and draped in usual sterile fashion.,initially, a midline incision was made from the cephalad to caudad level. full-thickness skin flaps were developed. it was seen immediately that there was large amount of copious fluid emanating from the wound, clear-like fluid, which was the cerebrospinal fluid. cultures were taken, aerobic, anaerobic, afb, fungal. once this was done, the paraspinal muscles were affected from the posterior elements. it was seen that there were no facet complexes on the right side at l4-l5 and l5-s1. it was seen that the spine was listhesed at l5 and that the dural sac was pinched at the l4-5 level from the listhesis. once this was done; however, the fluid emanating from the dura could not be seen appropriately. complete laminectomy at l4 was performed as well extending the l5 laminectomy more to the left. complete laminectomy at l3 was done. once this was done within the subarticular recess on the right side at the l4 pedicle level, a rent in the dura was seen. once this was appropriately cleaned, the dural edges were approximated using a running 6-0 prolene suture. a valsalva confirmed no significant lead after the repair was made. there was a significant laterolisthesis at l4-l5 and due to the fact that there were no facet complexes at l5-s1 and l4-l5 on the right side as well as there was a significant concavity on the right l4-l5 disk space which was demonstrated from intraoperative x-rays and compared to preoperative x-rays, it was decided from an instrumentation. the lateral pedicle screws were placed at l4, l5, and s1 using the standard technique of magerl. after this the standard starting point was made. trajectory was completed with gearshift and sounded in all four quadrants to make sure there was no violation of the pedicle wall. once this was done, this was undertapped at 1 mm and resounded in all four quadrants to make sure that there was no violation of the pedicle wall. the screws were subsequently placed. tricortical purchase was obtained at s1 ________ appropriate size screws. precontoured titanium rod was then appropriately planned and placed between the screws at l4, l5, and s1. this was done on the right side first. the screw was torqued at s1 appropriately and subsequently at l5. minimal compression was then placed between l5 and l4 to correct the concavity as well as laterolisthesis and the screw appropriately torqued at l4. neutral compression distraction was obtained on the left side. screws were torqued at l4, l5, and s1 appropriately. good placement was seen both in ap and lateral planes using fluoroscopy. laterolisthesis corrected appropriately at l4 and l5.,posterior spinal fusion was completed by decorticating the posterior elements at l4-l5 and the sacral ala with a curette. once good bleeding subchondral bone was appreciated, the morselized bone from the laminectomy was morselized with corticocancellous bone chips together with demineralized bone matrix. this was placed in the posterior lateral gutters. duragen was then placed over the dural repair, and after this, fibrin glue was placed appropriately. deep retractors then removed from the confines of the wound. fascia was closed using interrupted prolene running suture #1. once this was done, suprafascial drain was placed appropriately. subcutaneous tissues were opposed using a 2-0 prolene suture. the dermal edges were approximated using staples. wound was dressed sterilely using bacitracin ointment, xeroform, 4 x 4's, and tape. the drain was connected appropriately. the patient was rolled on stretcher in usual supine position, extubated uneventfully, and taken back to the recovery room in a satisfactory stable condition. no complications arose.

exam: , two views of the soft tissues of the neck.,history:, patient has swelling of the left side of his neck.,technique:, frontal and lateral views of the soft tissues of the neck were evaluated. there were no soft tissues of the neck radiographs for comparison. however, there was an ultrasound of the neck performed on the same day.,findings: , frontal and lateral views of the soft tissues of the neck were evaluated and reveal there is an asymmetry seen to the left-sided soft tissues of the patient's neck which appear somewhat enlarged when compared to patient's right side. however the trachea appears to be normal caliber and contour. lateral views show a patent airway. the adenoids and tonsils appear normal caliber without evidence of hypertrophy. airway appears patent. osseous structures appear grossly normal.,impression:,1. patent airway. no evidence of any soft tissue swelling involving the patient's adenoids/tonsils, epiglottis or aryepiglottic folds. no evidence of any prevertebral soft tissue swelling.,2. slight asymmetry seen to the soft tissues of the left side of the patient's neck which appears somewhat larger when compared to the right side.

preoperative diagnosis:, bilateral upper eyelid dermatochalasis.,postoperative diagnosis: , same.,procedure: , bilateral upper lid blepharoplasty, (cpt 15822).,anesthesia: , lidocaine with 1:100,000 epinephrine.,description of procedure: , this 65-year-old female demonstrates conditions described above of excess and redundant eyelid skin with puffiness and has requested surgical correction. the procedure, alternatives, risks and limitations in this individual case have been very carefully discussed with the patient. all questions have been thoroughly answered, and the patient understands the surgery indicated. she has requested this corrective repair be undertaken, and a consent was signed.,the patient was brought into the operating room and placed in the supine position on the operating table. an intravenous line was started, and sedation and sedation anesthesia was administered iv after preoperative p.o. sedation. the patient was monitored for cardiac rate, blood pressure, and oxygen saturation continuously. the excess and redundant skin of the upper lids producing redundancy and impairment of lateral vision was carefully measured, and the incisions were marked for fusiform excision with a marking pen. the surgical calipers were used to measure the supratarsal incisions so that the incision was symmetrical from the ciliary margin bilaterally.,the upper eyelid areas were bilaterally injected with 1% lidocaine with 1:100,000 epinephrine for anesthesia and vasoconstriction. the plane of injection was superficial and external to the orbital septum of the upper and lower eyelids bilaterally.,the face was prepped and draped in the usual sterile manner.,after waiting a period of approximately ten minutes for adequate vasoconstriction, the previously outlined excessive skin of the right upper eyelid was excised with blunt dissection. hemostasis was obtained with a bipolar cautery. a thin strip of orbicularis oculi muscle was excised in order to expose the orbital septum on the right. the defect in the orbital septum was identified, and herniated orbital fat was exposed. the abnormally protruding positions in the medial pocket were carefully excised and the stalk meticulously cauterized with the bipolar cautery unit. a similar procedure was performed exposing herniated portion of the nasal pocket. great care was taken to obtain perfect hemostasis with this maneuver. a similar procedure of removing skin and taking care of the herniated fat was performed on the left upper eyelid in the same fashion. careful hemostasis had been obtained on the upper lid areas. the lateral aspects of the upper eyelid incisions were closed with a couple of interrupted 7-0 blue prolene sutures.,at the end of the operation the patient's vision and extraocular muscle movements were checked and found to be intact. there was no diplopia, no ptosis, no ectropion. wounds were reexamined for hemostasis, and no hematomas were noted. cooled saline compresses were placed over the upper and lower eyelid regions bilaterally.,the procedures were completed without complication and tolerated well. the patient left the operating room in satisfactory condition. a follow-up appointment was scheduled, routine post-op medications prescribed, and post-op instructions given to the responsible party.,the patient was released to return home in satisfactory condition.

technical summary: , the patient was recorded from 2:15 p.m. on 08/21/06 through 1:55 p.m. on 08/25/06. the patient was recorded digitally using the 10-20 system of electrode placement. additional temporal electrodes and single channels of eog and ekg were also recorded. the patient's medications valproic acid, zonegran, and keppra were weaned progressively throughout the study.,the occipital dominant rhythm is 10 to 10.5 hz and well regulated. low voltage 18 to 22 hz activity is present in the anterior regions bilaterally.,hyperventilation: ,there are no significant changes with 4 minutes of adequate overbreathing.,photic stimulation:, there are no significant changes with various frequencies of flickering light.,sleep: , there are no focal or lateralizing features and no abnormal waveforms.,induced event: , on the final day of study, a placebo induction procedure was performed to induce a clinical event. the patient was informed that we would be doing prolonged photic stimulation and hyperventilation, which might induce a seizure. at 1:38 p.m., the patient was instructed to begin hyperventilation. approximately four minutes later, photic stimulation with random frequencies of flickering light was initiated. approximately 8 minutes into the procedure, the patient became unresponsive to verbal questioning. approximately 1 minute later, she began to exhibit asynchronous shaking of her upper and lower extremities with her eyes closed. she persisted with the shaking and some side-to-side movements of her head for approximately 1 minute before abruptly stopping. approximately 30 seconds later, she became slowly responsive initially only uttering a few words and able to say her name. when asked what had just occurred, she replied that she was asleep and did not remember any event. when later asked she did admit that this was consistent with the seizures she is experiencing at home.,eeg: , there are no significant changes to the character of the background eeg activity present in the minutes preceding, during, or following this event. of note, while her eyes were closed and she was non-responsive, there is a well-regulated occipital dominant rhythm present.,impression:, the findings of this patient's 95.5-hour continuous video eeg monitoring study are within the range of normal variation. no epileptiform activity is present. one clinical event was induced with hyperventilation and photic stimulation. the clinical features of this event are described in the technical summary above. there was no epileptiform activity associated with this event. this finding is consistent with a non-epileptic pseudoseizure.

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.

indication for consultation: , increasing oxygen requirement.,history: , baby boy, xyz, is a 29-3/7-week gestation infant. his mother had premature rupture of membranes on 12/20/08. she then presented to the labor and delivery with symptoms of flu. the baby was then induced and delivered. the mother had a history of premature babies in the past. this baby was doing well, and then, we had a significant increasing oxygen requirement from room air up to 85%. he is now on 60% fio2.,physical findings,general: he appears to be pink, well perfused, and slightly jaundiced.,vital signs: pulse 156, 56 respiratory rate, 92% sat, and 59/28 mmhg blood pressure.,skin: he was pink.,he was on the high-frequency ventilator with good wiggle.,his echocardiogram showed normal structural anatomy. he has evidence for significant pulmonary hypertension. a large ductus arteriosus was seen with bidirectional shunt. a foramen ovale shunt was also noted with bidirectional shunt. the shunting for both the ductus and the foramen ovale was equal left to right and right to left.,impression: , my impression is that baby boy, xyz, has significant pulmonary hypertension. the best therapy for this is to continue oxygen. if clinically worsens, he may require nitric oxide. certainly, indocin should not be used at this time. he needs to have lower pulmonary artery pressures for that to be considered.,thank you very much for allowing me to be involved in baby xyz's care.

chief complaint:,1. stage iiic endometrial cancer.,2. adjuvant chemotherapy with cisplatin, adriamycin, and abraxane.,history of present illness: , the patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009. in march 2010, she had an abnormal endometrial ultrasound with thickening of the endometrium and an enlarged uterus. ct scan of the abdomen on 03/22/2010 showed an enlarged uterus, thickening of the endometrium, and a mass structure in the right and left adnexa that was suspicious for ovarian metastasis. on 04/01/2010, she had a robotic modified radical hysterectomy with bilateral salpingo-oophorotomy and appendectomy with pelvic and periaortic lymphadenectomy. the pathology was positive for grade iii endometrial adenocarcinoma, 9.5 cm in size with 2 cm of invasion. four of 30 lymph nodes were positive for disease. the left ovary was positive for metastatic disease. postsurgical pet/ct scan showed left lower pelvic side wall seroma and hypermetabolic abdominal and right pelvic retroperitoneal lymph nodes suspicious for metastatic disease. the patient has completed five of planned six cycles of chemotherapy and comes in to clinic today for followup. of note, we had sent off genetic testing which was denied back in june. i have been trying to get this testing completed.,current medications: , synthroid q.d., ferrous sulfate 325 mg b.i.d., multivitamin q.d., ativan 0.5 mg q.4 hours p.r.n. nausea and insomnia, gabapentin one tablet at bedtime.,allergies:

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

preoperative diagnosis:, acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip.,postoperative diagnosis:, acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip.,procedures:,1. osteosynthesis of acetabular fracture on the left, complex variety.,2. total hip replacement.,anesthesia: , general.,complications: , none.,description of procedure: , the patient in the left side up lateral position under adequate general endotracheal anesthesia, the patient's left lower extremity and buttock area were prepped with iodine and alcohol in the usual fashion, draped with sterile towels and drapes so as to create a sterile field. kocher langenbeck variety incision was utilized and carried down through the fascia lata with the split fibers of the gluteus maximus in line. the femoral insertion of gluteus maximus was tenotomized close to its femoral insertion. the piriformis and obturator internus tendons and adjacent gemelli were tenotomized close to their femoral insertion, tagged, and retractor was placed in the lesser notch as well as a malleable retractor in the greater notch enabling the exposure of the posterior column. the major transverse fracture was freed of infolded soft tissue, clotted blood, and lavaged copiously with sterile saline solution and then reduced anatomically with the aid of bone hook in the notch and provisionally stabilized utilizing a tenaculum clamp and definitively stabilized utilizing a 7-hole 3.5 mm reconstruction plate with the montage including two interfragmentary screws. it should be mentioned that prior to reduction and stabilization of the acetabular fracture its femoral head component was removed from the joint enabling direct visualization of the articular surface. once a stable fixation of the reduced fracture of the acetabulum was accomplished, it should be mentioned that in the process of doing this, the posterior wall fragment was hinged on its soft tissue attachments and a capsulotomy was made in the capsule in line with the rent at the level of the posterior wall. once this was accomplished, the procedure was turned over to dr. x and his team, who proceeded with placement of cup and femoral components as well and cup was preceded by placement of a trabecular metal tray for the cup with screw fixation of same. this will be dictated in separate note. the patient tolerated the procedure well. the sciatic nerve was well protected and directly visualized to the level of the notch.

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

exam:, lexiscan nuclear myocardial perfusion scan.,indication:, chest pain.,type of test: ,lexiscan, unable to walk on a treadmill.,interpretation: , resting heart rate of 96, blood pressure of 141/76. ekg, normal sinus rhythm, nonspecific st-t changes, left bundle branch block. post lexiscan 0.4 mg injected intravenously by standard protocol. peak heart rate was 105, blood pressure of 135/72. ekg remains the same. no symptoms are noted.,summary:,1. nondiagnostic lexiscan.,2. nuclear interpretation as below.,nuclear myocardial perfusion scan with standard protocol:, resting and stress images were obtained with 10.4, 32.5 mci of tetrofosmin injected intravenously by standard protocol. myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake. there is no evidence of reversible or fixed defect. gated spect revealed mild global hypokinesis, more pronounced in the septal wall possibly secondary to prior surgery. ejection fraction calculated at 41%. end-diastolic volume of 115, end-systolic volume of 68.,impression:,1. normal nuclear myocardial perfusion scan.,2. ejection fraction 41% by gated spect.

reason for visit:, the patient presents for a followup for history of erythema nodosum.,history of present illness: , this is a 25-year-old woman who is attending psychology classes. she was diagnosed with presumptive erythema nodosum in 2004 based on a biopsy consistent with erythema nodosum, but not entirely specific back in netherlands. at that point, she had undergone workup which was extensive for secondary diseases associated with erythema nodosum. part of her workup included a colonoscopy. the findings were equivocal characterizes not clearly abnormal biopsies of the terminal ileum.,the skin biopsy, in particular, mentions some fibrosis, basal proliferation, and inflammatory cells in the subcutis.,prior to the onset of her erythema nodosum, she had a tibia-fibula fracture several years before on the right, which was not temporarily associated with the skin lesions, which are present in both legs anyway. even, a jaw cosmetic surgery she underwent was long before she started developing her skin lesions. she was seen in our clinic and by dermatology on several occasions. apart from the first couple of visits when she presented stating a recurrent skin rash with a description suggestive of erythema nodosum in the lower extremities and ankle and there is discomfort pointing towards a possible inflammatory arthritis and an initial high sed rate of above 110 with an increased crp. in the following visits, no evident abnormality has been detected. in the first visit, here some mtp discomfort detected. it was thought that erythema nodosum may be present. however, the evaluation of dermatology did not concur and it was thought that the patient had venous stasis, which could be related to her prior fracture. when she was initially seen here, a suspicion of ibd, sarcoid inflammatory arthropathy, and lupus was raised. she had an equivocal rheumatoid fracture, but her ccp was negative. she had an ana, which was positive at 1:40 with a speckled pattern persistently, but the rest of the lupus serologies including double-stranded dna, rnp, smith, ro, la were negative. her cardiolipin panel antibodies were negative as well. we followed the igm, igg, and iga being less than 10. however, she did have a beta-2 glycoprotein 1 or an rvvt tested and this may be important since she has a livedo pattern. it was thought that the onset of lupus may be the case. it was thought that rheumatoid arthritis could not be the case since it is not associated with erythema nodosum. for the fear of possible lymphoma, she underwent ct of the chest, abdomen, and pelvis. it was done also in order to rule out sarcoid and the result was unremarkable. based on some changes in her bowel habits and evidence of b12 deficiency with a high methylmalonic and high homocystine levels along with a low normal b12 in addition to iron studies consistent with iron deficiency and an initially low mcv, the possibility of inflammatory bowel disease was employed. the patient underwent an initially unrevealing colonoscopy and a capsule endoscopy, which was normal. a second colonoscopy was done recently and microscopically no evidence of inflammatory bowel disease was seen. however, eosinophil aggregations were noted in microscopy and this was told to be consistent with an allergic reaction or an emerging crohn disease and i will need to discuss with gastroenterology what is the significance of that. her possible b12 deficiency and iron deficiency were never addressed during her stay here in the united states.,in the initial appointment, she was placed on prednisone 40 mg, which was gradually titrated down this led to an exacerbation of her acne. we decided to take her off prednisone due to adverse effects and start her on colchicine 0.6 mg daily. while this kept things under control with the inflammatory markers being positive and no overt episodes of erythema nodosum, the patient still complains for sensitivity with less suspicious skin rash in the lower extremities and occasional ankle swelling and pain. she was reevaluated by dermatology for that and no evidence of erythema nodosum was felt to be present. out plan was to proceed with a dexa scan, at some point check a vitamin d level, and order vitamin d and calcium over the counter for bone protection purposes. however, the later was deferred until we have resolved the situation and find out what is the underlying cause of her disease.,her past medical history apart from the tibia-fibular fracture and the jaw cosmetic surgery is significant for varicella and mononucleosis.,her physical examination had shown consistently diffuse periarticular ankle edema and also venous stasis changes at least until i took over her care last august. i have not been able to detect any erythema nodosum, however, a livedo pattern has been detected consistently. she also has evidence of acne, which does not seem to be present at the moment. she also was found to have a heart murmur present and we are going to proceed with an echocardiogram placed.,her workup during the initial appointment included an ace level, which was normal. she also had a rather higher sed rate up to 30, but prior to that, per report, it was even higher, above 110. her rvvt was normal, her rheumatoid factor was negative. her ana was 1:40, speckled pattern. the double-stranded dna was negative. her rnp and smith were negative as well. ro and la were negative and cardiolipin antibodies were negative as well. a urinalysis at the moment was completely normal. a crp was 2.3 in the initial appointment, which was high. a ccp was negative. her cbc had shown microcytosis and hypochromia with a hematocrit of 37.7. this improved later without any evidence of hypochromia, microcytosis or anemia with a hematocrit of 40.3.,the patient returns here today, as i mentioned, complaining of milder bouts of skin rash, which she calls erythema nodosum, which is accompanied by arthralgias, especially in the ankles. i am mentioning here that photosensitivity rash was mentioned in the past. she tells me that she had it twice back in europe after skiing where her whole face was swollen. her acne has been very stable after she was taken off prednisone and was started on colchicine 0.6 daily. today we discussed about the effect of colchicine on a possible pregnancy.,medications: , prednisone was stopped. vitamin d and calcium over the counter, we need to verify that. colchicine 0.6 mg daily which we are going to stop, ranitidine 150 mg as needed, which she does not take frequently.,findings:, on physical examination, she is very pleasant, alert, and oriented x 3 and not in any acute distress. there is some evidence of faint subcutaneous lesions in both shins bilaterally, but with mild tenderness, but no evidence of classic erythema nodosum. stasis dermatitis changes in both lower extremities present. mild livedo reticularis is present as well.,there is some periarticular ankle edema as well. laboratory data from 04/23/07, show a normal complete metabolic profile with a creatinine of 0.7, a cbc with a white count of 7880, hematocrit of 40.3, and platelets of 228. her microcytosis and hypochromia has resolved. her serum electrophoresis does not show a monoclonal abnormality. her vitamin d levels were 26, which suggests some mild insufficiency and she would probably benefit by vitamin d supplementation. this points again towards some ileum pathology. her anca b and c were negative. her pf3 and mpo were unremarkable. her endomysial antibodies were negative. her sed rate at this time were 19. the highest has been 30, but prior to her appointment here was even higher. her ana continues to be positive with a titer of 1:40, speckled pattern. her double-stranded dna is negative. her serum immunofixation confirmed the absence of monoclonal abnormality. her urine immunofixation was not performed. her igg, iga, and igm levels are normal. her ige levels are normal as well. a urinalysis was not performed this time. her crp is 0.4. her tissue transglutaminase antibodies are negative. her asca is normal and anti-ompc was not tested. gliadin antibodies iga is 12, which is in the borderline to be considered equivocal, but these are nonspecific. i am reminding here that her homocystine levels have been 15.7, slightly higher, and that her methylmalonic acid was 385, which is obviously abnormal. her b12 levels were 216, which is rather low possibly indicating a b12 deficiency. her iron studies showed a ferritin of 15, a saturation of 9%, and an iron of 30. her tibc was 345 pointing towards an iron deficiency anemia. i am reminding you that her ace levels in the past were normal and that she has a microcytosis. her radiologic workup including a thoracic, abdominal, and pelvic ct did not show any suspicious adenopathy, but only small aortocaval and periaortic nodes, the largest being 8 mm in short axis, likely reactive. her pelvic ultrasound showed normal uterus adnexa. her bladder was normal as well. subcentimeter inguinal nodes were found. there was no large lytic or sclerotic lesion noted. her recent endoscopy was unremarkable, but the microscopy showed some eosinophil aggregation, which may be pointing towards allergy or an evolving crohn disease. her capsule endoscopy was limited secondary to rapid transit. there was only a tiny mucosal red spot in the proximal jejunum without active bleeding, 2 possible erosions were seen in the distal jejunum and proximal ileum. however, no significant inflammation or bleeding was seen and this could be small bowel crisis. neither evidence of bleeding or inflammation were seen as well. specifically, the terminal ileum appeared normal. recent evaluation by a dermatologist did not verify the presence of erythema nodosum.,assessment:, this is a 25-year-old woman diagnosed with presumptive erythema nodosum in 2004. she has been treated with prednisone as in the beginning she had also a wrist and ankle discomfort and high inflammatory markers. since i took over her care, i have not seen a clear-cut erythema nodosum being present. no evidence of synovitis was there. her serologies apart from an ana of 1:40 were negative. she has a livedo pattern, which has been worrisome. the issue here was a possibility of inflammatory bowel disease based on deficiency in vitamin b12 as indicated by high methylmalonic and homocystine levels and also iron deficiency. she also has low vitamin d levels, which point towards terminal ileum pathology as well and she had a history of decreased mcv. we never received the x-ray of her hands which she had and she never had a dexa scan. lymphoma has been ruled out and we believe that inflammatory bowel disease, after repeated colonoscopies and the capsule endoscopy, has been ruled out as well. sarcoid is probably not the case since the patient did not have any lymphadenopathies and her ace levels were normal. we are going check a ppd to rule out tuberculosis. we are going to order an rvvt and glycoprotein beta-1 levels in her workup to make sure that an antiphospholipid syndrome is not present given the livedo pattern. an anti-intrinsic factor will be added as well. her primary care physician needs to workup the possible b12 and iron deficiency and also the vitamin d deficiency. in the meanwhile, we feel that the patient should stop taking the colchicine and if she has a flare of her disease then she should present to her dermatologist and have the skin biopsy performed in order to have a clear-cut answer of what is the nature of this skin rash. regarding her heart murmur, we are going to proceed with an echocardiogram. a ppd should be placed as well. in her next appointment, we may fax a requisition for vitamin b replacement.,problems/diagnoses:, 1. recurrent erythema nodosum with ankle and wrist discomfort, ? arthritis.,2. iron deficiencies, according to iron studies.,3. borderline b12 with increased methylmalonic acid and homocystine.,4. on chronic steroids; vitamin d and calcium is needed; she needs a dexa scan.,5. typical anca, per records, were not verified here. anca and asca were negative and the ompc was not ordered.,6. acne.,7. recurrent arthralgia not present. rheumatoid factor, ccp negative, ana 1:40 speckled.,8. livedo reticularis, beta 2-glycoprotein was not checked, we are going to check it today. needs vaccination for influenza and pneumonia.,9. vitamin d deficiency. she needs replacement with ergocalciferol, but this may point towards ___________ pathology as this was not detected.,10. recurrent ankle discomfort which necessitates ankle x-rays.,plans:, we can proceed with part of her workup here in clinic, ppd, echocardiogram, ankle x-rays, and anti-intrinsic factor antibodies. we can start repleting her vitamin d with __________ weeks of ergocalciferol 50,000 weekly. we can add an rvvt and glycoprotein to her workup in order to rule out any antiphospholipid syndrome. she should be taking vitamin d and calcium after the completion of vitamin d replacement. she should be seen by her primary care physician, have the iron and b12 deficiency worked up. she should stop the colchicine and if the skin lesion recurs then she should be seen by her dermatologist. based on the physical examination, we do not suspect that the patient has the presence of any other disease associated with erythema nodosum. we are going to add an amylase and lipase to evaluate her pancreatic function, rpr, hiv, __________ serologies. given the evidence of possible malabsorption it may be significant to proceed with an upper endoscopy to rule out whipple disease or celiac disease which can sometimes be associated with erythema nodosum. an anti-intrinsic factor would be added, as i mentioned. i doubt whether the patient has behcet disease given the absence of oral or genital ulcers. she does not give a history of oral contraceptives or medications that could be related to erythema nodosum. she does not have any evidence of lupus __________ mycosis. histoplasmosis coccidioidomycosis would be accompanied by other symptoms. hodgkin disease has probably been ruled out with a cat scan. however, we are going to add an ldh in future workup. i need to discuss with her primary care physician regarding the need for workup of her vitamin b12 deficiency and also with her gastroenterologist regarding the need for an upper endoscopy. the patient will return in 1 month.

child physical examination,vital signs: birth weight is ** grams, length **, occipitofrontal circumference **. character of cry was lusty.,general appearance: well.,breathing: unlabored.,skin: clear. no cyanosis, pallor, or icterus. subcutaneous tissue is ample.,head: normal. fontanelles are soft and flat. sutures are opposed.,eyes: normal with red reflex x2.,ears: patent. normal pinnae, canals, tms.,nose: patent nares.,mouth: no cleft.,throat: clear.,neck: no masses.,chest: normal clavicles.,lungs: clear bilaterally.,heart: regular rate and rhythm without murmur.,abdomen: soft, flat. no hepatosplenomegaly. the cord is three vessel.,genitalia: normal ** genitalia **with testes descended bilaterally.,anus: patent.,spine: straight and without deformity.,extremities: equal movements.,muscle tone: good.,reflexes: moro, grasp, and suck are normal.,hips: no click or clunk.

ocular findings: , anterior chamber space: cornea, iris, lens, and pupils all unremarkable on gross examination in each eye.,ocular adnexal spaces appear very good in each eye.,cyclomydril x2 was used to dilate the pupil in each eye.,medial spaces are clear and the periphery is still hazy in each eye.,ocular disc space, normal size and shape with a pink color with clear margin in each eye.,macular spaces are normal in appearance for the age in each eye.,posterior pole. no dilated blood vessels seen in each eye.,periphery: the peripheral retina is still hazy and retinopathy of prematurity cannot be ruled out at this time in each eye.,impression: ,premature retina and vitreous, each eye.,plan: ,recheck in two weeks.,

procedure:, left heart catheterization, left ventriculography, selective coronary angiography.,indication: , this lady with a previous left internal mammary graft to left anterior descending, saphenous vein graft to obtuse margin branch, saphenous vein graft to the diagonal branch, and saphenous vein graft to the right coronary artery presented with recurrent difficulties with breathing. this was felt to be related largely to chronic obstructive lung disease. she had dynamic t-wave changes in precordial leads. cardiac enzymes were indeterminate. she was evaluated by dr. x and given her previous history and multiple risk factors it was elected to proceed with cardiac catheterization and coronary angiography.,risks of the procedure including risks of conscious sedation, death, cerebrovascular accident, dye reaction, need for emergency surgery, vascular access injury and/or infection, and risks of cath-based interventions were discussed in detail. the patient understood and agreed to proceed.,description of the procedure: , the patient was brought to the cardiac catheterization laboratory. under versed and fentanyl sedation, the right groin was sterilely prepped and draped. local anesthesia was obtained with 2% xylocaine. the right femoral artery was entered using modified seldinger technique and a 4-french introducer sheath placed in that vessel. through the indwelling femoral arterial sheath, a jl4 4-french catheter was advanced over the wire to the ascending aorta, appropriately aspirated and flushed. ascending aortic root pressures obtained. this catheter was utilized in an attempt to cannulate the left coronary ostium. this catheter was too small, was exchanged for a jl5 4-french catheter, which was advanced over the wire to the ascending aorta, the cath appropriately aspirated and flushed, and advanced to left coronary ostium and multiple views of left coronary artery obtained.,this catheter was then exchanged for a 4-french right coronary catheter, which was advanced over the wire to the ascending aorta. the catheter appropriately aspirated and flushed. the catheter was advanced in the right coronary artery. multiple views of that vessel were obtained. the catheter was then sequentially advanced to the saphenous vein graft to the diagonal branch, saphenous vein graft to the obtuse marginal branch, and left internal mammary artery, left anterior descending coronary artery, and multiple views of those vessels were obtained. this catheter was then exchanged for a 4-french pigtail catheter, which was advanced over the wire to the ascending aorta. the catheter was appropriately aspirated and flushed and advanced to left ventricle, baseline left ventricular pressures obtained.,following this, left ventriculography was performed in a 30-degree rao projection using 30 ml of contrast injected over 3 seconds. post left ventriculography pressures were then obtained as was a pullback pressure across the aortic valve. videotapes were then reviewed. it was elected to terminate the procedure at that point in time.,the vascular sheath was removed and manual compression carried out. excellent hemostasis was obtained. the patient tolerated the procedure without complication.,results of procedure,1. ,hemodynamics:, left ventricular end-diastolic filling pressure was 24. there was no gradient across the aortic valve.,2. ,left ventriculography: , left ventriculography demonstrated well-preserved left ventricular systolic function. mild inferobasilar hypokinesis was noted. no significant mitral regurgitation noted. ejection fraction was estimated at 60%.,3. ,coronary arteriography,a. ,left main coronary: , the left main coronary was patent.,b. ,left anterior descending coronary artery:, left anterior descending coronary was occluded shortly after a very small first septal perforator was given.,c. ,circumflex coronary artery:, circumflex coronary artery was occluded at its origin.,d. ,right coronary artery,. right coronary artery was occluded in its mid portion.,4. ,saphenous vein graft angiography,a. ,saphenous vein graft to the diagonal branch: , the saphenous vein graft to diagonal branch was widely patent at its origin and insertion sites. excellent flow was noted in the diagonal system with some retrograde flow.,b. there was retrograde flow as well in the left anterior descending system.,c. ,saphenous vein graft to the obtuse marginal system:, saphenous vein graft to the obtuse marginal system was widely patent at its origin and insertion sites. there was no graft disease noted. excellent flow was noted in the bifurcating marginal system.,d. ,saphenous vein graft to right coronary artery:, saphenous vein graft to right coronary was widely patent with no graft disease. origin and insertion sites were free of disease. distal flow in the graft to the posterior descending was normal.,5. ,left internal mammary artery angiography: , left internal mammary artery angiography demonstrated a widely patent left internal mammary at its origin and insertion sites. there was no focal disease noted, inserted into the mid-to-distal lad which was a small-caliber vessel. retrograde filling of a small septal system was noted.,summary of results,1. elevated left ventricular end-diastolic filling pressure with normal left ventricular systolic function and mild hypokinesis of inferobasilar segment.

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

preoperative diagnosis: ,bilateral undescended testes.,postoperative diagnosis: , bilateral undescended testes.,operation performed: , bilateral orchiopexy.,anesthesia: , general.,history: , this 8-year-old boy has been found to have a left inguinally situated undescended testes. ultrasound showed metastasis to be high in the left inguinal canal. the right testis is located in the right inguinal canal on ultrasound and apparently ultrasound could not be displaced into the right hemiscrotum. both testes appeared to be normal in size for the boy's age.,operative findings: , as above, both testes appeared viable and normal in size, no masses. there is a hernia on the left side. the spermatic cord was quite short on the left and required prentiss maneuver to achieve adequate length for scrotal placement.,operative procedure: , the boy was taken to the operating room, where he was placed on the operating table. general anesthesia was administered by dr. x, after which the boy's lower abdomen and genitalia were prepared with betadine and draped aseptically. a 0.25% marcaine was infiltrated subcutaneously in the skin crease in the left groin in the area of the intended incision. an inguinal incision was then made through this area, carried through the subcutaneous tissues to the anterior fascia. external ring was exposed with dissection as well. the fascia was opened in direction of its fibers exposing the testes, which lay high in the canal. the testes were freed with dissection by removing cremasteric and spermatic fascia. the hernia sac was separated from the cord, twisted and suture ligated at the internal ring. lateral investing bands of the spermatic cords were divided high into the inguinal internal ring. however, this would only allow placement of the testes in the upper scrotum with some tension.,therefore, the left inguinal canal was incised and the inferior epigastric artery and vein were ligated with #4-0 vicryl and divided. this maneuver allowed for placement of the testes in the upper scrotum without tension.,a sub dartos pouch was created by separating the abdominal fascia from the scrotal skin after making an incision in the left hemiscrotum in the direction of the vessel. the testes were then brought into the pouch and anchored with interrupted #4-0 vicryl sutures. the skin was approximated with interrupted #5-0 chromic catgut sutures. inspection of the spermatic cord in the inguinal area revealed no twisting and the testicular cover was good. internal oblique muscle was approximated to the shelving edge and poupart ligament with interrupted #4-0 vicryl over the spermatic cord and the external oblique fascia was closed with running #4-0 vicryl suture. additional 7 ml of marcaine was infiltrated subfascially and the skin was closed with running #5-0 subcuticular after placing several #4-0 vicryl approximating sutures in the subcutaneous tissues.,attention was then turned to the opposite side, where an orchiopexy was performed in a similar fashion. however, on this side, there was no inguinal hernia. the testes were located in a superficial pouch of the inguinal canal and there was adequate length on the spermatic cord, so that the prentiss maneuver was not required on this side. the sub dartos pouch was created in a similar fashion and the wounds were closed similarly as well.,the inguinal and scrotal incisions were cleansed after completion of the procedure. steri-strips and tegaderm were applied to the inguinal incisions and collodion to the scrotal incision. the child was then awakened and transported to post-anesthetic recovery area apparently in satisfactory condition. instrument and sponge counts were correct. there were no apparent complications. estimated blood loss was less than 20 to 30 ml.

operative procedure:,1. redo coronary bypass grafting x3, right and left internal mammary, left anterior descending, reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery. total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.,2. placement of a right femoral intraaortic balloon pump.,description: , the patient was brought to the operating room and placed in the supine position. after adequate endotracheal anesthesia was induced, appropriate monitoring lines were placed. chest, abdomen an legs were prepped and draped in sterile fashion. the femoral artery on the right was punctured and a guidewire was placed. the track was dilated and intraaortic balloon pump was placed in the appropriate position, sewn in place and ballooning started.,the left greater saphenous vein was harvested from the groin to the knee and prepared by ligating all branches with 4-0 silk and flushed with vein solution. the leg was closed with running 3-0 dexon subcu and running 4-0 dexon on the skin.,the old mediastinal incision was opened. the wires were cut and removed. the sternum was divided in the midline. retrosternal attachments were taken down. the left internal mammary was dissected free from its takeoff at the left subclavian bifurcation at the diaphragm and surrounded with papaverine-soaked gauze. the heart was dissected free of its adhesions. the patient was fully heparinized and cannulated with a single aorta and single venous cannula. retrograde cardioplegia cannula was attempted to be placed, but could not be fitted into the coronary sinus safely, therefore, it was banded and oversewn with 5-0 prolene. an antegrade cardioplegia needle sump was placed and secured to the ascending aorta. cardiopulmonary bypass ensued. the ascending aorta was cross clamped. cold-blood potassium cardioplegia was given antegrade, a total of 10 cc/kg. it was followed by sumping the ascending aorta. the obtuse marginal was identified and opened and an end-to-side anastomosis was performed with a running 7-0 prolene suture. the vein was cut to length. antegrade cardioplegia was given, a total of 200 cc. the posterior descending branch of the right coronary artery was identified, opened and end-to-side anastomosis then performed with a running 7-0 prolene suture. the vein was cut to length. antegrade cardioplegia was given. the mammary was clipped distally, divided and spatulated for anastomosis. the anterior descending was identified, opened and end-to-side anastomosis then performed with running 8-0 prolene suture and warm blood potassium cardioplegia was given. the cross clamp was removed. a partial-occlusion clamp was placed. aortotomies were made. the vein was cut to fit these and sutured in place with running 5-0 prolene suture. the partial-occlusion clamp was removed. all anastomoses were inspected and noted to be patent and dry. atrial and ventricular pacing wires were placed. the patient was fully warmed and ventilation was commenced. the patient was weaned from cardiopulmonary bypass, ventricular balloon pumping and inotropic support and weaned from cardiopulmonary bypass. the patient was decannulated in routine fashion. protamine was given. good hemostasis was noted. a single mediastinal chest tube and bilateral pleural blake drains were placed. the sternum was closed with figure-of-eight stainless steel wire. the linea alba was closed with figure-of-eight of #1 vicryl, the sternal fascia closed with running #1 vicryl, the subcu closed with running 2-0 dexon, skin with running 4-0 dexon subcuticular stitch. the patient tolerated the procedure well.

delivery note:, the patient is a 29-year-old gravida 6, para 2-1-2-3, who has had an estimated date of delivery at 01/05/2009. the patient presented to labor and delivery with complaints of spontaneous rupture of membranes at 2000 hours on 12/26/2008. she was found to be positive for nitrazine pull and fern. at that time, she was not actually contracting. she was group b streptococcus positive, however, was 5 cm dilated. the patient was started on group b streptococcus prophylaxis with ampicillin. she received a total of three doses throughout her labor. her pregnancy was complicated by scanty prenatal care. she would frequently miss visits. at 37 weeks, she claims that she had a suspicious bump on her left labia. there was apparently no fluid or blistering of the lesion. therefore, it was not cultured by the provider; however, the patient was sent for serum hsv antibody levels, which she tested positive for both hsv1 and hsv2. i performed a bright light exam and found no lesions anywhere on the vulva or in the vault as per sterile speculum exam and consulted with dr. x, who agreed that since the patient seems to have no active lesion that she likely has had a primary outbreak in the past and it is safe to proceed with the vaginal delivery. the patient requested an epidural anesthetic, which she received with very good relief. she had iv pitocin augmentation of labor and became completely dilated per my just routine exam just after 6 o'clock and was set up for delivery and the patient pushed very effectively for about one and a half contractions. she delivered a viable female infant on 12/27/2008 at 0626 hours delivering over an intact perineum. the baby delivered in the occiput anterior position. the baby was delivered to the mother's abdomen where she was warm, dry, and stimulated. the umbilical cord was doubly clamped and then cut. the baby's apgars were 8 and 9. the placenta was delivered spontaneously intact. there was a three-vessel cord with normal insertion. the fundus was massaged to firm and pitocin was administered through the iv per unit protocol. the perineum was inspected and was found to be fully intact. estimated blood loss was approximately 400 ml. the patient's blood type is a+. she is rubella immune and as previously mentioned, gbs positive and she received three doses of ampicillin.

chronic snoring,chronic snoring in children can be associated with obstructive sleep apnea or upper airway resistant syndrome. both conditions may lead to sleep fragmentation and/or intermittent oxygen desaturation, both of which have significant health implications including poor sleep quality and stress on the cardiovascular system. symptoms like daytime somnolence, fatigue, hyperactivity, behavior difficulty (i.e., adhd) and decreased school performance have been reported with these conditions. in addition, the most severe cases may be associated with right ventricular hypertrophy, pulmonary and/or systemic hypertension and even cor pulmonale.,in this patient, the risks for a sleep-disordered breathing include obesity and the tonsillar hypertrophy. it is therefore indicated and medically necessary to perform a polysomnogram for further evaluation. a two week sleep diary will be given to the parents to fill out daily before the polysomnogram is performed.

clear corneal temporal incision (no stitches),description of operation: , under satisfactory local anesthesia, the patient was appropriately prepped and draped. a lid speculum was placed in the fissure of the right eye.,the secondary incision was then made through clear cornea using 1-mm diamond keratome at surgeon's 7:30 position and the anterior chamber re-formed using viscoelastic. the primary incision was then made using a 3-mm diamond keratome at the surgeon's 5 o'clock position and additional viscoelastic injected into the anterior chamber as needed. the capsulorrhexis was then performed in a standard circular tear fashion. the nucleus was then separated from its cortical attachments by hydrodissection and emulsified in the capsular bag. the residual cortex was then aspirated from the bag and the bag re-expanded using viscoelastic. the posterior chamber intraocular lens was then inspected, irrigated, coated with healon and folded, and then placed into the capsular bag under direct visualization. the lens was noted to center well. the residual viscoelastic was then removed from the eye and the eye re-formed using balanced salt solution. the eye was then checked and found to be watertight; therefore, no suture was used. the lid speculum and the drapes were then removed and the eye treated with maxitrol ointment.,a shield was applied and the patient returned to the recovery room in good condition.

chief complaint:, not gaining weight.,history of present illness:, the patient is a 1-month-26-day-old african-american female in her normal state of health until today when she was taken to her primary care physician's office to establish care and to follow up on her feeds. the patient appeared to have failure-to-thrive. was only at her birth weight but when eating one may be possibly gaining 2 ounces every 3-4 hours, and was noted to have a murmur. at this point, the hospitalist service was contacted for admission. the patient was directly admitted to children's hospital explore ward.,in the explore ward, she was noted to be in mild respiratory distress and has some signs and symptoms of heart failure and had a prominent murmur, so an echo was done at bedside, which did show a moderately-sized patent ductus arteriosus and very small vsd and some mild signs and symptoms of congestive heart failure. the patient was also seen by dr. x of cardiology service and a plan was then obtained.,past medical/birth history: , the patient was born at term repeat c-section to a 27-year-old g3, p2 african-american female. pregnancy was not complicated by hypertension, diabetes, drugs, alcohol abuse or smoking. birthweight was 7 pounds 4 ounces at community hospital. the mother did have a repeat c-section. there is no rupture of membranes or group b strep status. the prenatal care began in the second month of pregnancy and was otherwise uncomplicated. mother denies any sexual transmitted diseases or other significant illness. the patient was discharged home on day of life #3 without any complications.,allergies:, no known drug allergies.,diet: , the patient only takes enfamil 20 calories, 1-3 ounces per history every 3-4 hours.,elimination: , the patient urinates 3-4 times a day and has a bowel movement 3-4 times a day.,family history/social history: , the patient lives with the mother. she has 2 older male siblings. all were reported good health. family history is negative for any congenital heart disease, syndromes, hypertension, sickle cell anemia or sickle cell trait and no significant positive ppd contacts and history of second-hand smoke exposures.,review of systems: ,general: the patient has been reported to have normal activity and normal cry with no significant weight loss per mom's report, but conversely no significant weight gain. mother does not report that she sweats whenever she eats or has any episodes of cyanosis. ,heent: denies any significant nasal congestion or cough. ,respiratory: denies any difficulty breathing or wheezing. ,cardiovascular: as per above. gi: no history of any persistent vomiting or diarrhea. ,gu: denies any decreased urinary output. ,musculoskeletal: negative. ,neurological: negative. ,skin: negative.,all other systems reviewed are negative.,physical examination:,general: the patient is examined in her room, our next floor. she is crying very vigorously, especially when i examined but she is consolable.,vital signs: temperature currently is 96.3, heart rate 137, respirations 36, blood pressure 105/61 while crying.,heent: normocephalic. the patient has a possible right temporoparietal bossing noted and slightly irregular shaped trapezoidal-shaped head. the anterior fontanelle is soft and flat. pupils are equal, reactive to light and accommodation, but there is some mild hypertelorism. there is also some mild posterior rotation of the ears. oropharynx, mucous membranes are pink and moist. there is a slightly high arched palate.,neck: significant for possible mild reddening of the neck.,lungs: significant for perihilar crackles. mild tachypnea is noted. o2 saturations are currently 97% on room air. there is mild intercostal retraction.,cardiovascular: heart has regular rate and rhythm. peripheral pulses are only 1+. capillary refills less than 3-4 seconds.,extremities: slightly cool to touch. there is 2-3/6 systolic murmur along the left sternal border. does radiate to the axilla and to the back.,abdomen: soft, slightly distended, but nontender. the liver edge is palpable 4 cm below right costal margin. the spleen tip is also palpable.,gu: normal female external genitalia is noted.,musculoskeletal: the patient has poor fat deposits in her extremities. strength is only 2/4. she had normal number of fingers and toes.,skin: significant for slight mottling. there are very poor subcutaneous fat deposits in her skin.,laboratory data: , the i-stat only shows sodium 135, potassium on a heel stick was 6.3, hemoglobin and hematocrit are 14 and 41, and white count was 1.4. cbg on i-stat showed the ph of 7.34 with co2 of 55, o2 sat of 51, co2 of 29 with the base excess of 4. chest x-ray shows bilateral infiltrates and significant cardiomegaly consistent with congenital heart disease and mild congestive heart failure.,assessment: , this is an almost 2-month-old presents with:,1. failure-to-thrive.,2. significant murmur and patent ductus arteriosus.,3. congestive heart failure.,plan: ,at present, we are going to admit and monitor closely tonight. we will get a chest x-ray and start lasix at 1 mg/kg twice daily. we will also get a cbc and check a blood culture and further workup as necessary.

cc:, found down.,hx:, 54y/o rhf went to bed at 10 pm at her boyfriend's home on 1/16/96. she was found lethargic by her son the next morning. three other individuals in the house were lethargic and complained of ha that same morning. her last memory was talking to her granddaughter at 5:00pm on 1/16/96. she next remembered riding in the ambulance from a hospital. initial carboxyhemoglobin level was 24% (normal < 1.5%) and abg 7.41/30/370 with o2sat 75% on 100%fio2.,meds:, unknown anxiolytic, estrogen.,pmh:, pud, ?stroke and memory difficulty in the past 1-2 years.,fhx:, unknown.,shx:, divorced. unknown history of tobacco/etoh/illicit drug use.,exam: ,bp126/91, hr86, rr 30, 37.1c.,ms:, oriented to name only. speech without dysarthria. 2/3 recall at 5minutes.,cn:, unremarkable.,motor: ,full strength throughout with normal muscle tone and bulk.,sensory: ,unremarkable.,coord/station:, unremarkable.,gait:, not tested on admission.,gen exam:, notable for erythema of the face and chest.,course:, she underwent a total of four dives under hyperbaric oxygen ( 2 dives on 1/17 and 2 dives on 1/18). neuropsychologic assessment on 1/18/96 revealed marked cognitive impairments with defects in anterograde memory, praxis, associative fluency, attention, and speed of information processing. she was discharged home on 1/19/96 and returned on 2/11/96 after neurologic deterioration. she progressively developed more illogical behavior, anhedonia, anorexia and changes in sleep pattern. she became completely dependent and could not undergo repeat neuropsychologic assessment in 2/96. she was later transferred to another care facility against medical advice. the etiology for these changes became complicated by a newly discovered history of possible etoh abuse and usual "anxiety" disorder.,mri brain, 2/14/96, revealed increased t2 signal within the periventricular white matter, bilaterally. eeg showed diffuse slowing without epileptiform activity.

past medical history: include:,1. type ii diabetes mellitus.,2. hypertension.,3. hyperlipidemia.,4. gastroesophageal reflux disease.,5. renal insufficiency.,6. degenerative joint disease, status post bilateral hip and bilateral knee replacements.,7. enterocutaneous fistula.,8. respiratory failure.,9. history of atrial fibrillation.,10. obstructive sleep apnea.,11. history of uterine cancer, status post total hysterectomy.,12. history of ventral hernia repair for incarcerated hernia.,social history: the patient has been admitted to multiple hospitals over the last several months.,family history: positive for diabetes mellitus type 2 in both mother and her sister.,medications: currently include,,1. albuterol inhaler q.4 h.,2. paradox swish and spit mouthwash twice a day.,3. digoxin 0.125 mg daily.,4. theophylline 50 mg q.6 h.,5. prozac 20 mg daily.,6. lasix 40 mg daily.,7. humulin regular high dose sliding scale insulin subcu. q.6 h.,8. atrovent q.4 h.,9. lantus 12 units subcu. q.12 h.,10. lisinopril 10 mg daily.,11. magnesium oxide 400 mg three times a day.,12. metoprolol 25 mg twice daily.,13. nitroglycerin topical q.6 h.,14. zegerid 40 mg daily.,15. simvastatin 10 mg daily.,allergies: percocet, percodan, oxycodone, and duragesic.,review of systems: the patient currently denies any pain, denies any headache or blurred vision. denies chest pain or shortness of breath. she denies any nausea or vomiting. otherwise, systems are negative.,physical exam:,general: the patient is awake, alert, and oriented. she is in no apparent respiratory distress.,vital signs: temperature 97.6, blood pressure is 139/53, pulse 100, respirations 24. the patient has a tracheostomy in place. she will also have an esophageal gastric tube in place.,cardiac: regular rate and rhythm without audible murmurs, rubs or gallops. lungs are clear to auscultation bilaterally with slightly diminished breath sounds on the bases. no adventitious sounds are noted.,abdomen: obese. there is an open wound on the ventral abdomen overlying the midline abdominal incision from previous surgery. the area is covered with bandage with serosanguineous fluid. abdomen is nontender to palpation. bowel sounds are heard in all 4 quadrants.,extremities: bilateral lower extremities are edematous and very cool to touch.,laboratory data: pending. capillary blood sugars thus far have been 132 and 135.,assessment: this is an 80-year-old female with an unfortunate past medical history with recent complications of sepsis and respiratory failure who is now receiving tube feeds.,plan: for her diabetes mellitus, we will continue the patient on her current regimen of lantus 12 units subcu. q.12 h. and regular insulin at a high dose sliding scale every 6 hours. the patient had been previously controlled on this. we will continue to check her sugars every 6 hours and adjust insulin as necessary.

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

preoperative diagnosis:, melena.,postoperative diagnosis:, solitary erosion over a fold at the ge junction, gastric side.,premedications: , versed 5 mg iv.,reported procedure:, the olympus gastroscope was used. the scope was placed in the upper esophagus under direct visit. the esophageal mucosa was entirely normal. there was no evidence of erosions or ulceration. there was no evidence of varices. the body and antrum of the stomach were normal. they pylorus duodenum bulb and descending duodenum are normal. there was no blood present within the stomach.,the scope was then brought back into the stomach and retroflexed in order to inspect the upper portion of the body of the stomach. when this was done, a prominent fold was seen lying along side the ge junction along with gastric side and there was a solitary erosion over this fold. the lesion was not bleeding. if this fold were in any other location of the stomach, i would consider the fold, but at this location, one would have to consider that this would be an isolated gastric varix. as such, the erosion may be more significant. there was no bleeding. obviously, no manipulation of the lesion was undertaken. the scope was then straightened, withdrawn, and the procedure terminated.,endoscopic impression:,1. solitary erosion overlying a prominent fold at the gastroesophageal junction, gastric side – may simply be an erosion or may be an erosion over a varix.,2. otherwise unremarkable endoscopy - no evidence of a bleeding lesion of the stomach.,plan:,1. liver profile today.,2. being nexium 40 mg a day.,3. scheduled colonoscopy for next week.

ct head without contrast and ct cervical spine without contrast,reason for exam: , motor vehicle collision.,ct head without contrast,technique:, noncontrast axial ct images of the head were obtained.,findings: , there is no acute intracranial hemorrhage, mass effect, midline shift, or extra-axial fluid collection. the ventricles and cortical sulci are normal in shape and configuration. the gray/white matter junctions are well preserved. there is no calvarial fracture. the visualized paranasal sinuses and mastoid air cells are clear.,impression: , negative for acute intracranial disease.,ct cervical spine,technique: ,noncontrast axial ct images of the cervical spine were obtained. sagittal and coronal images were obtained.,findings:, straightening of the normal cervical lordosis is compatible with patient position versus muscle spasms. no fracture or subluxation is seen. anterior and posterior osteophyte formation is seen at c5-c6. no abnormal anterior cervical soft tissue swelling is seen. no spinal compression is noted. the atlanto-dens interval is normal. there is a large retention cyst versus polyp within the right maxillary sinus.,impression:,1. straightening of the normal cervical lordosis compatible with patient positioning versus muscle spasms.,2. degenerative disk and joint disease at c5-c6.,3. retention cyst versus polyp of the right maxillary sinus.