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subjective:, the patient is in with several medical problems. she complains of numbness, tingling, and a pain in the toes primarily of her right foot described as a moderate pain. she initially describes it as a sharp quality pain, but is unable to characterize it more fully. she has had it for about a year, but seems to be worsening. she has little bit of paraesthesias in the left toe as well and seem to involve all the toes of the right foot. they are not worse with walking. it seems to be worse when she is in bed. there is some radiation of the pain up her leg. she also continues to have bilateral shoulder pains without sinus allergies. she has hypothyroidism. she has thrombocythemia, insomnia, and hypertension.,past medical history:, surgeries include appendectomy in 1933, bladder obstruction surgery in 1946, gallbladder surgery in 1949, another gallbladder surgery in 1954, c-section in 1951, varicose vein surgery in 1951 and again in 1991, thyroid gland surgery in 1964, hernia surgery in 1967, bilateral mastectomies in 1968 for benign disease, hysterectomy leaving her ovaries behind in 1970, right shoulder surgery x 4 and left shoulder surgery x 2 between 1976 and 1991, and laparoscopic bowel adhesion removal in october 2002. she had a port-a-cath placed in june 2003, left total knee arthroplasty in june 2003, and left hip pinning due to fracture in october 2003, with pins removed in may 2004. she has had a number of colonoscopies; next one is being scheduled at the end of this month. she also had a right total knee arthroplasty in 1993. she was hospitalized for synovitis of the left knee in april 2004, for zoster and infection of the left knee in may 2003, and for labyrinthitis in june 2004.,allergies: , sulfa, aspirin, darvon, codeine, nsaid, amoxicillin, and quinine.,current medications:, hydroxyurea 500 mg daily, metamucil three teaspoons daily, amitriptyline 50 mg at h.s., synthroid 0.1 mg daily, ambien 5 mg at h.s., triamterene/hydrochlorothiazide 75/50 daily, and lortab 5/500 at h.s. p.r.n.,social history:, she is a nonsmoker and nondrinker. she has been widowed for 18 years. she lives alone at home. she is retired from running a restaurant.,family history:, mother died at age 79 of a stroke. father died at age 91 of old age. her brother had prostate cancer. she has one brother living. no family history of heart disease or diabetes.,review of systems:,general: negative.,heent: she does complain of some allergies, sneezing, and sore throat. she wears glasses.,pulmonary history: she has bit of a cough with her allergies.,cardiovascular history: negative for chest pain or palpitations. she does have hypertension.,gi history: negative for abdominal pain or blood in the stool.,gu history: negative for dysuria or frequency. she empties okay.,neurologic history: positive for paresthesias to the toes of both feet, worse on the right.,musculoskeletal history: positive for shoulder pain.,psychiatric history: positive for insomnia.,dermatologic history: positive for a spot on her right cheek, which she was afraid was a precancerous condition.,metabolic history: she has hypothyroidism.,hematologic history: positive for essential thrombocythemia and anemia.,objective:,general: she is a well-developed, well-nourished, elderly female in no acute distress.,vital signs: her age is 81. temperature: 98.0. blood pressure: 140/70. pulse: 72. weight: 127.,heent: head was normocephalic. pupils equal, round, and reactive to light. extraocular movements are intact. fundi are benign. tms, nares, and throat were clear.,neck: supple without adenopathy or thyromegaly.,lungs: clear.,heart: regular rate and rhythm without murmur, click, or rub. no carotid bruits are heard.,abdomen: normal bowel sounds. it is soft and nontender without hepatosplenomegaly or mass.,breasts: surgically absent. no chest wall mass was noted, except for the port-a-cath in the left chest. no axillary adenopathy is noted.,extremities: examination of the extremities reveals no ankle edema or calf tenderness x 2 in lower extremities. there is a cyst on the anterior portion of the right ankle. pedal pulses were present.,neurologic: cranial nerves ii-xii grossly intact and symmetric. deep tendon reflexes were 1 to 2+ bilaterally at the knees. no focal neurologic deficits were observed.,pelvic: bus and external genitalia were atrophic. vaginal rugae were atrophic. cervix was surgically absent. bimanual exam confirmed the absence of uterus and cervix and i could not palpate any ovaries.,rectal: exam confirmed there is brown stool present in the rectal vault.,skin: clear other than actinic keratosis on the right cheek.,psychiatric: affect is normal.,assessment:,1. peripheral neuropathy primarily of the right foot.,2. hypertension.,3. hypothyroidism.,4. essential thrombocythemia.,5. allergic rhinitis.,6. insomnia.,plan:

preoperative diagnosis: , tremor, dystonic form.,postoperative diagnosis: , tremor, dystonic form.,complications: , none.,estimated blood loss: , less than 100 ml.,anesthesia:, mac (monitored anesthesia care) with local anesthesia.,title of procedures:,1. left frontal craniotomy for placement of deep brain stimulator electrode.,2. right frontal craniotomy for placement of deep brain stimulator electrode.,3. microelectrode recording of deep brain structures.,4. stereotactic volumetric ct scan of head for target coordinate determination.,5. intraoperative programming and assessment of device.,indications: ,the patient is a 61-year-old woman with a history of dystonic tremor. the movements have been refractory to aggressive medical measures, felt to be candidate for deep brain stimulation. the procedure is discussed below.,i have discussed with the patient in great deal the risks, benefits, and alternatives. she fully accepted and consented to the procedure.,procedure in detail:, the patient was brought to the holding area and to the operating room in stable condition. she was placed on the operating table in seated position. her head was shaved. scalp was prepped with betadine and a leksell frame was mounted after anesthetizing the pin sites with a 50:50 mixture of 0.5% marcaine and 2% lidocaine in all planes. iv antibiotics were administered as was the sedation. she was then transported to the ct scan and stereotactic volumetric ct scan of the head was undertaken. the images were then transported to the surgery planned work station where a 3-d reconstruction was performed and the target coordinates were then chosen. target coordinates chosen were 20 mm to the left of the ac-pc midpoint, 3 mm anterior to the ac-pc midpoint, and 4 mm below the ac-pc midpoint. each coordinate was then transported to the operating room as leksell coordinates.,the patient was then placed on the operating table in a seated position once again. foley catheter was placed, and she was secured to the table using the mayfield unit. at this point then the patient's right frontal and left parietal bossings were cleaned, shaved, and sterilized using betadine soap and paint in scrubbing fashion for 10 minutes. sterile drapes placed around the perimeter of the field. this same scalp region was then anesthetized with same local anesthetic mixture.,a bifrontal incision was made as well as curvilinear incision was made over the parietal bossings. bur holes were created on either side of the midline just behind the coronal suture. hemostasis was controlled using bipolar and bovie, and self-retaining retractors had been placed in the field. using the drill, then two small grooves were cut in the frontal bone with a 5-mm cutting burs and stryker drill. the bur holes were then curetted free, the dura cauterized, and then opened in a cruciate manner on both sides with a #11 blade. the cortical surface was then nicked with a #11 blade on both sides as well. the leksell arc with right-sided coordinate was dialed in, was then secured to the frame. microelectrode drive was secured to the arc. microelectrode recording was then performed. the signatures of the cells were recognized. microelectrode unit was removed. deep brain stimulating electrode holding unit was mounted. the dbs electrode was then loaded into target and intraoperative programming and testing was performed. using the screener box and standard parameters, the patient experienced some relief of symptoms on her left side. this electrode was secured in position using bur-hole ring and cap system.,attention was then turned to the left side, where left-sided coordinates were dialed into the system. the microelectrode unit was then remounted. microelectrode recording was then undertaken. after multiple passes, the microelectrode unit was removed. deep brain stimulator electrode holding unit was mounted at the desired trajectory. the dbs electrode was loaded into target, and intraoperative programming and testing was performed once again using the screener box. using standard parameters, the patient experienced similar results on her right side. this electrode was secured using bur-hole ring and cap system. the arc was then removed. a subgaleal tunnel was created between the two incisions whereby distal aspect of the electrodes led through this tunnel.,we then closed the electrode, replaced subgaleally. copious amounts of betadine irrigation were used. hemostasis was controlled using the bipolar only. closure was instituted using 3-0 vicryl in a simple interrupted fashion for the fascial layer followed by skin closure with staples. sterile dressings were applied. the leksell arc was then removed.,she was rotated into the supine position and transported to the recovery room in stable and satisfactory condition. all needle, sponge, cottonoid, and blade counts were correct x2 as verified by the nurses.

reason for consultation:, chest pain.,history of present illness: , the patient is a 37-year-old gentleman admitted through emergency room. he presented with symptoms of chest pain, described as a pressure-type dull ache and discomfort in the precordial region. also, shortness of breath is noted without any diaphoresis. symptoms on and off for the last 3 to 4 days especially when he is under stress. no relation to exertional activity. no aggravating or relieving factors. his history is significant as mentioned below. his workup so far has been negative.,coronary risk factors:, no history of hypertension or diabetes mellitus. active smoker. cholesterol status, borderline elevated. no history of established coronary artery disease. family history positive.,family history: , his father died of coronary artery disease.,surgical history: , no major surgery except for prior cardiac catheterization.,medications at home:, includes pravastatin, paxil, and buspar.,allergies:, none.,social history: , active smoker. does not consume alcohol. no history of recreational drug use.,past medical history: , hyperlipidemia, smoking history, and chest pain. he has been, in october of last year, hospitalized. subsequently underwent cardiac catheterization. the left system was normal. there was a question of a right coronary artery lesion, which was thought to be spasm. subsequently, the patient did undergo nuclear and myocardial perfusion scan, which was normal. the patient continues to smoke actively since in last 3 to 4 days especially when he is stressed. no relation to exertional activity.,review of systems:,constitutional: no history of fever, rigors, or chills.,heent: no history of cataract, blurring vision, or glaucoma.,cardiovascular: as above.,respiratory: shortness of breath. no pneumonia or valley fever.,gastrointestinal: no epigastric discomfort, hematemesis, or melena.,urological: no frequency or urgency.,musculoskeletal: no arthritis or muscle weakness.,cns: no tia. no cva. no seizure disorder.,endocrine: nonsignificant.,hematological: nonsignificant.,physical examination:,vital signs: pulse of 75, blood pressure of 112/62, afebrile, and respiratory rate 16 per minute.,heent: head is atraumatic and normocephalic. neck veins flat.,lungs: clear.,heart: s1 and s2, regular.,abdomen: soft and nontender.,extremities: no edema. pulses palpable. no clubbing or cyanosis.,cns: benign.,psychological: normal.,musculoskeletal: within normal limits.,diagnostic data: , ekg, normal sinus rhythm. chest x-ray unremarkable.,laboratory data: , first set of cardiac enzyme profile negative. h&h stable. bun and creatinine within normal limits.,impression:,1. chest pain in a 37-year-old gentleman with negative cardiac workup as mentioned above, questionably right coronary spasm.,2. hyperlipidemia.,3. negative ekg and cardiac enzyme profile.,recommendations:

cc:, memory difficulty.,hx: ,this 64 y/o rhm had had difficulty remembering names, phone numbers and events for 12 months prior to presentation, on 2/28/95. this had been called to his attention by the clerical staff at his parish--he was a catholic priest. he had had no professional or social faux pas or mishaps due to his memory. he could not tell whether his problem was becoming worse, so he brought himself to the neurology clinic on his own referral.,meds:, none.,pmh: ,1)appendectomy, 2)tonsillectomy, 3)childhood pneumonia, 4)allergy to sulfa drugs.,fhx:, both parents experienced memory problems in their ninth decades, but not earlier. 5 siblings have had no memory trouble. there are no neurological illnesses in his family.,shx:, catholic priest. denied tobacco/etoh/illicit drug use.,exam:, bp131/74, hr78, rr12, 36.9c, wt. 77kg, ht. 178cm.,ms: a&o to person, place and time. 29/30 on mmse; 2/3 recall at 5 minutes. 2/10 word recall at 10 minutes. unable to remember the name of the president (clinton). 23words/60 sec on category fluency testing (normal). mild visual constructive deficit.,the rest of the neurologic exam was unremarkable and there were no extrapyramidal signs or primitive reflexes noted.,course:, tsh 5.1, t4 7.9, rpr non-reactive. neuropsychological evaluation, 3/6/95, revealed: 1)well preserved intellectual functioning and orientation, 2) significant deficits in verbal and visual memory, proper naming, category fluency and working memory, 3)performances which were below expectations on tests of speed of reading, visual scanning, visual construction and clock drawing, 4)limited insight into the scope and magnitude of cognitive dysfunction. the findings indicated multiple areas of cerebral dysfunction. with the exception of the patient's report of minimal occupational dysfunction ( which may reflect poor insight), the clinical picture is consistent with a progressive dementia syndrome such as alzheimer's disease. mri brain, 3/6/95, showed mild generalized atrophy, more severe in the occipital-parietal regions.,in 4/96, his performance on repeat neuropsychological evaluation was relatively stable. his verbal learning and delayed recognition were within normal limits, whereas delayed recall was "moderately severely" impaired. immediate and delayed visual memory were slightly below expectations. temporal orientation and expressive language skills were below expectation, especially in word retrieval. these findings were suggestive of particular, but not exclusive, involvement of the temporal lobes.,on 9/30/96, he was evaluated for a 5 minute spell of visual loss, ou. the episode occurred on friday, 9/27/96, in the morning while sitting at his desk doing paperwork. he suddenly felt that his gaze was pulled toward a pile of letters; then a "curtain" came down over both visual fields, like "everything was in the shade." during the episode he felt fully alert and aware of his surroundings. he concurrently heard a "grating sound" in his head. after the episode, he made several phone calls, during which he reportedly sounded confused, and perseverated about opening a bank account. he then drove to visit his sister in muscatine, iowa, without accident. he was reportedly "normal" when he reached her house. he was able to perform mass over the weekend without any difficulty. neurologic examination, 9/30/96, was notable for: 1)category fluency score of 18items/60 sec. 2)vfftc and eom were intact. there was no rapd, ino, loss of visual acuity. glucose 178 (elevated), esr ,lipid profile, gs, cbc with differential, carotid duplex scan, ekg, and eeg were all normal. mri brain, 9/30/96, was unchanged from previous, 3/6/95.,on 1/3/97, he had a 30 second spell of lightheadedness without vertigo, but with balance difficulty, after picking up a box of books. the episode was felt due to orthostatic changes.,1/8/97 neuropsychological evaluation was stable and his mmse score was 25/30 (with deficits in visual construction, orientation, and 2/3 recall at 1 minute). category fluency score 23 items/60 sec. neurologic exam was notable for graphesthesia in the left hand.,in 2/97, he had episodes of anxiety, marked fluctuations in job performance and resigned his pastoral position. his neurologic exam was unchanged. an fdg-pet scan on 2/14/97 revealed decreased uptake in the right posterior temporal-parietal and lateral occipital regions.

preoperative diagnosis:, a 60% total body surface area flame burns, status post multiple prior excisions and staged graftings.,postoperative diagnosis:, a 60% total body surface area flame burns, status post multiple prior excisions and staged graftings.,procedures performed:,1. epidermal autograft on integra to the back (3520 cm2).,2. application of allograft to areas of the lost integra, not grafted on the back (970 cm2).,anesthesia: , general endotracheal.,estimated blood loss:, approximately 50 cc.,blood products received:, one unit of packed red blood cells.,complications: , none.,indications: , the patient is a 26-year-old male, who sustained a 60% total body surface area flame burn involving the head, face, neck, chest, abdomen, back, bilateral upper extremities, hands, and bilateral lower extremities. he has previously undergone total burn excision with placement of integra and an initial round of epidermal autografting to the bilateral upper extremities and hands. his donor sites have healed particularly over his buttocks and he returns for a second round of epidermal autografting over the integra on his back utilizing the buttock donor sites, the extent they will provide coverage.,operative findings:,1. variable take of integra, particularly centrally and inferiorly on the back. a fair amount of lost integra over the upper back and shoulders.,2. no evidence of infection.,3. healthy viable wound beds prior to grafting.,procedure in detail:, the patient was brought to the operating room and positioned supine. general endotracheal anesthesia was uneventfully induced and an appropriate time out was performed. he was then repositioned prone and perioperative iv antibiotics were administered. he was prepped and draped in the usual sterile manner. all staples were removed from the integra and the adherent areas of silastic were removed. the entire wound bed was further prepped with scrub brushes and more betadine followed by a sulfamylon solution. hemostasis of the wound bed was ensured using epinephrine-soaked telfa pads. following dermal tumescence of the buttocks, epidermal autografts were harvested 8 one-thousandths of an inch using the air zimmer dermatome. these grafts were passed to the back table where they were meshed 3:1. the donor sites were hemostased using epinephrine-soaked telfa and lap pads. once all the grafts were meshed, we brought them back up onto the field, positioned them over the wounds beginning inferiorly and moving cephalad where we had best areas of integra engraftment. we were happy with the lie of the grafts and they were stapled into place. the grafts were then overlaid with conformant 2, which was also stapled into place. utilizing all of his buttocks skin, we did not have enough to cover his entire back, so we elected to apply allograft to the cephalad and a few areas on his flanks where we had had poor integra engraftment. allograft was thawed and meshed 1:1. it was then brought up onto the field, trimmed to fit and stapled into place over the wound. once the entirety of the posterior wounds on his back were covered out with epidermal autograft or allograft sulfamylon soaked dressings were applied. donor sites on his buttocks were dressed in acticoat and secured with staples. he was then repositioned supine and extubated in the operating room having tolerated the procedure without any apparent complications. he was transported to pacu in stable condition.

preoperative diagnoses:,1. painful enlarged navicula, right foot.,2. osteochondroma of right fifth metatarsal.,postoperative diagnoses:,1. painful enlarged navicula, right foot.,2. osteochondroma of right fifth metatarsal.,procedure performed:,1. partial tarsectomy navicula, right foot.,2. partial metatarsectomy, right foot.,history: ,this 41-year-old caucasian female who presents to abcd general hospital with the above chief complaint. the patient states that she has extreme pain over the navicular bone with shoe gear as well as history of multiple osteochondromas of unknown origin. she states that she has been diagnosed with hereditary osteochondromas. she has had previous dissection of osteochondromas in the past and currently has not been diagnosed in her feet as well as spine and back. the patient desires surgical treatment at this time.,procedure: ,an iv was instituted by the department of anesthesia in the preoperative holding area. the patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap. copious amounts of webril were placed on the left ankle followed by a blood pressure cuff. after adequate sedation by the department of anesthesia, a total of 5 cc of 1:1 mixture of 1% lidocaine plain and 0.5% marcaine plain were injected in the diamond block type fashion around the navicular bone as well as the fifth metatarsal. foot was then prepped and draped in the usual sterile orthopedic fashion.,foot was elevated from the operating table and exsanguinated with an esmarch bandage. the pneumatic ankle tourniquet was then inflated to 250 mmhg. the foot was lowered as well as the operating table. the sterile stockinet was reflected and the foot was cleansed with wet and dry sponge. attention was then directed to the navicular region on the right foot. the area was palpated until the bony prominence was noted. a curvilinear incision was made over the area of bony prominence. at that time, a total of 10 cc with addition of 1% additional lidocaine plain was injected into the surgical site. the incision was then deepened with #15 blade. all vessels encountered were ligated for hemostasis. the dissection was carried down to the level of the capsule and periosteum. a linear incision was made over the navicular bone obliquely from proximal dorsal to distal plantar over the navicular bone. the periosteum and the capsule were then reflected from the navicular bone at this time. a bony prominence was noted both medially and plantarly to the navicular bone. an osteotome and mallet were then used to resect the enlarged portion of the navicular bone. after resection with an osteotome there was noted to be a large plantar shelf. the surrounding soft tissues were then freed from this plantar area. care was taken to protect the attachments of the posterior tibial tendon as much as possible. only minimal resection of its attachment to the fiber was performed in order to expose the bone. sagittal saw was then used to resect the remaining plantar medial prominent bone. the area was then smoothed with reciprocating rasp until no sharp edges were noted. the area was flushed with copious amount of sterile saline at which time there was noted to be a palpable ________ where the previous bony prominence had been noted. the area was then again flushed with copious amounts of sterile saline and the capsule and periosteum were then reapproximated with #3-0 vicryl. the subcutaneous tissues were then reapproximated with #4-0 vicryl to reduce tension from the incision and running #5-0 vicryl subcuticular stitch was performed.,attention was then directed to the fifth metatarsal. there was noted to be a palpable bony prominence dorsally with fifth metatarsal head as well as radiographic evidence laterally of an osteochondroma at the neck of the fifth metatarsal. approximately 7 cm incision was made dorsolaterally over the fifth metatarsal. the incision was then deepened with #15 blade. care was taken to preserve the extensor tendon. the incision was then created over the capsule and periosteum of the fifth metatarsal head. capsule and periosteum were reflected both dorsally, laterally, and plantarly. at that time, there was noted to be a visible osteochondroma on the plantar lateral aspect of the fifth metatarsal neck as well as on the dorsal aspect of the head of the fifth metatarsal. a sagittal saw was used to resect both of these osteal prominences.,all remaining sharp edges were then smoothed with reciprocating rasp. the area was inspected for the remaining bony prominences and none was noted. the area was flushed with copious amounts of sterile saline. the capsule and periosteum were then reapproximated with #3-0 vicryl. subcutaneous closure was then performed with #4-0 vicryl in order to reduce tension around the incision line. running #5-0 subcutaneous stitch was then performed. steri-strips were applied to both surgical sites. dressings consisted of adaptic, soaked in betadine, 4x4s, kling, kerlix, and coban. the pneumatic ankle tourniquet was released and the hyperemic flush was noted to all five digits of the right foot.,the patient tolerated the above procedure and anesthesia well without complications. the patient was transferred to the pacu with vital signs stable and vascular status intact. the patient was given postoperative pain prescription and instructed to be partially weightbearing with crutches as tolerated. the patient is to follow-up with dr. x in his office as directed or sooner if any problems or questions arise.

chief complaint:, well-child check.,history of present illness:, this is a 12-month-old female here with her mother for a well-child check. mother states she has been doing well. she is concerned about drainage from her left eye. mother states she was diagnosed with a blocked tear duct on that side shortly after birth, and normally she has crusted secretions every morning. she states it is worse when the child gets a cold. she has been using massaging when she can remember to do so. the patient is drinking whole milk without problems. she is using solid foods three times a day. she sleeps well without problems. her bowel movements are regular without problems. she does not attend daycare.,developmental assessment:, social: she can feed herself with fingers. she is comforted by parent’s touch. she is able to separate and explore. fine motor: she scribbles. she has a pincer grasp. she can drink from a cup. language: she says dada. she says one to two other words and she indicates her wants. gross motor: she can stand alone. she cruises. she walks alone. she stoops and recovers.,physical examination:,general: she is alert, in no distress.,vital signs: weight: 25th percentile. height: 25th percentile. head circumference: 50th percentile.,heent: normocephalic, atraumatic. pupils are equal, round, and reactive to light. left eye with watery secretions and crusted lashes. conjunctiva is clear. tms are clear bilaterally. nares are patent. mild nasal congestion present. oropharynx is clear.,neck: supple.,lungs: clear to auscultation.,heart: regular. no murmur.,abdomen: soft. positive bowel sounds. no masses. no hepatosplenomegaly.,gu: female external genitalia.,extremities: symmetrical. femoral pulses are 2+ bilaterally. full range of motion of all extremities.,neurologic: grossly intact.,skin: normal turgor.,testing: hearing and vision assessments grossly normal.,assessment:,1. well child.,2. left lacrimal duct stenosis.,plan:, mmr #1 and varivax #1 today. vis statements given to mother after discussion. evaluation and treatment as needed with dr. xyz with respect to the blocked tear duct. anticipatory guidance for age. she is to return to the office in three months.

history of present illness:, the patient is a 43-year-old male who was recently discharged from our care on the 1/13/06 when he presented for shortness of breath. he has a past history of known hyperthyroidism since 1992 and a more recent history of atrial fibrillation and congestive cardiac failure with an ejection fraction of 20%-25%. the main cause for his shortness of breath was believed to be due to atrial fibrillation secondary to hyperthyroidism in a setting with congestive cardiac failure. during his hospital stay, he was commenced on metoprolol for rate control, and given that he had atrial fibrillation, he was also started on warfarin, which his inr has been followed up by the homeless clinic. for his congestive cardiac failure, he was restarted on digoxin and lisinopril. for his hyperthyroidism, we restarted him on ptu and the endocrinologists were happy to review him when he was euthymic to discuss further radioiodine or radiotherapy. he was restarted on ptu and discharged from the hospital on this medication. while in the hospital, it was also noted that he abused cigarettes and cocaine, and we advised strongly against this given the condition of his heart. it was also noted that he had elevated liver function tests, which an ultrasound was normal, but his hepatitis panel was pending. since his discharge, his hepatitis panel has come back normal for hepatitis a, b, and c. since discharge, the patient has complained of shortness of breath, mainly at night when lying flat, but otherwise he states he has been well and compliant with his medication.,medications:, digoxin 250 mcg daily, lisinopril 5 mg daily, metoprolol 50 mg twice daily, ptu (propylthiouracil) 300 mg orally four times a day, warfarin variable dose based on inr.,physical examination:,vital signs: he was afebrile today. blood pressure 114/98. pulse 92 but irregular. respiratory rate 25.,heent: obvious exophthalmus, but no obvious lid lag today.,neck: there was no thyroid mass palpable.,chest: clear except for occasional bibasilar crackles.,cardiovascular: heart sounds were dual, but irregular, with no additional sounds.,abdomen: soft, nontender, nondistended.,extremities: mild +1 peripheral edema in both legs.,plan:, the patient has also been attending the homeless clinic since discharge from the hospital, where he has been receiving quality care and they have been looking after every aspect of his health, including his hyperthyroidism. it is our recommendation that a tsh and t4 be continually checked until the patient is euthymic, at which time he should attend endocrine review with dr. huffman for further treatment of his hyperthyroidism. regarding his atrial fibrillation, he is moderately rate controlled with metoprolol 50 mg b.i.d. his rate in clinic today was 92. he could benefit from increasing his metoprolol dose, however, in the hospital it was noted that he was bradycardic in the morning with a pulse rate down to the 50s, and we were concerned with making this patient bradycardic in the setting of congestive cardiac failure. regarding his congestive cardiac failure, he currently appears stable, with some variation in his weight. he states he has been taking his wife's lasix tablets for diuretic benefit when he feels weight gain coming on and increased edema. we should consider adding him on a low-dose furosemide tablet to be taken either daily or when his weight is above his target range. a digoxin level has not been repeated since discharge, and we feel that this should be followed up. we have also increased his lisinopril to 5 mg daily, but the patient did not receive his script upon departing our clinic. regarding his elevated liver function tests, we feel that these are very likely secondary to hepatic congestion secondary to congestive cardiac failure with a normal ultrasound and normal hepatitis panel, but yet the liver function tests should be followed up.

preoperative diagnosis:, left thyroid mass.,postoperative diagnosis:, left thyroid mass.,procedure performed:, left total thyroid lumpectomy.,anesthesia,: general endotracheal.,estimated blood loss: , less than 50 cc.,complications:, none.,indications for procedure:, the patient is a 76-year-old caucasian female with a history of a left thyroid mass nodule that was confirmed with ct scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole. the patient was then discussed the risks, complications, and consequences of a surgical procedure and a written consent was obtained.,procedure: ,the patient is brought to the operative suite by anesthesia. the patient was placed on the operative table in supine position. after this, the patient was placed under general endotracheal intubation anesthesia and the patient was then placed upon a shoulder roll. after this, the skin incision was marked approximately two fingerbreadths above the sternal notch. it was then localized with 1% lidocaine with epinephrine 1:1000 approximately 7 cc total.,after this, the patient was then prepped and draped in the usual sterile fashion and a #10 blade was then utilized to make a skin incision. the subcutaneous tissue was then bluntly dissected utilizing a ray-tec sponge and a bear claw was then utilized to retract the upper incisional skin with counter retraction performed to allow a subplatysmal plane of skin flaps to be performed in superior and inferolateral directions. after this, the midline was then identified and grasped on either side with a debakey forceps. the raphe was noted and bovie cauterization was utilized to cut down into this region. the fine stats were utilized to further open this area with exposure and bisection of the sternothyroid muscle. it was separated on the left side from the patient's sternothyroid muscle. after this, the sternothyroid muscle was identified, grasped with the debakey forceps and infiltrated initially through its fascial plane with the metzenbaum scissors. blunt dissection was then utilized to free the sternothyroid muscle from the thyroid gland in superior and inferior directions and laterally with the help of kitners. after this, the plane was rotated more anteriorly with the superior and inferior parathyroid glands identified. the fat cap was noted to be attached on the superior parathyroid to the posterior aspect of the thyroid itself. it was freed from the thyroid gland and reflected laterally and posteriorly. the inferior parathyroid gland actually appeared to be attached also to the inferior aspect of the thyroid itself and was reflected laterally. after this, the patient's thyroid gland was palpated noting a thyroid nodule in the posterior inferior aspect along with the calcification laterally. the nodule appeared to be sort of rubbery in consistency and approximately 1 cm diameter. as the gland was rotated more anteriorly, the recurrent laryngeal nerve on the left side was identified and further dissection along berry's ligament on the medial aspect was performed. the middle thyroid vein and inferior thyroid artery were both cauterized with a bipolar cautery and bisected. after this, the gland was easily rotated anteriorly with further dissection carried up to the superior pole. the superior pole was exposed with the help of a richardson and army-navy retractors with cross-clamping and tying of the superior laryngeal artery and vein. further, the small bleeding vessels were identified and bipolared, and cut with the metzenbaum scissors. the superior pole was finally freed and the gland was rotated more anteriorly onto the anterior aspect of the trachea. berry's ligament was finally freed and the gland was cross-clamped on the opposing thyroid isthmus with a mosquito. after this, the gland was cut with a metzenbaum scissors and tied with a #3-0 undyed vicryl tie. the defect on the neck now was thoroughly irrigated with normal saline solution and further bleeding was controlled with bipolar cauterization. surgicel was then cut in small strips and three replaced in the lateral part of the neck.,the opposing side of the thyroid gland on the right was palpated with no noticeable nodules or masses. the strap muscles were then reapproximated with #3-0 vicryl on a sh, followed by reapproximation of the subcutaneous tissue with #4-0 vicryl, followed by reapproximation of the skin by running subcuticular #5-0 prolene and a #6-0 fast absorbing gut. mastisol, steri-strips, and bacitracin were placed followed by a sterile 4 x 4 dressing. the patient was then turned back to anesthesia, extubated in the operating room, and transferred to recovery in stable condition. the patient tolerated the procedure well and will be admitted to hospital for 23-hour observation and will be followed up in one week afterwards.

procedure: , elective male sterilization via bilateral vasectomy.,preoperative diagnosis: ,fertile male with completed family.,postoperative diagnosis:, fertile male with completed family.,medications: ,anesthesia is local with conscious sedation.,complications: , none.,blood loss: , minimal.,indications: ,this 34-year-old gentleman has come to the office requesting sterilization via bilateral vasectomy. i discussed the indications and the need for procedure with the patient in detail, and he has given consent to proceed. he has been given prophylactic antibiotics.,procedure note: , once satisfactory sedation have been obtained, the patient was placed in the supine position on the operating table. genitalia was shaved and then prepped with betadine scrub and paint solution and were draped sterilely. the procedure itself was started by grasping the right vas deferens in the scrotum, and bringing it up to the level of the skin. the skin was infiltrated with 2% xylocaine and punctured with a sharp hemostat to identify the vas beneath. the vas was brought out of the incision carefully. a 2-inch segment was isolated, and 1-inch segment was removed. the free ends were cauterized and were tied with 2-0 silk sutures in such a fashion that the ends double back on themselves. after securing hemostasis with a cautery, the ends were allowed to drop back into the incision, which was also cauterized.,attention was now turned to the left side. the vas was grasped and brought up to the level of the skin. the skin was infiltrated with 2% xylocaine and punctured with a sharp hemostat to identify the vas beneath. the vas was brought out of the incision carefully. a 2-inch segment was isolated, and 1-inch segment was removed. the free ends were cauterized and tied with 2-0 silk sutures in such a fashion that the ends double back on themselves. after securing hemostasis with the cautery, the ends were allowed to drop back into the incision, which was also cauterized.,bacitracin ointment was applied as well as dry sterile dressing. the patient was awakened and was returned to recovery in satisfactory condition.

preoperative diagnoses:,1. ischemic cardiomyopathy.,2. status post redo coronary artery bypass.,3. status post insertion of intraaortic balloon.,postoperative diagnoses:,1. ischemic cardiomyopathy.,2. status post redo coronary artery bypass.,3. status post insertion of intraaortic balloon.,4. postoperative coagulopathy.,operative procedure:,1. orthostatic cardiac allograft transplantation utilizing total cardiopulmonary bypass.,2. open sternotomy covered with ioban.,3. insertion of mahurkar catheter for hemofiltration via the left common femoral vein.,anesthesia: , general endotracheal.,operative procedure: , with the patient in the supine position, he was prepped from shin to knees and draped in a sterile field. a right common femoral artery vein were then exposed through a longitudinal incision in the right groin and prepared for cardiopulmonary bypass. a sternotomy incision was then opened and the lesions from the previous operative procedures were lysed and they were very dense and firm, freeing up the right atrium and the ascending aorta and anterior right ventricle. the patient was heparinized and then a pursestring suture was placed in the right atrium superior and inferior just above the superior and inferior vena cava. a percutaneous catheter for arterial return was placed using seldinger technique through exposed right femoral artery and then two 3-mm catheters were inserted with two pursestring sutures in the right atrium just superior to inferior vena cava. after satisfactory heparinization has been obtained, the patient was placed on cardiopulmonary bypass and another pursestring suture was placed in the right superior pulmonary vein and a catheter was placed for suction in the left atrium. after the heart was brought to the operating room and triggered, the patient had the ascending aorta clamped and tapes were placed around superior and inferior vena cava and were secured in place. a cardiectomy was then performed by starting in the right atrium. the wires from the pacemaker and defibrillator were transected coming from the superior vena cava and the swan-ganz catheter was brought out into the operative field. cardiectomy was then performed, first resecting the anterior portion of the right atrium and then transecting the aorta, the pulmonary artery, the septum between the right and left atriums, and then the heart was removed. the right and left atrium, aorta, and pulmonary artery were prepared for the transplant. first, we did a side-to-side anastomosis, continued to the left atrium and this was performed using 3-0 prolene suture and a right atrial anastomosis side-to-side was performed using 3-0 prolene suture. the pulmonary artery was then anastomosed using 5-0 prolene and the aorta was anastomosed with 4-0 prolene. the arterial anastomosis in the pulmonary artery and aorta were not completed until the heart was filled with blood. air was evacuated and the sutures were tied down. the clamp on the ascending aorta was removed and the patient was gradually overtime weaned from cardiopulmonary bypass. the patient had a postoperative coagulopathy which prolonged the period of time in the operating room after completion and weaning off of the cardiopulmonary bypass. blood factors and factor vii were given to try and correct the coagulopathy. because of excessive transfusions that were required, a mahurkar catheter was inserted through the left common femoral vein, first placing a needle into the vein and then guidewire removed, and the needle dilators were then placed and then the mahurkar catheter was then placed with 2-0 nylon suture. hemofiltration was started in the operating room at this time. after he had satisfactory hemostasis, we decided to do the chest open and cover it with ioban, which we did, and one chest tube was inserted into the mediastinum through a separate stab wound. the patient also had an intraaortic balloon for counterpulsation which had been inserted into the left subclavian vein preoperatively. this was left in place and the pulse generation, the pacemaker was in a right infraclavicular position, which was left in place because of the coagulopathy. the patient received 11 units of packed red blood cells, 7 platelets, 23 fresh-frozen plasma, 20 cryoprecipitates, and factor vii. urine output for the procedure was 520 ml. the preservation time of the heart is in the anesthesia sheet. the estimated blood loss was at least 6 l. the patient was taken to the intensive care unit in guarded condition.

preoperative diagnosis: , gastrostomy (gastrocutaneous fistula).,postoperative diagnosis: , gastrostomy (gastrocutaneous fistula).,operation performed: , surgical closure of gastrostomy.,anesthesia: , general.,indications: , this 1-year-old child had a gastrostomy placed due to feeding difficulties. since then, he has reached a point where he is now eating completely by mouth and no longer needed the gastrostomy. the tube was, therefore, removed, but the tract has not shown signs of spontaneous closure. he, therefore, comes to the operating room today for surgical closure of his gastrostomy.,operative procedure: , after the induction of general anesthetic, the abdomen was prepped and draped in the usual manner. an elliptical incision was made around the gastrostomy site and carried down through skin and subcutaneous tissue with sharp dissection. the tract and the stomach were freed. stay sutures were then placed on either side of the tract. the tract was amputated. the intervening stomach was then closed with interrupted #4-0 lembert, nurolon sutures. the fascia was then closed over the stomach using #3-0 vicryl sutures. the skin was closed with #5-0 subcuticular monocryl. a dressing was applied, and the child was awakened and taken to the recovery room in satisfactory condition.

cc: ,difficulty with speech.,hx:, this 72 y/o rhm awoke early on 8/14/95 to prepare to play golf. he felt fine. however, at 6:00am, on 8/14/95, he began speaking abnormally. his wife described his speech as "word salad" and "complete gibberish." she immediately took him to a local hospital . enroute, he was initially able to understand what was spoken to him. by the time he arrived at the hospital at 6:45am, he was unable to follow commands. his speech was reportedly unintelligible the majority of the time, and some of the health care workers thought he was speaking a foreign language. there were no other symptoms or signs. he had no prior history of cerebrovascular disease. blood pressure 130/70 and pulse 82 upon admission to the local hospital on 8/14/95.,evaluation at the local hospital included: 1)hct scan revealed an old left putaminal hypodensity, but no acute changes or evidence of hemorrhage, 2) carotid duplex scan showed ica stenosis of 40%, bilaterally. he was placed on heparin and transferred to uihc on 8/16/95.,in addition, he had noted memory and word finding difficulty for 2 months prior to presentation. he had undergone a gastrectomy 16 years prior for peptic ulcer disease. his local physician found him vitamin b12 deficient and he was placed on vitamin b12 and folate supplementation 2 months prior to presentation. he and his wife felt that this resulted in improvement of his language and cognitive skills.,meds:, heparin iv, vitamin b12 injection q. week, lopressor, folate, mvi.,pmh:, 1)hypothyroidism (reportedly resolved), 2) gastrectomy, 3)vitamin b12 deficiency.,fhx: ,mother died of mi, age 70. father died of prostate cancer, age 80. bother died of cad and prostate cancer, age 74.,shx:, married. 3 children who are alive and well. semi-retired attorney. denied h/o tobacco/etoh/illicit drug use.,exam:, bp 110/70, hr 50, rr 14, afebrile.,ms: a&o to person and place, but not time. oral comprehension was poor beyond the simplest of conversational phrases. speech was fluent, but consisted largely of "word salad." when asked how he was, he replied: "abadeedleedlebadle." repetition was defective, especially with long phrases. on rare occasions, he uttered short comments appropriately. speech was marred by semantic and phonemic paraphasias. he named colors and described most actions well, although he described a "faucet dripping" as a "faucet drop." he called "red" "reed." reading comprehension was better than aural comprehension. he demonstrated excellent written calculations. spoken calculations were accurate except when the calculations became more complex. for example, he said that ten percent of 100 was equal to "1,200.",cn: pupils 2/3 decreasing to 1/1 on exposure to light. vfftc. there were no field cuts or evidence of visual neglect. eom were intact. face moved symmetrically. the rest of the cn exam was unremarkable.,motor: full strength throughout with normal muscle tone and bulk. there was no evidence of drift.,sensory: unremarkable.,coord: unremarkable.,station: unremarkable. gait: mild difficulty with tw.,reflexes: 2/2 in bue. 2/2+ patellae, 1/1 achilles. plantar responses were flexor on the left and equivocal on the right.,gen exam: unremarkable.,course:, lab data on admission: glucose 97, bun 20, na 134, k 4.0, cr 1.3, chloride 98, co2 24, pt 11, ptt 42, wbc 12.0 (normal differential), hgb 11.4, hct 36%, plt=203k. ua normal. tsh 6.0, ft4 0.88, vit b12 876, folate 19.1. he was admitted and continued on heparin. mri scan, 8/16/95, revealed increased signal on t2-weighted images in wernicke's area in the left temporal region. transthoracic echocardiogram on 8/17/95 was unremarkable. transesophageal echocardiogram on 8/18/95 revealed a sclerotic aortic valve and myxomatous degeneration of the anterior leaflet of the mitral valve. lae 4.8cm, and spontaneous echo contrast in the left atrium were noted. there was no evidence of intracardiac shunt or clot. carotid duplex scan on 8/16/95 revealed 0-15% bica stenosis with anterograde vertebral artery flow, bilaterally. neuropsychologic testing revealed a wernicke's aphasia.,the impression was that the patient had had a cardioembolic stroke involving a lower-division branch of the left mca. he was subsequently placed on warfarin. thoughout his hospital stay he showed continued improvement of language skills and was enrolled in speech therapy following discharge, 8/21/95.,he has had no further stroke like episodes up until his last follow-up visit in 1997.

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

exam:,mri left foot,clinical:, a 49-year-old female with ankle pain times one month, without a specific injury. patient complains of moderate to severe pain, worse with standing or walking on hard surfaces, with tenderness to palpation at the plantar aspect of the foot and midfoot region and tenderness over the course of the posterior tibialis tendon.,findings:,received for second opinion interpretations is an mri examination performed on 05/27/2005.,there is edema of the subcutis adipose space extending along the medial and lateral aspects of the ankle.,there is edema of the subcutis adipose space posterior to the achilles tendon. findings suggest altered biomechanics with crural fascial strains.,there is tendinosis of the posterior tibialis tendon as it rounds the tip of the medial malleolus with mild tendon thickening. there is possible partial surface tearing of the anterior aspect of the tendon immediately distal to the tip of the medial malleolus (axial inversion recovery image #16) which is a possible hypertrophic tear less than 50% in cross sectional diameter. the study has been performed with the foot in neutral position. confirmation of this possible partial tendon tear would require additional imaging with the foot in a plantar flexed position with transaxial images of the posterior tibialis tendon as it rounds the tip of the medial malleolus oriented perpendicular to the course of the posterior tibialis tendon.,there is minimal synovitis of the flexor digitorum longus and flexor hallucis longus tendon sheaths consistent with flexor splinting but intrinsically normal tendons.,normal peroneal tendons.,there is tendinosis of the tibialis anterior tendon with thickening but no demonstrated tendon tear. normal extensor hallucis longus and extensor digitorum tendons.,normal achilles tendon. there is a low-lying soleus muscle that extends to within 2cm of the teno-osseous insertion of the achilles tendon.,normal distal tibiofibular syndesmotic ligamentous complex.,normal lateral, subtalar and deltoid ligamentous complexes.,there are no erosions of the inferior neck of the talus and there are no secondary findings of a midfoot pronating force.,normal plantar fascia. there is no plantar calcaneal spur.,there is venous engorgement of the plantar veins of the foot extending along the medial and lateral plantar cutaneous nerves which may be acting as intermittent entrapping lesions upon the medial and lateral plantar cutaneous nerves.,normal tibiotalar, subtalar, talonavicular and calcaneocuboid articulations.,the metatarsophalangeal joint of the hallux was partially excluded from the field-of-view of this examination.,impression:,tendinosis of the posterior tibialis tendon with tendon thickening and possible surface fraying / tearing of the tendon immediately distal to the tip of the medial malleolus, however, confirmation of this finding would require additional imaging.,minimal synovitis of the flexor digitorum longus and flexor hallucis longus tendon sheaths, consistent with flexor splinting.,edema of the subcutis adipose space along the medial and lateral aspects of the ankle suggesting altered biomechanics and crural fascial strain.,mild tendinosis of the tibialis anterior tendon with mild tendon thickening.,normal plantar fascia and no plantar fasciitis.,venous engorgement of the plantar veins of the foot which may be acting as entrapping lesions upon the medial and lateral plantar cutaneous nerves.

cc:, decreasing visual acuity.,hx: ,this 62 y/o rhf presented locally with a 2 month history of progressive loss of visual acuity, od. she had a 2 year history of progressive loss of visual acuity, os, and is now blind in that eye. she denied any other symptomatology. denied ha.,pmh:, 1) depression. 2) blind os,meds:, none.,shx/fhx: ,unremarkable for cancer, cad, aneurysm, ms, stroke. no h/o tobacco or etoh use.,exam:, t36.0, bp121/85, hr 94, rr16,ms: alert and oriented to person, place and time. speech fluent and unremarkable.,cn: pale optic disks, ou. visual acuity: 20/70 (od) and able to detect only shadow of hand movement (os). pupils were pharmacologically dilated earlier. the rest of the cn exam was unremarkable.,motor: 5/5 throughout with normal bulk and tone.,sensory: no deficits to lt/pp/vib/prop.,coord: fnf-ram-hks intact bilaterally.,station: no pronator drift. gait: nd,reflexes: 3/3 bue, 2/2 ble. plantar responses were flexor bilaterally.,gen exam: unremarkable. no carotid/cranial bruits.,course:, ct brain showed large, enhancing 4 x 4 x 3 cm suprasellar-sellar mass without surrounding edema. differential dx: included craniopharyngioma, pituitary adenoma, and aneurysm. mri brain findings were consistent with an aneurysm. the patient underwent 3 vessel cerebral angiogram on 12/29/92. this clearly revealed a supraclinoid giant aneurysm of the left internal carotid artery. ten minutes following contrast injection the patient became aphasic and developed a right hemiparesis. emergent hct showed no evidence of hemorrhage or sign of infarct. emergent carotid duplex showed no significant stenosis or clot. the patient was left with an expressive aphasia and right hemiparesis. spect scans were obtained on 1/7/93 and 2/24/93. they revealed hypoperfusion in the distribution of the left mca and decreased left basal-ganglia perfusion which may represent in part a mass effect from the lica aneurysm. she was discharged home and returned and underwent placement of a selverstone clamp on 3/9/93. the clamp was gradually and finally closed by 3/14/93. she did well, and returned home. on 3/20/93 she developed sudden confusion associated with worsening of her right hemiparesis and right expressive aphasia. a hct then showed sah around her aneurysm, which had thrombosed. she was place on nimodipine. her clinical status improved; then on 3/25/93 she rapidly deteriorated over a 2 hour period to the point of lethargy, complete expressive aphasia, and right hemiplegia. an emergent hct demonstrated a left aca and left mca infarction. she required intubation and worsened as cerebral edema developed. she was pronounced brain dead. her organs were donated for transplant.

subjective:, this 47-year-old white female presents with concern about possible spider bite to the left side of her neck. she is not aware of any specific injury. she noticed a little tenderness and redness on her left posterior shoulder about two days ago. it seems to be getting a little bit larger in size, and she saw some red streaks extending up her neck. she has had no fever. the area is very minimally tender, but not particularly so.,current medications:, generic maxzide, climara patch, multivitamin, tums, claritin, and vitamin c.,allergies:, no known medicine allergies.,objective:,vital signs: weight is 150 pounds. blood pressure 122/82.,extremities: examination of the left posterior shoulder near the neckline is an area of faint erythema which is 6 cm in diameter. in the center is a tiny mark which could certainly be an insect or spider bite. there is no eschar there, but just a tiny marking. there are a couple of erythematous streaks extending towards the neck.,assessment:, possible insect bite with lymphangitis.,plan:,1. duricef 1 g daily for seven days.,2. cold packs to the area.,3. discussed symptoms that were suggestive of the worsening, in which case she would need to call me.,4. incidentally, she has noticed a little bit of dryness and redness on her eyelids, particularly the upper ones’ and the lower lateral areas. i suspect she has a mild contact dermatitis and suggested hydrocortisone 1% cream to be applied sparingly at bedtime only.

admission diagnosis: , left hip fracture.,chief complaint: , diminished function, secondary to the above.,history: , this pleasant 70-year-old gentleman had a ground-level fall at home on 05/05/03 and was brought into abcd medical center, evaluated by dr. x and brought in for orthopedic stay. he had left hip fracture identified on x-rays at that time. pain and inability to ambulate brought him in. he was evaluated and then underwent medical consultation as well, where they found a history of resolving pneumonia, hypertension, chronic obstructive pulmonary disease, congestive heart failure, hypothyroidism, depression, anxiety, seizure and chronic renal failure, as well as anemia. his medical issues are under good control. the patient underwent left femoral neck fixation with hemiarthroplasty on that left side on 05/06/03. the patient has had some medical issues including respiratory insufficiency, perioperative anemia, pneumonia, and hypertension. cardiology has followed closely, and the patient has responded well to medical treatment, as well as physical therapy and occupational therapy. he is gradually tolerating more activities with less difficulties, made good progress and tolerated more consistent and more prolonged interventions.,past medical history: , positive for congestive heart failure, chronic renal insufficiency, azotemia, hyperglycemia, coronary artery disease, history of paroxysmal atrial fibrillation. remote history of subdural hematoma precluding the use of coumadin. history of depression, panic attacks on doxepin. perioperative anemia. swallowing difficulties.,allergies:, zyloprim, penicillin, vioxx, nsaids.,current medications,1. heparin.,2. albuterol inhaler.,3. combivent.,4. aldactone.,5. doxepin.,6. xanax.,7. aspirin.,8. amiodarone.,9. tegretol.,10. synthroid.,11. colace.,social history: , lives in a 1-story home with 1 step down; wife is there. speech and language pathology following with current swallowing dysfunction. he is minimum assist for activities of daily living, bed mobility.,review of systems:, currently negative for headache, nausea and vomiting, fevers, chills or shortness of breath or chest pain.,physical examination,heent: oropharynx clear.,cv: regular rate and rhythm without murmurs, rubs or gallops.,lungs: clear to auscultation bilaterally.,abdomen: nontender, nondistended. bowel sounds positive.,extremities: without clubbing, cyanosis, or edema.,neurologic: there are no focal motor or sensory losses to the lower extremities. bulk and tone normal in the lower extremities. wound site has healed well with staples out.,impression ,1. status post left hip fracture and hemiarthroplasty.,2. history of panic attack, anxiety, depression.,3. myocardial infarction with stent placement.,4. hypertension.,5. hypothyroidism.,6. subdural hematoma.,7. seizures.,8. history of chronic obstructive pulmonary disease. recent respiratory insufficiency.,9. renal insufficiency.,10. recent pneumonia.,11. o2 requiring.,12. perioperative anemia.,plan: , rehab transfer as soon as medically cleared.

preoperative diagnosis: , right ureteral calculus.,postoperative diagnosis: , right ureteropelvic junction calculus.,procedure performed:,1. cystourethroscopy.,2. right retrograde pyelogram.,3. right double-j stent placement 22 x 4.5 mm.,first second anesthesia: , general.,specimen:, urine for culture and sensitivity.,drains: , 22 x 4.5 mm right double-j ureteral stent.,procedure: , after consent was obtained, the patient was brought to operating room and placed in the supine position. she was given general anesthesia and then placed in the dorsal lithotomy position. a #21 french cystoscope was then passed through the urethra into the bladder. there was noted to be some tightness of the urethra on passage. on visualization of the bladder, there were no stones or any other debris within the bladder. there were no abnormalities seen. no masses, diverticuli, or other abnormal findings. attention was then turned to the right ureteral orifice and attempts to pass to a cone tip catheter, however, the ureteral orifice was noted to be also tight and we were unable to pass the cone tip catheter. the cone tip catheter was removed and a glidewire was then passed without difficulty up into the renal pelvis. an open-end ureteral catheter was then passed ________ into the distal right ureter. retrograde pyelogram was then performed.,there was noted to be an upj calculus with no noted hydronephrosis. the wire was then passed back through the ureteral catheter. the catheter was removed and a 22 x 4.5 mm double-j ureteral stent was then passed over the glidewire under fluoroscopic and cystoscopic guidance. the stent was clear within the kidney as well as within the bladder. the bladder was drained and the cystoscope was removed. the patient tolerated the procedure well. she will be discharged home. she is to follow up with dr. x for eswl procedure. she will be given prescription for darvocet and will be asked to have a kub x-ray done prior to her followup and to bring them with her to her appointment.

history of present illness:, the patient is a 67-year-old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and taxol, is here today for followup. her last cycle of chemotherapy was finished on 01/18/08, and she complains about some numbness in her right upper extremity. this has not gotten worse recently and there is no numbness in her toes. she denies any tingling or burning.,review of systems: , negative for any fever, chills, nausea, vomiting, headache, chest pain, shortness of breath, abdominal pain, constipation, diarrhea, melena, hematochezia or dysuria. the patient is concerned about her blood pressure being up a little bit and also a mole that she had noticed for the past few months in her head.,physical examination:,vital signs: temperature 35.6, blood pressure 143/83, pulse 65, respirations 18, and weight 66.5 kg. general: she is a middle-aged white female, not in any distress. heent: no lymphadenopathy or mucositis. cardiovascular: regular rate and rhythm. lungs: clear to auscultation bilaterally. extremities: no cyanosis, clubbing or edema. neurological: no focal deficits noted. pelvic: normal-appearing external genitalia. vaginal vault with no masses or bleeding.,laboratory data: , none today.,radiologic data: , ct of the chest, abdomen, and pelvis from 01/28/08 revealed status post total abdominal hysterectomy/bilateral salpingo-oophorectomy with an unremarkable vaginal cuff. no local or distant metastasis. right probably chronic gonadal vein thrombosis.,assessment: , this is a 67-year-old white female with history of uterine papillary serous carcinoma, status post total abdominal hysterectomy and bilateral salpingo-oophorectomy and 6 cycles of carboplatin and taxol chemotherapy. she is doing well with no evidence of disease clinically or radiologically.,plan:,1. plan to follow her every 3 months and ct scans every 6 months for the first 2 years.,2. the patient was advised to contact the primary physician for repeat blood pressure check and get started on antihypertensives if it is persistently elevated.,3. the patient was told that the mole that she is mentioning in her head is no longer palpable and just to observe it for now.,4. the patient was advised about doing kegel exercises for urinary incontinence, and we will address this issue again during next clinic visit if it is persistent.,

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.

preoperative diagnosis and indications:, acute non-st-elevation mi.,postoperative diagnosis and summary:, the patient presented with an acute non-st-elevation mi. despite medical therapy, she continued to have intermittent angina. angiography demonstrated the severe lad as the culprit lesion. this was treated as noted above with angioplasty alone as the stent could not be safely advanced. she has residual lesions of 75% in the proximal right coronary and 60% proximal circumflex, and the other residual lad lesions as noted above. she will be continued on her medical therapy. at age 90, she is not a good candidate for aortic valve replacement and coronary bypass grafting.,procedure performed: , selective coronary angiography, coronary angioplasty.,procedure in detail:, after informed consent was obtained, the patient was taken to the cath lab, placed on the table in the supine position. the area of the right femoral artery was prepped and draped in a sterile fashion. using the percutaneous technique, a 6-french sheath was placed in the right femoral artery under fluoroscopic guidance. with the guidewire in place, a 5-french jl-4 catheter was used to selectively angiogram the left coronary system. the catheter was removed. the sheath flushed. the 5-french 3drc catheter was then used to selectively angiogram the right coronary artery. the cath removed, the sheath flushed.,it was decided that intervention was needed in the severe lesions in the lad, which appeared to be the culprit lesions for the non-st elevation-mi. the patient was given a bolus of heparin and an act of approximately 50 seconds was obtained, we rebolused and the act was slightly lower. we repeated the level and it was slightly higher. we administered 500 more units of heparin and then proceeded with an act of approximately 270 seconds prior to the 500 units of heparin iv. additionally, the patient had been given 300 mg of plavix orally during the procedure and integrilin iv bolus and then maintenance drip was started.,a 6-french cls 3.5 left coronary guide catheter was used to cannulate the left main and hew guidewire was positioned in the distal lad and another hew guidewire in the relatively large third diagonal. an apex 2.5 x 15 mm balloon was positioned in the distal portion of the mid lad stenosis and inflated to 6 atmospheres for 15 seconds and then deflated. angiography was then performed, demonstrated marked improvement in the stenosis and this image was used for sizing the last of the needed stent. the balloon was pulled more proximally and then inflated again at 6 atmospheres for approximately 20 seconds, with the proximal end of the balloon positioned distal to the origin of the third diagonal so as to not compromise the ostium. the balloon was inflated and removed, repeat angiography performed. we attempted to advance a driver 2.5 x 24 mm bare metal stent, but i could not advance it beyond the proximal lad, where there was significant calcification. the stent was removed. attempts to advance the same 2.5 x 15 mm apex balloon that was previously used were unsuccessful. it was removed, a new apex 2.5 x 15 mm balloon was then positioned in the proximal lad and inflated to 6 atmospheres for 15 seconds and then deflated and advanced slightly with the distal tip of the balloon proximal to the third diagonal ostium and it was inflated to 6 atmospheres for 15 seconds and then deflated and removed. repeat angiography demonstrated no evidence of dissection. one more attempt was made to advance the driver 2.5 x 24 mm bare metal stent, but again i could not advance it beyond the calcified plaque in the proximal lad and this was despite the presence of the buddy wire in the diagonal. i felt that further attempts in this calcified vessel in a 90-year-old with severe aortic stenosis and severe aortic insufficiency would likely result in complications of dissection, so the stent was removed. the guidewires and guide cath were removed. the sheath flushed and sutured into position. the patient moved to icu in stable condition with no chest discomfort at all.,contrast: , isovue-370, 120 ml.,fluoro time: , 9.4 minutes.,estimated blood loss: , 30 ml.,hemodynamics:, aorta 185/54.,left ventriculography was not performed. i did not make an attempt to cross this severely stenotic aortic valve.,the left main is a large vessel, giving rise to lad and circumflex vessels. the left main has no significant disease other than calcification in the walls.,the lad is a moderate-to-large vessel, giving rise to small diagonals and then a moderate-to-large third diagonal, and then a small fourth diagonal. the lad has significant calcification proximally. there is a 50% stenosis between the first and second diagonals that we treated with angioplasty alone in an attempt to be able to advance the stent. this resulted in a 30% residual, mostly eccentric calcified plaque. following this, there was a 50% stenosis in the lad just after the takeoff of the third diagonal. this was not ballooned. beyond this is an 80% stenosis prior to the fourth diagonal and then a 99% stenosis after the fourth diagonal. these 2 lesions were dilated with 10% residual prior to the fourth diagonal and 25% residual distal to the fourth diagonal. as noted above, this area was not stented because i could not safely advance the stent. note, there was also a 50% stenosis at the origin of the moderate-to-large third diagonal that did not change with angioplasty.,the circumflex is a large, nondominant vessel consisting of a large obtuse marginal with multiple branches. the proximal circumflex has an eccentric 60% stenosis prior to the takeoff of the obtuse marginal. the remainder of the vessel was without significant disease.,the right coronary was a large, dominant vessel giving rise to a large posterior descending artery and small-to-moderate first posterolateral, small second posterolateral, and a small-to-moderate third posterolateral branch. the right coronary has an eccentric smooth 75% stenosis beginning about a centimeter after the origin of the vessel and prior to the acute marginal branch. the remainder of the right coronary and its branches were without significant disease.

procedure performed: , nissen fundoplication.,description of procedure: , after informed consent was obtained detailing the risks of infection, bleeding, esophageal perforation and death, the patient was brought to the operative suite and placed supine on the operating room table. general endotracheal anesthesia was induced without incident. the patient was then placed in a modified lithotomy position taking great care to pad all extremities. teds and venodynes were placed as prophylaxis against deep venous thrombosis. antibiotics were given for prophylaxis against surgical infection.,a 52-french bougie was placed in the proximal esophagus by anesthesia, above the cardioesophageal junction. a 2 cm midline incision was made at the junction of the upper two-thirds and lower one-third between the umbilicus and the xiphoid process. the fascia was then cleared of subcutaneous tissue using a tonsil clamp. a 1-2 cm incision was then made in the fascia gaining entry into the abdominal cavity without incident. two sutures of 0 vicryl were then placed superiorly and inferiorly in the fascia, and then tied to the special 12 mm hasson trocar fitted with a funnel-shaped adaptor in order to occlude the fascial opening. pneumoperitoneum was then established using carbon dioxide insufflation to a steady state of pressure of 16 mmhg. a 30-degree laparoscope was inserted through this port and used to guide the remaining trocars.,the remaining trocars were then placed into the abdomen taking care to make the incisions along langer's line, spreading the subcutaneous tissue with a tonsil clamp, and confirming the entry site by depressing the abdominal wall prior to insertion of the trocar. a total of 4 other 10/11 mm trocars were placed. under direct vision 1 was inserted in the right upper quadrant at the midclavicular line, at a right supraumbilical position; another at the left upper quadrant at the midclavicular line, at a left supraumbilical position; 1 under the right costal margin in the anterior axillary line; and another laterally under the left costal margin on the anterior axillary line. all of the trocars were placed without difficulty. the patient was then placed in reverse trendelenburg position.,the triangular ligament was taken down sharply, and the left lobe of the liver was retracted superolaterally using a fan retractor placed through the right lateral cannula. the gastrohepatic ligament was then identified and incised in an avascular plane. the dissection was carried anteromedially onto the phrenoesophageal membrane. the phrenoesophageal membrane was divided on the anterior aspect of the hiatal orifice. this incision was extended to the right to allow identification of the right crus. then along the inner side of the crus, the right esophageal wall was freed by dissecting the cleavage plane.,the liberation of the posterior aspect of the esophagus was started by extending the dissection the length of the right diaphragmatic crus. the pars flaccida of the lesser omentum was opened, preserving the hepatic branches of the vagus nerve. this allowed free access to the crura, left and right, and the right posterior aspect of the esophagus, and the posterior vagus nerve.,attention was next turned to the left anterolateral aspect of the esophagus. at its left border, the left crus was identified. the dissection plane between it and the left aspect of the esophagus was freed. the gastrophrenic ligament was incised, beginning the mobilization of the gastric pouch. by dissecting the intramediastinal portion of the esophagus, we elongated the intra-abdominal segment of the esophagus and reduced the hiatal hernia.,the next step consisted of mobilization of the gastric pouch. this required ligation and division of the gastrosplenic ligament and several short gastric vessels using the harmonic scalpel. this dissection started on the stomach at the point where the vessels of the greater curvature turned towards the spleen, away from the gastroepiploic arcade. the esophagus was lifted by a babcock inserted through the left upper quadrant port. careful dissection of the mesoesophagus and the left crus revealed a cleavage plane between the crus and the posterior gastric wall. confirmation of having opened the correct plane was obtained by visualizing the spleen behind the esophagus. a one-half inch penrose drain was inserted around the esophagus and sewn to itself in order to facilitate retraction of the distal esophagus. the retroesophageal channel was enlarged to allow easy passage of the antireflux valve.,the 52-french bougie was then carefully lowered into the proximal stomach, and the hiatal orifice was repaired. two interrupted 0 silk sutures were placed in the diaphragmatic crura to close the orifice.,the last part of the operation consisted of the passage and fixation of the antireflux valve. with anterior retraction on the esophagus using the penrose drain, a babcock was passed behind the esophagus, from right to left. it was used to grab the gastric pouch to the left of the esophagus and to pull it behind, forming the wrap. the,52-french bougie was used to calibrate the external ring. marcaine 0.5% was injected 1 fingerbreadth anterior to the anterior 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.

procedure in detail:, after appropriate operative consent was obtained, the patient was brought supine to the operating room and placed on the operating room table. 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 a sterile ophthalmic fashion and the procedure begun. a wire lid speculum was inserted into the right eye and a 360-degree conjunctival peritomy was performed at the limbus. the 4 rectus muscles were looped and isolated using 2-0 silk suture. the retinal periphery was then inspected via indirect ophthalmoscopy.,

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

procedure: , trigger finger release.,procedure in detail: , after administering appropriate antibiotics and mac anesthesia, the upper extremity was prepped and draped in the usual standard fashion. the arm was exsanguinated with esmarch, and the tourniquet inflated to 250 mmhg.,a longitudinal incision was made over the digit's a1 pulley. dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles. the sheath was opened under direct vision with a scalpel, and then a scissor was used to release it under direct vision from the proximal extent of the a1 pulley to just proximal to the proximal digital crease. meticulous hemostasis was maintained with bipolar electrocautery.,the tendons were identified and atraumatically pulled to ensure that no triggering remained. the patient then actively moved the digit, and no triggering was noted.,after irrigating out the wound with copious amounts of sterile saline, the skin was closed with 5-0 nylon simple interrupted sutures.,the wound was dressed and the patient was sent to the recovery room in good condition, having tolerated the procedure well.

subjective:, mr. sample patient returns to the sample clinic with the chief complaint of painful right heel. the patient states that the heel has been painful for approximately two weeks, it is starts with the first step in the morning and gets worse with activity during the day. the patient states that he is currently doing no treatment for it. he states that most of his pain is along medial tubercle of the right calcaneus and extends to the medial arch. the patient states that he has no change in the past medical history since his last visit and denies any fever, chills, vomiting, headache, chest, or shortness of breath.,objective:, upon removal of shoes and socks bilaterally, neurovascular status remains unchanged since the last visit. there is tenderness to palpation to the medial tubercle of the right foot. the pain is elicited along the medial arch as well. there are no open areas or signs of infection noted.,assessment:, plantar fascitis/heel spur syndrome, right foot.,plan:, the patient was given injections of 3 cc 2:1 mixture of 1% lidocaine plain with dexamethasone phospate. he was given a low dye strapping and a heel lift was placed in his right shoe. the patient will be seen back in approximately one month for further evaluation if necessary. he was told to call if anything should occur before that. the patient was told to continue with the good work on his diabetic control.

preoperative diagnosis:, medial meniscal tear of the right knee.,postoperative diagnoses:,1. medial meniscal tear, right knee.,2. lateral meniscal tear, right knee.,3. osteochondral lesion, medial femoral condyle, right knee.,4. degenerative joint disease, right knee.,5. patella grade-ii chondromalacia.,6. lateral femoral condyle grade ii-iii chondromalacia.,procedure performed:,1. arthroscopy, right knee.,2. medial meniscoplasty, right knee.,3. lateral meniscoplasty, right knee.,4. medial femoral chondroplasty, right knee.,5. medical femoral microfracture, right knee.,6. patellar chondroplasty.,7. lateral femoral chondroplasty.,anesthesia: , general.,estimated blood loss: , minimal.,complications:, none.,brief history and indication for procedure: , the patient is a 47-year-old female who has knee pain since 03/10/03 after falling on ice. the patient states she has had inability to bear significant weight and had swelling, popping, and giving away, failing conservative treatment and underwent an operative procedure.,procedure:, the patient was taken to the operative suite at abcd general hospital on 09/08/03, placed on the operative table in supine position. department of anesthesia administered general anesthetic. once adequately anesthetized, the right lower extremity was placed in a johnson knee holder. care was ensured that all bony prominences were well padded and she was positioned and secured. after adequately positioned, the right lower extremity was prepped and draped in the usual sterile fashion. attention was then directed to creation of the arthroscopic portals, both medial and lateral portal were made for arthroscope and instrumentation respectively. the arthroscope was advanced through the inferolateral portal taking in a suprapatellar pouch. all compartments were then examined in sequential order with photodocumentation of each compartment. the patella was noted to have grade-ii changes of the inferior surface, otherwise appeared to track within the trochlear groove. there was mild grooving of the trochlear cartilage. the medial gutter was visualized. there was no evidence of loose body. the medial compartment was then entered. there was noted to be a large defect on the medial femoral condyle grade iii-iv chondromalacia changes with exposed bone in evidence of osteochondral displaced fragment. there was also noted to be a degenerative meniscal tear of the posterior horn of the medial meniscus. the arthroscopic probe was then introduced and the meniscus and chondral surfaces were probed throughout its entirety and photos were taken. at this point, a meniscal shaver was then introduced and the chondral surfaces were debrided as well as any loose bodies removed. this gave a smooth shoulder to the chondral lesion. after this, the meniscus was debrided until it had been smooth over the frayed edges. at this point, the shaver was removed. the meniscal binder was then introduced and the meniscus was further debrided until the tear was adequately contained at this point. the shaver was reintroduced and all particles were again removed and the meniscus was smoothed over the edge. the probe was then reintroduced and the shaver removed, the meniscus was probed ___________ and now found to be stable. at this point, attention was directed to the rest of the knee. the acl was examined. it was intact and stable. the lateral compartment was then entered. there was noted to be a grade ii-iii changes of the lateral femoral condyle. again, with the edge of some friability at the shoulder of this cartilage lesion. there was noted to be some mild degenerative fraying of the posterior horn of the lateral meniscus. the probe was introduced and the remaining meniscus appeared stable. this was then removed and the stapler was introduced. a chondroplasty and meniscoplasty were then performed until adequately debrided and smoothed over. the lateral gutter was then visualized. there was no evidence of loose bodies. attention was then redirected back to the medial and femoral condyles.,at this point, a 0.62 k-wire was then placed in through the initial portal, medial portal, as well as an additional poke hole, so we can gain access and proper orientation to the medial femoral lesion. microfacial technique was then used to introduce the k-wire into the subchondral bone in multiple areas until we had evidence of some bleeding to allow ___________ of this lesion. after this was performed, the shaver was then reintroduced and the loose bodies and loose fragments were further debrided. at this point, the shaver was then moved to the suprapatellar pouch and the patellar chondroplasty was then performed until adequately debrided. again, all compartments were then re-visualized and there was no further evidence of other pathology or loose bodies. the knee was then copiously irrigated and suctioned dry. all instrumentation was removed. approximately 20 cc of 0.25% plain marcaine was injected into the portal site and the remaining portion intraarticular. sterile dressings of adaptic, 4x4s, abds, and webril were then applied. the patient was then transferred back to the gurney in supine position.,disposition: the patient tolerated the procedure well with no complications. the patient was transferred to pacu in satisfactory condition.

chief complaint:, right hydronephrosis.,history of present illness: , the patient is a 56-year-old female who has a history of uterine cancer, breast cancer, mesothelioma. she is scheduled to undergo mastectomy in two weeks. in september 1999, she was diagnosed with right breast cancer and underwent lumpectomy and axillary node dissection and radiation. again, she is scheduled for mastectomy in two weeks. she underwent a recent pet scan for dr. x, which revealed marked hydronephrosis on the right possibly related to right upj obstruction and there is probably a small nonobstructing stone in the upper pole of the right kidney. there was no dilation of the right ureter noted. urinalysis today is microscopically negative.,past medical history: , uterine cancer, mesothelioma, breast cancer, diabetes, hypertension.,past surgical history: , lumpectomy, hysterectomy.,medications:, diovan hct 80/12.5 mg daily, metformin 500 mg daily.,allergies:, none.,family history: , noncontributory.,social history:, she is retired. does not smoke or drink.,review of systems:, i have reviewed his review of systems sheet and it is on the chart.,physical examination:, please see the physical exam sheet i completed. abdomen is soft, nontender, nondistended, no palpable masses, no cva tenderness.,impression and plan: , marked right hydronephrosis without hydruria. she believes she had a ct scan of the abdomen and pelvis at hospital in 2005. i will try to obtain the report to see if the right kidney was evaluated at that time. she will need evaluation with an ivp and renal scan to determine the point of obstruction and renal function of the right kidney. she is quite anxious about her upcoming surgery and would like to delay any evaluation of this until the surgery is completed. she will call us back to schedule the x-rays. she understands the great importance and getting back in touch with us to schedule these x-rays due to the possibility that it may be somehow related to the cancer. there is also a question of a stone present in the kidney. she voiced a complete understanding of that and will call us after she recovers from her surgery to schedule these tests.

chief complaint: ,blood in toilet.,history: , ms. abc is a 77-year-old female who is brought down by way of ambulance from xyz nursing home after nursing staff had noted there to be blood in the toilet after she had been sitting on the toilet. they did not note any urine or stool in the toilet and the patient had no acute complaints. the patient is unfortunately a poor historian in that she has dementia and does not recall any of the events. the patient herself has absolutely no complaints, such as abdominal pain or back pain, urinary and gi complaints. there is no other history provided by the nursing staff from xyz. there apparently were no clots noted within there. she does not have a history of being on anticoagulants.,past medical history: , actually quite limited, includes that of dementia, asthma, anemia which is chronic, hypothyroidism, schizophrenia, positive ppd in the past.,past surgical history: ,unknown.,social history: , no tobacco or alcohol.,medications: , listed in the medical records.,allergies:, no known drug allergies.,physical examination: , vital signs: stable.,general: this is a well-nourished, well-developed female who is alert, oriented in all spheres, pleasant, cooperative, resting comfortably, appearing otherwise healthy and well in no acute distress.,heent: visually normal. pupils are reactive. tms, canals, nasal mucosa, and oropharynx are intact.,neck: no lymphadenopathy or jvd.,heart: regular rate and rhythm. s1, s2. no murmurs, gallops, or rubs.,lungs: clear to auscultation. no wheeze, rales, or rhonchi.,abdomen: benign, flat, soft, nontender, and nondistended. bowel sounds active. no organomegaly or mass noted.,gu/rectal: external rectum was normal. no obvious blood internally. there is no stool noted within the vault. there is no gross amount of blood noted within the vault. guaiac was done and was trace positive. visual examination anteriorly during the rectal examination noted no blood within the vaginal region.,extremities: no significant abnormalities.,workup: , ct abdomen and pelvis was negative. cbc was entirely within normal limits without any signs of anemia with an h and h of 14 and 42%. cmp also within normal limits. ptt, pt, and inr were normal. attempts at getting the patient to give a urine were unsuccessful and the patient was very noncompliant, would not allow us to do any kind of foley catheterization.,er course:, uneventful. i have discussed the patient in full with dr. x who agrees that she does not require any further workup or evaluation as an inpatient. we have decided to send the patient back to xyz with observation by the staff there. she will have a cbc done daily for the next 3 days with results to dr. x. they are to call him if there is any recurrences of blood or worsening of symptoms and they are to do a urinalysis at xyz for blood.,assessment: , questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.

reason for exam: , dynamic st-t changes with angina.,procedure:,1. selective coronary angiography.,2. left heart catheterization with hemodynamics.,3. lv gram with power injection.,4. right femoral artery angiogram.,5. closure of the right femoral artery using 6-french angioseal.,procedure explained to the patient, with risks and benefits. the patient agreed and signed the consent form.,the patient received a total of 2 mg of versed and 25 mcg of fentanyl for conscious sedation. the patient was draped and dressed in the usual sterile fashion. the right groin area infiltrated with lidocaine solution. access to the right femoral artery was successful, okayed with one attempt with anterior wall stick. over a j-wire, 6-french sheath was introduced using modified seldinger technique.,over the j-wire, a jl4 catheter was passed over the aortic arch. the wire was removed. catheter was engaged into the left main. multiple pictures with rao caudal, ap cranial, lao cranial, shallow rao, and lao caudal views were all obtained. catheter disengaged and exchanged over j-wire into a jr4 catheter, the wire was removed. catheter with counter-clock was rotating to the rca one shot with lao, position was obtained. the cath disengaged and exchanged over j-wire into a pigtail catheter. pigtail catheter across the aortic valve. hemodynamics obtained. lv gram with power injection of 36 ml of contrast was obtained.,the lv gram assessed followed by pullback hemodynamics.,the catheter exchanged out and the right femoral artery angiogram completed to the end followed by the removal of the sheath and deployment of 6-french angioseal with no hematoma. the patient tolerated the procedure well with no immediate postprocedure complication.,hemodynamics: ,the aortic pressure was 117/61 with a mean pressure of 83. the left ventricular pressure was 119/9 to 19 with left ventricular end-diastolic pressure of 17 to 19 mmhg. the pullback across the aortic valve reveals zero gradient.,anatomy: ,the left main showed minimal calcification as well as the proximal lad. no stenosis in the left main seen, the left main bifurcates in to the lad and left circumflex.,the lad was a large and a long vessel that wraps around the apex showed no focal stenosis or significant atheromatous plaque and the flow was timi 3 flow in the lad. the lad gave off two early diagonal branches. the second was the largest of the two and showed minimal lumen irregularities, but no focal stenosis.,left circumflex was a dominant system supplying three obtuse marginal branches and distally supplying the pda. the left circumflex was large and patent, 6.0 mm in diameter. all three obtuse marginal branches appeared to be with no significant stenosis.,the obtuse marginal branch, the third om3 showed at the origin about 30 to 40% minimal narrowing, but no significant stenosis. the pda was wide, patent, with no focal stenosis.,the rca was a small nondominant system with no focal stenosis and supplying the rv marginal.,lv gram showed that the lv ef is preserved with ef of 60%. no mitral regurgitation identified.,impression:,1. patent coronary arteries with normal left anterior descending, left circumflex, and dominant left circumflex system.,2. nondominant right, which is free of atheromatous plaque.,3. minimal plaque in the diagonal branch ii, and the obtuse,marginal branch iii, with no focal stenosis.,4. normal left ventricular function.,5. evaluation for noncardiac chest pain would be recommended.

review of systems,there was no weight loss, fevers, chills, sweats. there is no blurring of the vision, itching, throat or neck pain, or neck fullness. there is no vertigo or hoarseness or painful swallowing. there is no chest pain, shortness of breath, paroxysmal nocturnal dyspnea, or chest pain with exertion. there is no shortness of breath and no cough or hemoptysis. no melena, nausea, vomiting, dysphagia, abdominal pain, diarrhea, constipation or blood in the stools. no dysuria, hematuria or excessive urination. no muscle weakness or tenderness. no new numbness or tingling. no arthralgias or arthritis. there are no rashes. no excessive fatigability, loss of motor skills or sensation. no changes in hair texture, change in skin color, excessive or decreased appetite. no swollen lymph nodes or night sweats. no headaches. the rest of the review of systems is negative.

preoperative diagnosis: , severe scoliosis.,anesthesia: , general. lines were placed by anesthesia to include an a line.,procedures: ,1. posterior spinal fusion from t2-l2.,2. posterior spinal instrumentation from t2-l2.,3. a posterior osteotomy through t7-t8 and t8-t9. posterior elements to include laminotomy-foraminotomy and decompression of the nerve roots.,implant: , sofamor danek (medtronic) legacy 5.5 titanium system.,monitoring: , sseps, and the eps were available.,indications: , the patient is a 12-year-old female, who has had a very dysmorphic scoliosis. she had undergone a workup with an mri, which showed no evidence of cord abnormalities. therefore, the risks, benefits, and alternatives were discussed with surgery with the mother, to include infections, bleeding, nerve injuries, vascular injuries, spinal cord injury with catastrophic loss of motor function and bowel and bladder control. i also discussed ___________ and need for revision surgery. the mom understood all this and wished to proceed.,procedure: , the patient was taken to the operating room and underwent general anesthetic. she then had lines placed, and was then placed in a prone position. monitoring was then set up, and it was then noted that we could not obtain motor-evoked potentials. the sseps were clear and were compatible with the preoperative, but no preoperative motors had been done, and there was a concern that possibly this could be from the result of the positioning. it was then determined at that time, that we would go ahead and proceed to wake her up, and make sure she could move her feet. she was then lightened under anesthesia, and she could indeed dorsiflex and plantarflex her feet, so therefore, it was determined to go ahead and proceed with only monitoring with the sseps.,the patient after being prepped and draped sterilely, a midline incision was made, and dissection was carried down. the dissection utilized a combination of hand instruments and electrocautery and dissected out along the laminae and up to the transverse processes. this occurred from t2-l2. fluoroscopy was brought in to verify positions and levels. once this was done, and all bleeding was controlled, retractors were then placed. attention was then turned towards placing screws first on the left side. lumbar screws were placed at the junction of the transverse process and the facets under fluoroscopic guidance. the area was opened with a high speed burr, and then the track was defined with a blunt probe, and a ball-tipped feeler was then utilized to verify all walls were intact. they were then tapped, and then screws were then placed. this technique was used at l1 and l2, both the right and left. at t12, a direct straight-ahead technique was utilized, where the facet was removed, and then the position was chosen under the fluoroscopy, and then it was spurred, the track was defined and then probed and tapped, and it was felt to be in good position. two screws, in the right and left were placed at t12 as well, reduction screws on the left. the same technique was used for t11, where right and left screws were placed as well as t10 on the left. at t9, a screw was placed on the left, and this was a reduction screw. on the left at t8, a screw could not be placed due to the dysmorphic nature of the pedicle. it was not felt to be intact; therefore, a screw was left out of this. on the right, a thoracic screw was placed as well as at 7 and 6. this was the dysmorphic portion of this. screws were attempted to be placed up, they could not be placed, so attention was then turned towards placing pedicle hooks. pedicle hooks were done by first making a box out of the pedicle, removing the complete pedicle, feeling the undersurface of the pedicle with a probe, and then seating the hook. upgoing pedicle hooks were placed at t3, t4, and t5. a downgoing laminar hook was placed at the t7 level. screws had been placed at t6 and t7 on the right. an upgoing pedicle hook was also placed at t3 on the right, and then, downgoing laminar hooks were placed at t2. this was done by first using a transverse process, lamina finders to go around the transverse process and then ___________ laminar hooks. once all hooks were in place, spinal osteotomies were performed at t7-t8 and t8-t9. this was the level of the kyphosis, to bring her back out of her kyphoscoliosis. first the ligamentum flavum was resected using a large kerrisons. next, the laminotomy was performed, and then a kerrison was used to remove the ligamentum flavum at the level of the facet. once this was accomplished, a laminotomy was performed by removing more of the lamina, and to create a small wedge that could be closed down later to correct the kyphosis. this was then brought out with resection of bone out to the foramen, doing a foraminotomy to free up the foramen on both sides. this was done also between the t8-t9. once this was completed, gelfoam was then placed. next, we observed, and measured and contoured. the rods were then seated on the left, and then a derotation maneuver was performed. hooks had come loose, so the rod was removed on the left. the hooks were then replaced, and the rod was reseated. again, it was derotated to give excellent correction. hooks were then well seated underneath, and therefore, they were then locked. a second rod was then chosen on the right, and was measured, contoured, and then seated. next, once this was done, the rods were locked in the midsubstance, and then the downgoing pedicle hook, which had been placed at t7 was then helped to compress t8 as was the pedicle screw, and then this compressed the osteotomy sites quite nicely. next, distraction was then utilized to further correct at the spine, and to correct on the left, the left concave curve, which gave excellent correction. on the right, compression was used to bring it down, and then, in the lower lumbar areas, distraction and compression were used to level out l2. once this was done, all screws were tightened. fluoroscopy was then brought in to verify l1 was level, and the first ribs were also level, and it gave a nice balanced spine. everything was copiously irrigated, ___________. next, a wake-up test was performed, and the patient was then noted to flex and extend the knees as well as dorsiflex and plantar flex both the feet. the patient was then again sedated and brought back under general anesthesia. next, a high-speed burr was used for decortication. after final tightening had been accomplished, and then allograft bone and autograft bone were mixed together with 10 ml of iliac crest aspirate and were placed into the wound. the open canal areas had been protected with gelfoam. once this was accomplished, the deep fascia was closed with multiple figure-of-eight #1's, oversewn with a running #1, _________ were then placed in the subcutaneous spaces which were then closed with 3-0 vicryl, and then the skin was closed with 3-0 monocryl and dermabond. sterile dressing was applied. drains had been placed in the subcutaneous layer x2. the patient during the case had no changes in the sseps, had a normal wake-up test, and had received ancef and clindamycin during the case. she was taken from the operating room in good condition.

there is normal and symmetrical filling of the caliceal system. subsequent films demonstrate that the kidneys are of normal size and contour bilaterally. the caliceal system and ureters are in their usual position and show no signs of obstruction or intraluminal defects. the postvoid films demonstrate normal emptying of the collecting system, including the urinary bladder.,impression:, negative intravenous urogram.,

preoperative diagnosis: , lipodystrophy of the abdomen and thighs.,postoperative diagnosis:, lipodystrophy of the abdomen and thighs.,operation: , suction-assisted lipectomy.,anesthesia:, general.,findings and procedure:, with the patient under satisfactory general endotracheal anesthesia, the entire abdomen, flanks, perineum, and thighs to the knees were prepped and draped circumferentially in sterile fashion. after this had been completed, a #15 blade was used to make small stab wounds in the lateral hips, the pubic area, and upper edge of the umbilicus. through these small incisions, a cannula was used to infiltrate lactated ringers with 1000 cc was infiltrated initially into the abdomen. a 3 and 4-mm cannulas were then used to carry out the liposuction of the abdomen removing a total of 1100 cc of aspirate, which was mostly fat, little fluid, and blood. attention was then directed to the thighs both inner and outer. a total of 1000 cc was infiltrated in both lateral thighs only about 50 cc in the medial thighs. after this had been completed, 3 and 4-mm cannulas were used to suction 650 cc from each side, approximately 50 cc in the inner thigh and 600 on each lateral thigh. the patient tolerated the procedure very well. all of this aspirate was mostly fat with little fluid and very little blood. wounds were cleaned and steri-stripped and dressing of abd pads and ***** was then applied. the patient tolerated the procedure very well and was sent to the recovery room in good condition.

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

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

impression:, abnormal electroencephalogram revealing generalized poorly organized slowing, with more prominent slowing noted at the right compared to the left hemisphere head regions and rare sharp wave activity noted bilaterally, somewhat more prevalent on the right. clinical correlation is suggested.

title of operation: ,1. arthrotomy, removal humeral head implant, right shoulder.,2. repair of torn subscapularis tendon (rotator cuff tendon) acute tear.,3. debridement glenohumeral joint.,4. biopsy and culturing the right shoulder.,indication for surgery: , the patient had done well after a previous total shoulder arthroplasty performed by dr. x. however, the patient was lifted with subsequent significant pain and apparent tearing of his subscapularis. risks and benefits of the procedure had been discussed with the patient at length including, but not exclusive of infection, nerve or artery damage, stiffness, loss of range of motion, incomplete relief of pain, incomplete return of function, continued instability, retearing of the tendon, need for revision of his arthroplasty, permanent nerve or artery damage, etc. the patient understood and wished to proceed.,preop diagnosis: ,1. torn subscapularis tendon, right shoulder.,2. right total shoulder arthroplasty (biomet system).,postop diagnosis: ,1. torn subscapularis tendon, right shoulder.,2. right total shoulder arthroplasty (biomet system).,3. diffuse synovitis, right shoulder.,procedure: , the patient was anesthetized in the supine position. a foley catheter was placed in his bladder. he was then placed in a beach chair position. he was brought to the side of the table and the torso secured with towels and tape. his head was then placed in the neutral position with no lateral bending or extension. it was secured with paper tape over his forehead. care was taken to stay off his auricular cartilages and his orbits. right upper extremity was then prepped and draped in the usual sterile fashion. the patient was given antibiotics well before the beginning of the procedure to decrease any risk of infection. once he had been prepped and draped with the standard prep, he was prepped a second time with a chlorhexidine-type skin prep. this was allowed to dry and the skin was then covered with ioban bandages also to decrease his risk of infection.,also, preoperatively, the patient had his pacemaker defibrillator function turned off as a result during this case. bipolar type cautery had to be used as opposed to monopolar cautery.,the patient's deltopectoral incision was then opened and extended proximally and distally. the patient had significant amount of scar already in this interval. once we got down to the deltoid and pectoralis muscle, there was no apparent cephalic vein present, as a result the rotator cuff interval had to be developed through an area of scar. this created a significant amount of bleeding. as a result a very slow and meticulous dissection was performed to isolate his coracoid and then his proximal humerus. care was taken to stay above the pectoralis minor and the conjoint tendon. the deltoid had already started to scar down the proximal humerus as a result a very significant amount of dissection had to be performed to release the deltoid from proximal humerus. similarly, the deltoid insertion had to be released approximately 50% of its width to allow us enough mobility of the proximal humerus to be able to visualize the joint or the component. it was clear that the patient had an avulsion of the subscapularis tendon as the tissue on the anterior aspect of the shoulder was very thin. the muscle component of the subscapularis could be located approximately 1 cm off the glenoid rim and approximately 3 cm off the lesser tuberosity. the soft tissue in this area was significantly scarred down to the conjoint tendon, which had to be very meticulously released. the brachial plexus was identified as was the axillary nerve. once this was completed, an arthrotomy was then made leaving some tissue attached to the lesser tuberosity in case it was needed for closure later. this revealed sanguineous fluid inside the joint. we did not feel it was infected based upon the fluid that came from the joint. the sutures for the subscapularis repair were still located in the proximal humerus with no tearing through the bone, which was fortunate because in that we could use the bone later for securing the sutures. the remaining sutures were seen to be retracted medially to an area of the subscapularis as mentioned previously. some more capsule had to be released off the inferior neck in order for us to gain exposure during the scarring. this was done also very meticulously. the upper one half of the latissimus dorsi tendon was also released. once this was completed, the humerus could be subluxed enough laterally that we could remove the head. this was done with no difficulty. fortunately, the humeral component stayed intact. there were some exudates beneath the humeral head, which were somewhat mucinous. however, these do not really appear to be infected, however, we sent them to pathology for a frozen section. this frozen section later returned as possible purulent material. i discussed this personally with the pathologist at that point. we told him that the procedure is only 3 weeks old, but he was concerned that there might be more white blood cells in the tissue than he would expect. as a result, all the mucinous exudates were carefully removed. we also performed a fairly extensive synovectomy of the joint primarily to gain vision of the components, but also we irrigated the joint throughout the case with antibiotic impregnated irrigation. at that point, we also had sent portions of this mucinous material to pathology for a stat gram stain. this came back as no organisms seen. we also sent portions for culture and sensitivity both aerobic and anaerobic.,once this was completed, attention was then directed to the glenoid. the patient had significant amount of scar already. the subscapularis itself was significantly scarred down to the anterior rim. as a result, the adhesions along the anterior edge were released using a knife. also adhesions in the subcoracoid space area were released very carefully and meticulously to prevent any injury to the brachial plexus. two long retractors were placed medially to protect the brachial plexus during all portions of suturing of the subscapularis. the subscapularis was then tagged with multiple number 2 tycron sutures. adhesions were released circumferentially and it was found that with the arm in internal rotation about neutral degrees, the subscapularis could reach the calcar region without tension. as a result, seven number 2 tycron sutures were placed from the bicipital groove all the way down to the inferior calcar region of the humerus. these all had excellent security in bone. once the joint had been debrided and irrigated, the real humeral head was then placed back on the proximal humerus. care was taken to remove fluid off the morse taper. the head was then impacted. it should be noted that we tried multiple head sizes to see if a smaller or larger head size might be more appropriate for this patient. unfortunately, any of the larger head sizes would overstep the joint and any smaller sizes would not give good coverage to the proximal humerus. as a result, it was felt to place the offset head back on the humerus, we did insert a new component as opposed to using the old component. the old component was given to the family postoperatively.,with the arm in internal rotation, the tycron sutures were then placed through the subscapularis tendon in the usual horizontal mattress fashion. also, it should be noted that the rotator cuff interval had to be released as part of the exposure. we started the repair by closing the rotator cuff interval. anterior and posterior translation was then performed and was found to be very stable. the remaining sutures were then secured through the subscapularis tendon taking care to make sure that very substantial bites were obtained. this was then reinforced with the more flimsy tissue laterally being sewn into the tissue around the bicipital tuberosity essentially provided us with a two-layer repair of the subscapularis tendon. after the tendon had been repaired, there was no tension on repair until 0 degrees external rotation was reached with the arm to the side. similarly with the arm abducted 90 degrees, tension was on repair at 0 degrees of external rotation. it should be noted that the wound was thoroughly irrigated throughout with antibiotic impregnated irrigation. the rotator cuff interval was closed with multiple number 2 tycron sutures. it was reinforced with 0 vicryl sutures. two hemovac drains were then placed inferiorly at the deltoid. the deltopectoral interval was then closed with 0 vicryl sutures. a third drain was placed in the subcutaneous tissues to prevent any infections or any fluid collections. this was sewn into place with the drain pulled out superiorly. once all the sutures have been secured and the drain visualized throughout this part of the closure, the drain was pulled distally until it was completely covered. there were no signs that it had been tagged or hung up by any sutures.,the superficial subcutaneous tissues were closed with interrupted with 2-0 vicryl sutures. skin was closed with staples. a sterile bandage was applied along with a cold therapy device and a shoulder immobilizer. the patient was sent to the intensive care unit in stable and satisfactory condition.,due to the significant amount of scar and bleeding in this patient, a 22 modifier is being requested for this case. this was a very difficult revision case and was significantly increased in technical challenges and challenges in the dissection and exposure of this implant compared to a standard shoulder replacement. similarly, the repair of the subscapularis tendon presented significantly more challenges than that of a standard rotator cuff repair because of the implant. this was being dictated for insurance purposes only and reflects no inherent difficulties with this case. the complexity and the time involved in this case was approximately 30% greater than that of a standard shoulder replacement or of a rotator cuff repair. this is being dictated to indicate this was a revision case with significant amount of scar and bleeding due to the patient's situation with his pacemaker. this patient also had multiple medical concerns, which increased the complexity of this case including the necessity to place him in intensive care unit postoperatively for observation.

subjective:, this is a 29-year-old vietnamese female, established patient of dermatology, last seen in our office on 07/13/04. she comes in today as a referral from abc, d.o. for a reevaluation of her hand eczema. i have treated her with aristocort cream, cetaphil cream, increased moisturizing cream and lotion, and wash her hands in cetaphil cleansing lotion. she comes in today for reevaluation because she is flaring. her hands are very dry, they are cracked, she has been washing with soap. she states that the cetaphil cleansing lotion apparently is causing some burning and pain because of the fissures in her skin. she has been wearing some gloves also apparently. the patient is single. she is unemployed.,family, social, and allergy history: , the patient has asthma, sinus, hives, and history of psoriasis. no known drug allergies.,medications: , the patient is a nonsmoker. no bad sunburns or blood pressure problems in the past.,current medications:, claritin and zyrtec p.r.n.,physical examination:, the patient has very dry, cracked hands bilaterally.,impression:, hand dermatitis.,treatment:,1. discussed further treatment with the patient and her interpreter.,2. apply aristocort ointment 0.1% and equal part of polysporin ointment t.i.d. and p.r.n. itch.,3. discontinue hot soapy water and wash her hands with cetaphil cleansing lotion.,4. keflex 500 mg b.i.d. times two weeks with one refill. return in one month if not better; otherwise, on a p.r.n. basis and send dr. xyz a letter on this office visit.

past medical history: ,the patient denies any significant past medical history.,past surgical history: , the patient denies any significant surgical history.,medications: , the patient takes no medications.,allergies: , no known drug allergies.,social history: , she denies use of cigarettes, alcohol or drugs.,family history: , no family history of birth defects, mental retardation or any psychiatric history.,details: , i performed a transabdominal ultrasound today using a 4 mhz transducer. there is a twin gestation in the vertex transverse lie with an anterior placenta and a normal amount of amniotic fluid surrounding both of the twins. the fetal biometry of twin a is as follows. the biparietal diameter is 4.9 cm consistent with 20 weeks and 5 days, head circumference 17.6 cm consistent with 20 weeks and 1 day, the abdominal circumference is 15.0 cm consistent with 20 weeks and 2 days, and femur length is 3.1 cm consistent with 19 weeks and 5 days, and the humeral length is 3.0 cm consistent with 20 weeks and 0 day. the average gestational age by ultrasound is 20 weeks and 1 day and the estimated fetal weight is 353 g. the following structures are seen as normal on the fetal anatomical survey, the shape of the fetal head, the choroid plexuses, the cerebellum, nuchal fold thickness, the fetal spine and fetal face, the four-chamber view of the fetal heart, the outflow tracts of the fetal heart, the stomach, the kidneys, and cord insertion site, the bladder, the extremities, the genitalia, the cord, which appeared to have three vessels and the placenta.,limited in views of baby a with a nasolabial region.,the following is the fetal biometry for twin b. the biparietal diameter is 4.7 cm consistent with 20 weeks and 2 days, head circumference 17.5 cm consistent with 20 weeks and 0 day, the abdominal circumference is 15.5 cm consistent with 20 weeks and 5 days, the femur length is 3.3 cm consistent with 20 weeks and 3 days, and the humeral length is 3.1 cm consistent with 20 weeks and 2 days, the average gestational age by ultrasound is 22 weeks and 2 days, and the estimated fetal weight is 384 g. the following structures were seen as normal on the fetal anatomical survey. the shape of the fetal head, the choroid plexuses, the cerebellum, nuchal fold thickness, the fetal spine and fetal face, the four-chamber view of the fetal heart, the outflow tracts of the fetal heart, the stomach, the kidneys, and cord insertion site, the bladder, the extremities, the genitalia, the cord, which appeared to have three vessels, and the placenta. limited on today's ultrasound the views of nasolabial region.,in summary, this is a twin gestation, which may well be monochorionic at 20 weeks and 1 day. there is like gender and a single placenta. one cannot determine with certainty whether or not this is a monochorionic or dichorionic gestation from the ultrasound today.,i sat with the patient and her husband and discussed alternative findings and the complications. we focused our discussion today on the association of twin pregnancy with preterm delivery. we discussed the fact that the average single intrauterine pregnancy delivers at 40 weeks' gestation while the average twin delivery occurs at 35 weeks' gestation. we discussed the fact that 15% of twins deliver prior to 32 weeks' gestation. these are the twins which we have the most concern regarding the long-term prospects of prematurity. we discussed several etiologies of preterm delivery including preterm labor, incompetent cervix, premature rupture of the fetal membranes as well as early delivery from preeclampsia and growth restriction. we discussed the use of serial transvaginal ultrasound to assess for early cervical change and the use of serial transabdominal ultrasound to assess for normal interval growth. we discussed the need for frequent office visits to screen for preeclampsia. we also discussed treatment options such as cervical cerclage, bedrest, tocolytic medications, and antenatal steroids. i would recommend that the patient return in two weeks for further cervical assessment and assessment of fetal growth and well-being.,in closing, i do want to thank you very much for involving me in the care of your delightful patient. i did review all of the above findings and recommendations with the patient today at the time of her visit. please do not hesitate to contact me if i could be of any further help to you.,total visit time 40 minutes.

chief complaint:, joints are hurting all over and checkup.,history of present illness:, a 77-year-old white female who is having more problems with joint pain. it seems to be all over decreasing her mobility, hands and wrists. no real swelling but maybe just a little more uncomfortable than they have been. the daypro generic does not seem to be helping at all. no fever or chills. no erythema.,she actually is doing better. her diarrhea now has settled down and she is having less urinary incontinence, less pedal edema. blood sugars seem to be little better as well.,the patient also has gotten back on her zoloft because she thinks she may be depressed, sleeping all the time, just not herself and really is disturbed that she cannot be more mobile in things. she has had no polyuria, polydipsia, or other problems. no recent blood pressure checks.,past medical history:, little over a year ago, the patient was found to have lumbar discitis and was treated with antibiotics and ended up having debridement and instrumentation with dr. xyz and is doing really quite well. she had a pulmonary embolus with that hospitalization.,past surgical history:, she has also had a hysterectomy, salpingoophorectomy, appendectomy, tonsillectomy, two carpal tunnel releases. she also has had a parathyroidectomy but still has had some borderline elevated calcium. also, hypertension, hyperlipidemia, as well as diabetes. she also has osteoporosis.,social history:, the patient still smokes about a third of a pack a day, also drinks only occasional alcoholic drinks. the patient is married. she has three grown sons, all of which are very successful in professional positions. one son is a gastroenterologist in san diego, california.,medications:, nifedipine-xr 90 mg daily, furosemide 20 mg half tablet b.i.d., lisinopril 20 mg daily, gemfibrozil 600 mg b.i.d., synthroid 0.1 mg daily, miacalcin one spray in alternate nostrils daily, ogen 0.625 mg daily, daypro 600 mg t.i.d., also lortab 7.5 two or three a day, also flexeril occasionally, also other vitamin.,allergies: , she had some adverse reactions to penicillin, sulfa, perhaps contrast medium, and some mycins.,family history:, as far as heart disease there is none in the family. as far as cancer two cousins had breast cancer. as far as diabetes father and grandfather had type ii diabetes. son has type i diabetes and is struggling with that at the moment.,review of systems:,general: no fever, chills, or night sweats. weight stable.,heent: no sudden blindness, diplopia, loss of vision, i.e., in one eye or other visual changes. no hearing changes or ear problems. no swallowing problems or mouth lesions.,endocrine: hypothyroidism but no polyuria or polydipsia. she watches her blood sugars. they have been doing quite well.,respiratory: no shortness of breath, cough, sputum production, hemoptysis or breathing problems.,cardiovascular: no chest pain or chest discomfort. no paroxysmal nocturnal dyspnea, orthopnea, palpitations, or heart attacks.,gi: as mentioned, has had diarrhea though thought to be possibly due to clostridium difficile colitis that now has gotten better. she has had some irritable bowel syndrome and bowel abnormalities for years.,gu: no urinary problems, dysuria, polyuria or polydipsia, kidney stones, or recent infections. no vaginal bleeding or discharge.,musculoskeletal: as above.,hematological: she has had some anemia in the past.,neurological: no blackouts, convulsions, seizures, paralysis, strokes, or headaches.,physical examination:,vital signs: weight is 164 pounds. blood pressure: 140/64. pulse: 72. blood pressure repeated by me with the patient sitting taken on the right arm is 148/60, left arm 136/58; these are while sitting on the exam table.,general: a well-developed pleasant female who is comfortable in no acute distress otherwise but she does move slowly.,heent: skull is normocephalic. tms intact and shiny with good auditory acuity to finger rub. pupils equal, round, reactive to light and accommodation with extraocular movements intact. fundi benign. sclerae and conjunctivae were normal.,neck: no thyromegaly or cervical lymphadenopathy. carotids are 2+ and equal bilaterally and no bruits present.,lungs: clear to auscultation and percussion with good respiratory movement. no bronchial breath sounds, egophony, or rales are present.,heart: regular rhythm and rate with no murmurs, gallops, rubs, or enlargement. pmi normal position. all pulses are 2+ and equal bilaterally.,abdomen: obese, soft with no hepatosplenomegaly or masses.,breasts: no predominant masses, discharge, or asymmetry.,pelvic exam: normal external genitalia, vagina and cervix. pap smear done. bimanual exam shows no uterine enlargement and is anteroflexed. no adnexal masses or tenderness. rectal exam is normal with soft brown stool hemoccult negative.,extremities: the patient does appear to have some doughiness of all of the mcp joints of the hands and the wrists as well. no real erythema. there is no real swelling of the knees. no new pedal edema.,lymph nodes: no cervical, axillary, or inguinal adenopathy.,neurological: cranial nerves ii-xii are grossly intact. deep tendon reflexes are 2+ and equal bilaterally. cerebellar and motor function intact in all extremities. good vibratory and positional sense in all extremities and dermatomes. plantar reflexes are downgoing bilaterally.,laboratory: ,cbc shows a hemoglobin of 10.5, hematocrit 35.4, otherwise normal. urinalysis is within normal limits. chem profile showed a bun of 54, creatinine 1.4, glucose 116, calcium was 10.8, cholesterol 198, triglycerides 171, hdl 43, ldl 121, tsh is normal, hemoglobin a1c is 5.3.,assessment:,1. arthralgias that are suspicious for inflammatory arthritis, but certainly seems to be more active and bothersome. i think we need to look at this more closely.,2. diarrhea that seems to have resolved. whether this is related to the above is unclear.,3. diabetes mellitus type ii, really fairly well controlled.

the patient states that she has abnormal menstrual periods and cannot remember the first day of her last normal menstrual period. she states that she had spotting for three months daily until approximately two weeks ago, when she believes that she passed a fetus. she states that upon removal of a tampon, she saw a tadpole like structure and believed it to be a fetus. however, she states she did not know that she was pregnant at this time. she denies any abdominal pain or vaginal bleeding. she states that the pregnancy is unplanned; however, she would desire to continue the pregnancy.,past medical history: diabetes mellitus which resolved after weight loss associated with gastric bypass surgery.,past surgical history:,1. gastric bypass.,2. bilateral carpal tunnel release.,3. laparoscopic cholecystectomy.,4. hernia repair after gastric bypass surgery.,5. thoracotomy.,6. knee surgery.,medications:,1. lexapro 10 mg daily.,2. tramadol 50 mg tablets two by mouth four times a day.,3. ambien 10 mg tablets one by mouth at bedtime.,allergies: amoxicillin causes throat swelling. avelox causes iv site swelling.,social history: the patient denies tobacco, ethanol, or drug use. she is currently separated from her partner who is the father of her 21-month-old daughter. she currently lives with her parents in greenville. however, she was visiting the estranged boyfriend in wilkesboro, this week.,gyn history: the patient denies history of abnormal pap smears or stds.,obstetrical history: gravida 1 was a term spontaneous vaginal delivery, complicated only by increased blood pressures at the time of delivery. gravida 2 is current.,review of systems: the 14-point review of systems was negative with the exception as noted in the hpi.,physical examination:,vital signs: blood pressure 134/45, pulse 130, respirations 28. oxygen saturation 100%.,general: patient lying quietly on a stretcher. no acute distress.,heent: normocephalic, atraumatic. slightly dry mucous membranes.,cardiovascular exam: regular rate and rhythm with tachycardia.,chest: clear to auscultation bilaterally.,abdomen: soft, nontender, nondistended with positive bowel sounds. no rebound or guarding.,skin: normal turgor. no jaundice. no rashes noted.,extremities: no clubbing, cyanosis, or edema.,neurologic: cranial nerves ii through xii grossly intact.,psychiatric: flat affect. normal verbal response.,assessment and plan: a 34-year-old caucasian female, gravida 2 para 1-0-0-1, at unknown gestation who presents after suicide attempt.,1. given the substances taken, medications are unlikely to affect the development of the fetus. there have been no reported human anomalies associated with ambien or tramadol use. there is, however, a 4% risk of congenital anomalies in the general population.,2. recommend quantitative hcg and transvaginal ultrasound for pregnancy dating.,3. recommend prenatal vitamins.,4. the patient to follow up as an outpatient for routine prenatal care.,

preoperative diagnosis:, obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis.,postoperative diagnosis: , obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis.,surgical procedure performed: , tonsillectomy and adenoidectomy.,anesthesia: , general endotracheal technique.,surgical findings: ,a 4+/4+ cryptic and hypertrophic tonsils with 2+/3+ hypertrophic adenoid pads.,indications: , we were requested to evaluate the patient for complaints of enlarged tonsils, which cause difficulty swallowing, recurrent pharyngitis, and sleep-induced respiratory disturbance. she was evaluated and scheduled for an elective procedure.,description of surgery: ,the patient was brought to the operative suite and placed supine on the operating room table. general anesthetic was administered. once appropriate anesthetic findings were achieved, the patient was intubated and prepped and draped in the usual sterile manner for a tonsillectomy. he was placed in semi-rose ___ position and a crowe davis-type mouth gag was introduced into the oropharynx. under an operating headlight, the oropharynx was clearly visualized. the right tonsil was grasped with the fossa triangularis and using electrocautery enucleation technique, was removed from its fossa. this followed placing the patient in a suspension position using a mcivor-type mouth gag and a red rubber robinson catheter via the right naris. once the right tonsil was removed, the left tonsil was removed in a similar manner, once again using a needle point bovie dissection at 20 watts. with the tonsils removed, it was possible to visualize the adenoid pads. the oropharynx was irrigated and the adenoid pad evaluated with an indirect mirror technique. the adenoid pad was greater than 2+/4 and hypertrophic. it was removed with successive passes of electrocautery suction. the tonsillar fossa was then once again hemostased with suction cautery, injected with 0.5% ropivacaine with 1:100,000 adrenal solution and then closed with 2-0 monocryl on an sh needle. the redundant soft tissue of the uvula was removed posteriorly and cauterized with electrocautery to prevent swelling of the uvula in the postoperative period. the patient's oropharynx and nasopharynx were irrigated with copious amounts of normal saline contained with small amount of iodine, and she was recovered from her general endotracheal anesthetic. she was extubated and left the operating room in good condition to the postoperative recovery room area.,estimated blood loss was minimal. there were no complications. specimens produced were right and left tonsils. the adenoid pad was ablated with electrocautery.

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

chief complaint:, non-healing surgical wound to the left posterior thigh.,history of present illness: , this is a 49-year-old white male who sustained a traumatic injury to his left posterior thighthis past year while in abcd. he sustained an injury from the patellar from a boat while in the water. he was air lifted actually up to xyz hospital and underwent extensive surgery. he still has an external fixation on it for the healing fractures in the leg and has undergone grafting and full thickness skin grafting closure to a large defect in his left posterior thigh, which is nearly healed right in the gluteal fold on that left area. in several areas right along the graft site and low in the leg, the patient has several areas of hypergranulation tissue. he has some drainage from these areas. there are no signs and symptoms of infection. he is referred to us to help him get those areas under control.,past medical history:, essentially negative other than he has had c. difficile in the recent past.,allergies:, none.,medications: , include cipro and flagyl.,past surgical history: , significant for his trauma surgery noted above.,family history: , his maternal grandmother had pancreatic cancer. father had prostate cancer. there is heart disease in the father and diabetes in the father.,social history:, he is a non-cigarette smoker and non-etoh user. he is divorced. he has three children. he has an attorney.,review of systems:,cardiac: he denies any chest pain or shortness of breath.,gi: as noted above.,gu: as noted above.,endocrine: he denies any bleeding disorders.,physical examination:,general: he presents as a well-developed, well-nourished 49-year-old white male who appears to be in no significant distress.,heent: unremarkable.,neck: supple. there is no mass, adenopathy, or bruit.,chest: normal excursion.,lungs: clear to auscultation and percussion.,cor: regular. there is no s3, s4, or gallop. there is no murmur.,abdomen: soft. it is nontender. there is no mass or organomegaly.,gu: unremarkable.,rectal: deferred.,extremities: his right lower extremity is unremarkable. peripheral pulse is good. his left lower extremity is significant for the split thickness skin graft closure of a large defect in the posterior thigh, which is nearly healed. the open areas that are noted above __________ hypergranulation tissue both on his gluteal folds on the left side. there is one small area right essentially within the graft site, and there is one small area down lower on the calf area. the patient has an external fixation on that comes out laterally on his left thigh. those pin sites look clean.,neurologic: without focal deficits. the patient is alert and oriented.,impression: , several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg.,plan:, plan would be for chemical cauterization of these areas. series of treatment with chemical cauterization till these are closed.

preoperative diagnosis: ,grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening.,postoperative diagnosis: , grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening.,operations:,1. irrigation and debridement of skin subcutaneous tissues, muscle, and bone, right forearm.,2. open reduction, right both bone forearm fracture with placement of long-arm cast.,complications:, none.,tourniquet: , none.,estimated blood loss:, 25 ml.,anesthesia: , general.,indications: ,the patient suffered injury at which time he fell over a concrete bench. he landed mostly on the right arm. he noted some bleeding at the time of the injury and a small puncture wound. he was taken to the emergency room and diagnosed a compound both bone forearm fracture, and based on this, he was seen for malalignment.,he was indicated the above-noted procedure. this procedure as well as alternatives of this procedure was discussed at length with the patient's parents and they understood them well. risks and benefits were also discussed. risks such as bleeding, infection, damage to blood vessels, damage to nerve roots, need for further surgeries, chronic pain on full range of motion, risk of continued discomfort, risk of need for repeat debridement, risk of need for internal fixation, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed. they understood these well. all questions were answered and they signed the consent for procedure as described.,description of procedure: ,the patient was placed on the operating table and general anesthesia was achieved. the right forearm was inspected. there was noted to be a 3-mm puncture-type wound over the volar aspect of the forearm in the middle one-third overlying the radial one-half. there was bleeding in this region. no gross contamination was seen. at this point, under fluoroscopic control, i did attempt to see a fracture. i was unable to do the forearm under the close reduction techniques. at this point, the right upper extremity was then prepped and draped in the usual sterile manner. an incision was made through the puncture wound site extending this proximally and distally. there was noted to be some slight amount of nonviable tissue at the skin edge and debridement was required and performed. i also did perform a light debridement of the nonviable subcutaneous tissue, muscle, and small bony fragments were also removed. these were all completely debrided appropriately and then at this point, a thorough irrigation was performed of the radius, which i communicated through the puncture wound. both ends were clearly visualized, and thorough irrigation was performed using total of 6 l of antibiotic solution. all nonviable gross contaminated tissue was removed. at this point with the bones in direct visualization, i did reduce the bony ends to anatomic alignment with excellent bony approximation. proper alignment of tissue and angulation was confirmed.,at this point, under fluoroscopic control confirmed the radius and ulna in anatomic position, which will be completely displaced and shortened previously. the ulna was now also noted to be in anatomic alignment.,at this point, the region was thoroughly irrigated. hemostasis confirmed and closure then begun. the skin was reapproximated using 3-0 nylon suture. the visual puncture wound region was left open and this was intact with the depth of the wound down the bone using 1.5-inch nugauze with iodoform. sterile dressing applied and a long-arm cast with the forearm in neutral position was applied. x-ray with fluoroscopic evaluation was performed, which confirmed. they maintained excellent bony approximation and the anatomic alignment. the long-arm cast was then completely mature. no complications were encountered throughout the procedure. the patient tolerated the procedure well. the patient was then taken to the recovery room in stable condition.

chief complaint:, status epilepticus.,history of present illness: ,the patient is a 6-year-old male who is a former 27-week premature infant who suffered an intraventricular hemorrhage requiring shunt placement, and as a result, has developmental delay and left hemiparesis. at baseline, he can put about 2 to 4 words together in brief sentences. his speech is not always easily understood; however, he is in a special education classroom in kindergarten. he ambulates independently, but falls often. he has difficulty with his left side compared to the right, and prefers to use the right upper extremity more than the left. mother reports he postures the left upper extremity when running. he is being followed by medical therapy unit and has also been seen in the past by dr. x. he has not received botox or any other interventions with regard to his cerebral palsy.,the patient did require one shunt revision, but since then his shunt has done well.,the patient developed seizures about 2 years ago. these occurred periodically, but they are always in the same and with the involvement of the left side more than right and he had an eye deviation forcefully to the left side. his events, however, always tend to be prolonged. he has had seizures as long as an hour and a half. he tends to require multiple medications to stop them. he has been followed by dr. y and was started on trileptal. at one point, the patient was taken off his medication for presumed failure to prevent his seizures. he was more recently placed on topamax since march 2007. his last seizures were in march and may respectively. he is worked up to a dose of 25 mg capsules, 2 capsules twice a day or about 5 mg/kg/day at this point.,the patient was in his usual state of health until early this morning and was noted to be in seizure. his seizure this morning was similar to the previous seizures with forced deviation of his head and eyes to the left side and convulsion more on the left side than the right. family administered diastat 7.5 mg x1 dose. they did not know they could repeat this dose. ems was called and he received lorazepam 2 mg and then in the emergency department, 15 mg/kg of fosphenytoin. his seizures stopped thereafter, since that time, he had gradually become more alert and is eating, and is nearly back to baseline. he is a bit off balance and tends to be a bit weaker on the left side compared to baseline postictally.,review of systems: , at this time, he is positive for a low-grade fever, he has had no signs of illness otherwise. he does have some fevers after his prolonged seizures. he denies any respiratory or cardiovascular complaints. there is no numbness or loss of skills. he has no rashes, arthritis or arthralgias. he has no oropharyngeal complaints. visual or auditory complaints.,past medical history: , also positive for some mild scoliosis.,social history: , the patient lives at home with mother, father, and 2 other siblings. there are no ill contacts.,family history: , noncontributory.,physical examination:,general: the patient is a well-nourished, well-hydrated male, in no acute distress.,vital signs: his vital signs are stable and he is currently afebrile.,heent: atraumatic and normocephalic. oropharynx shows no lesions.,neck: supple without adenopathy.,chest: clear to auscultation.,cardiovascular: regular rate and rhythm, no murmurs.,abdomen: benign without organomegaly.,extremities: no clubbing, cyanosis or edema.,neurologic: the patient is alert and will follow instructions. his speech is very dysarthric and he tends to run his words together. he is about 50% understandable at best. he does put words and sentences together. his cranial nerves reveal his pupils are equal, round, and reactive to light. his extraocular movements are intact. his visual fields are full. disks are sharp bilaterally. his face shows left facial weakness postictally. his palate elevates midline. vision is intact bilaterally. tongue protrudes midline.,motor exam reveals clearly decreased strength on the left side at baseline. his left thigh is abducted at the hip at rest with the right thigh and leg straight. he has difficulty using the left arm and while reaching for objects, shows exaggerated tremor/dysmetria. right upper extremity is much more on target. his sensations are intact to light touch bilaterally. deep tendon reflexes are 2+ and symmetric. when sitting up, he shows some truncal instability and tendency towards decreased truncal tone and kyphosis. he also shows some scoliotic curve of the spine, which is mild at this point. gait was not tested today.,impression: , this is a 6-year-old male with recurrent status epilepticus, left hemiparesis, history of prematurity, and intraventricular hemorrhage. he is on topamax, which is at a moderate dose of 5 mg/kg a day or 50 mg twice a day. at this point, it is not clear whether this medication will protect him or not, but the dose is clearly not at maximum, and he is tolerating the dose currently. the plan will be to increase him up to 50 mg in the morning, and 75 mg at night for 2 weeks, and then 75 mg twice daily. reviewed the possible side effects of higher doses of topamax, they will monitor him for language issues, cognitive problems or excessive somnolence. i also discussed his imaging studies, which showed significant destruction of the cerebellum compared to other areas and despite this, the patient at baseline has a reasonable balance. the plan from ct standpoint is to continue stretching program, continue with medical therapy unit. he may benefit from botox.,in addition, i reviewed the diastat protocol with parents and given the patient tends to go into status epilepticus each time, they can administer diastat immediately and not wait the standard 2 minutes or even 5 minutes that they were waiting before. they are going to repeat the dose within 10 minutes and they can call ems at any point during that time. hopefully at home, they need to start to abort these seizures or the higher dose of topamax will prevent them. other medication options would include keppra, zonegran or lamictal.,followup: , followup has already been scheduled with dr. y in february and they will continue to keep that date for followup.

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.

re: sample patient,dear dr. sample:,sample patient was seen at the vision rehabilitation institute on month dd, yyyy. she is an 87-year-old woman with a history of macular degeneration, who admits to having pdt therapy within the last year. she would like to get started with some vision therapy so that she may be able to perform her everyday household chores, as well as reading small print. at this time, she uses a small handheld magnifier, which is providing her with only limited help.,a complete refractive work-up was performed today, in which we found a mild change in her distance correction, which allowed her the ability to see 20/70 in the right eye and 20/200 in the left eye. with a pair of +4 reading glasses, she was able to read 0.5m print quite nicely. i have loaned her a pair of +4 reading glasses at this time and we have started her with fine-detailed reading. she will return to our office in a matter of two weeks and we will make a better determination on what near reading glasses to prescribe for her. i think that she is an excellent candidate for low vision help. i am sure that we can be of great help to her in the near future.,thank you for allowing us to share in the care of your patient.,with best regards,,sample doctor, o.d.

chief complaint: , foot pain.,history of present illness: , this is a 17-year-old high school athlete who swims for the swimming team. he was playing water polo with some of his teammates when he dropped a weight on the dorsal aspects of his feet. he was barefoot at that time. he had been in the pool practicing an hour prior to this injury. because of the contusions and abrasions to his feet, his athletic trainer brought in him to the urgent care. he is able to bear weight; however, complains of pain in his toes. the patient did have some avulsion of the skin across the second and third toes of the left foot with contusions across the second, third, and fourth toes and dorsum of the foot. according to the patient, he was at his baseline state of health prior to this acute event.,past medical history: , significant for attention deficit hyperactivity disorder.,past surgical history: ,positive for wisdom tooth extraction.,family history: , noncontributory.,social history: ,he does not use alcohol, tobacco or illicit drugs. he plays water polo for the school team.,immunization history: , all immunizations are up-to-date for age.,review of systems: , the pertinent review of systems is as noted above; the remaining review of systems was reviewed and is noted to be negative.,present medications: , provigil, accutane and rozerem.,allergies: ,none.,physical examination:,general: this is a pleasant white male in no acute distress.,vital signs: he is afebrile. vitals are stable and within normal limits.,heent: negative for acute evidence of trauma, injury or infection.,lungs: clear.,heart: regular rate and rhythm with s1 and s2.,abdomen: soft.,extremities: there are some abrasions across the dorsum of the right foot including the second, third and fourth toes. there is some mild tenderness to palpation. however, there are no clinical fractures. distal pulses are intact. the left foot notes superficial avulsion lacerations to the third and fourth digit. there are no subungual hematomas. range of motion is decreased secondary to pain. no obvious fractures identified.,back exam: nontender.,neurologic exam: he is alert, awake and appropriate without deficit.,radiology: , ap, lateral, and oblique views of the feet were conducted per radiology, which were negative for acute fractures and significant soft tissue swelling or bony injuries.,on reevaluation, the patient was resting comfortably. he was informed of the x-ray findings. the patient was discharged in the care of his mother with a preliminary diagnosis of bilateral foot contusions with superficial avulsion lacerations, not requiring surgical repair.,discharge medications: , darvocet.,the patient's condition at discharge was stable. all medications, discharge instructions and follow-up appointments were reviewed with the patient/family prior to discharge. the patient/family understood the instructions and was discharged without further incident.

chief complaint:, headaches.,headache history:, the patient describes the gradual onset of a headache problem. the headache first began 2 months ago. the headaches are located behind both eyes. the pain is characterized as a sensation of pressure. the intensity is moderately severe, making normal activities difficult. associated symptoms include sinus congestion and photophobia. the headache may be brought on by stress, lack of sleep and alcohol. the patient denies vomiting and jaw pain.,past medical history:, no significant past medical problems.,past surgical history:, ,no significant past surgical history.,family medical history:, ,there is a history of migraine in the family. the condition affects the patient’s brother and maternal grandfather.,allergies:, codeine.,current medications:, see chart.,personal/social history:, marital status: married. the patient smokes 1 pack of cigarettes per day. denies use of alcohol.,neurologic drug history:, the patient has had no help with the headaches from over-the-counter analgesics.,review of systems:,ros general: generally healthy. weight is stable.,ros head and eyes: patient has complaints of headaches. vision can best be described as normal.,ros ears nose and throat: the patient notes some sinus congestion.,ros cardiovascular: the patient has no history of any cardiovascular problems and denies any present problems.,ros gastrointestinal: the patient has no history of gastrointestinal problems and denies any present problems.,ros musculoskeletal: no muscle cramps, no joint back or limb pain. the patient denies any past or present problem related to the musculoskeletal system.,exam:,exam general appearance: the patient was alert and cooperative, and did not appear acutely or chronically ill.,sex and race: male, caucasian.,exam mental status: serial 7’s were performed normally. the patient was oriented with regard to time, place and situation.,three out of three objects were readily recalled after several minutes. the patient correctly identified the president and past president. the patient could repeat 7 digits forward and 4 digits reversed without difficulty. the patient’s affect and emotional response was normal and appropriate. the patient related the clinical history in a coherent, organized fashion.,exam cranial nerves: sense of smell was intact.,exam neck: neck range of motion was normal in all directions. there was no evidence of cervical muscle spasm. no radicular symptoms were elicited by neck motions. shoulder range of motion was normal bilaterally. there were no areas of tenderness. tests of neurovascular compression were negative. there were no carotid bruits.,exam back: back range of motion was normal in all directions.,exam sensory: position and vibratory sense was normal.,exam reflexes: active and symmetrical. there were no pathological reflexes.,exam coordination: the patient’s gait had no abnormal components. tandem gait was performed normally.,exam musculoskeletal: peripheral pulses palpably normal. there is no edema or significant varicosities. no lesions identified.,impression diagnosis: ,migraine without aura (346.91),comments:, the patient has evolved into a chronic progressive course. medications prescribed: therapeutic trial of inderal 40mg - 1/2 tab b.i.d. x 1 week, then 1 tab. b.i.d. x 1 week then 1 tab t.i.d.,other treatment:, the patient was given a thorough explanation of the role of stress in migraine, and given a number of suggestions about implementing appropriate changes in lifestyle.,rationale for treatment plan:, the treatment plan chosen is the most effective and should result in the most beneficial outcome for the patient. there are no reasonable alternatives.,follow up instructions:

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

admission diagnosis: , symptomatic thyroid goiter.,discharge diagnosis: ,symptomatic thyroid goiter.,procedure performed during this hospitalization: , total thyroidectomy.,indications for the surgery: ,briefly, the patient is a 71-year-old female referred with increasingly symptomatic large nodular thyroid goiter. she presented now after informed consent for the above procedure, understanding the inherent risks and complications and risk-benefit ratio.,hospital course: ,the patient underwent total thyroidectomy on 09/22/08, which she tolerated very well and remained stable in the postoperative period. on postoperative day #1, she was tolerating her diet, began on thyroid hormone replacement, and remained afebrile with stable vital signs. she required intravenous narcotics for pain control. she was judged stable for discharge home on 09/25/08, tolerating a diet well, having no fever, stable vital signs, and good pain control. the wound was clean and dry. the drain was removed. she was instructed to follow up in the surgical office within one week after discharge. she was given prescription for vicodin for pain and synthroid thyroid hormone, and otherwise the appropriate wound care instructions per my routine wound care sheet.

history of present illness: , mr. a is a 50-year-old gentleman with a history of atrial fibrillation in the past, more recently who has had atrial flutter, who estimates he has had six cardioversions since 10/09, and estimates that he has had 12 to 24 in his life beginning in 2006 when the atrial fibrillation first emerged. he, since 10:17 p.m. on 01/17/10, noted recurrence of his atrial fibrillation, called our office this morning, that is despite being on flecainide, atenolol, and he is maintained on coumadin.,the patient has noted some lightheadedness as well as chest discomfort and shortness of breath when atrial flutter recurred and we see that on his 12-lead ekg here. otherwise, no chest pain.,past medical history: , significant for atrial fibrillation/atrial flutter and again he had atrial fibrillation more persistently in 2006, but more recently it has been atrial flutter and that is despite use of antiarrhythmics including flecainide. he completed a stress test in my office within the past several weeks that was normal without evidence of ischemia. other medical history is significant for hyperlipidemia.,medications:,as outpatient,,1. atenolol 25 mg once a day.,2. altace 2.5 mg once a day.,3. zocor 20 mg once a day.,4. flecainide 200 in the morning and 100 in the evening.,5. coumadin as directed by our office.,allergies: , to medications are none. he denies shrimp, sea food or dye allergy.,family history: , he has a nephew who was his sister's son who passed away at age 22 reportedly from an mi, but was reported to have hypertrophic cardiomyopathy as well. the patient has previously met with the electrophysiologist, dr. x, at general hospital and it sounds like he had a negative ep study.,social history: , the patient does not smoke cigarettes, abuse alcohol nor drink any caffeine. no use of illicit drugs. he has been married for 22 years and he is actually accompanied throughout today's cardiology consultation by his wife. he is not participating in regular exercises now because he states since starting flecainide, he has gotten sluggish. he is employed as an attorney and while he states that overall his mental stress is better, he has noted more recent mental stress this past weekend when he was taking his daughter back to college.,review of systems: , he denies any history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi. there are some questions especially as his wife has told me that he may have obstructive sleep apnea and not had a formal sleep study.,physical exam: , blood pressure 156/93, pulse is 100, respiratory rate 18. on general exam, he is a pleasant overweight gentleman, in no acute distress. heent: shows cranium is normocephalic and atraumatic. he has moist mucosal membranes. neck veins are not distended. there are no carotid bruits. visible skin warm and perfused. affect appropriate. he is quite oriented and pleasant. no significant kyphoscoliosis on recumbent back exam. lungs are clear to auscultation anteriorly. no wheezes. no egophony. cardiac exam: s1, s2. regular rate, controlled. no significant murmurs, rubs or gallops. pmi is nondisplaced. abdomen is soft, nondistended, appears benign. extremities without significant edema. pulses grossly intact.,diagnostic studies/lab data:, initial ecg shows atrial flutter.,impression: , mr. a is a 50-year-old gentleman with a history of paroxysmal atrial fibrillation in the past, more recently is having breakthrough atrial flutter despite flecainide and we had performed a transesophageal echocardiogram-guided cardioversion for him in late 12/20/09, who now has another recurrence within the past 41 hours or so. i have reviewed again with him in detail regarding risks, benefits, and alternatives of proceeding with cardioversion, which the patient is in favor of. after in depth explanation of the procedure with him that there would be more definitive resumption of normal sinus rhythm by using electrocardioversion with less long-term side effects, past the acute procedure, alternatives being continued atrial flutter with potential for electrophysiologic consultation for ablation and/or heart rate control with anticoagulation, which the patient was not interested nor was i primarily recommending as the next step, and risks including, but not limited to and the patient was aware and this was all done in the presence of his wife that this is not an all-inclusive list, but the risks include but not limited to oversedation from conscious sedation, risk of aspiration pneumonia from regurgitation of stomach contents, which would be less likely as i did confirm with the patient that he had been n.p.o. for greater than 15 hours, risk of induction of other arrhythmias including tachyarrhythmias requiring further management including cardioversion or risk of bradyarrhythmias, in the past when we had a cardioverter with 150 joules, he did have a 5.5-second pause especially while he is on antiarrhythmic therapy, statistically less significant risk of cva, although we cannot really make that null. the patient expressed understanding of this risk, benefit, and alternative analysis. i invited questions from him and his wife and once their questions were answered to their self-stated satisfaction, we planned to go forward with the procedure.,procedure note: ,the patient received a total of 7 mg of versed and 50 micrograms of fentanyl utilizing titrate-down sedation with good effect and this was after the appropriate time-out procedure had been done as per the medical center universal protocol with appropriate identification of the patient, position, procedure documentation, procedure indication, and there were no questions. the patient did actively participate in this time-out procedure. after the universal protocol was done, he then received the cardioversion attempt with 50 joules using "lollipop posterior patch" with hands-driven paddle on the side, which was 50 joules of synchronized biphasic energy. there was successful resumption of normal sinus rhythm, in fact this time there was not a significant pause as compared to when he had this done previously in late 12/09 and this sinus rhythm was confirmed by a 12-lead ekg.,impression: , cardioversion shows successful resumption of normal sinus rhythm from atrial flutter and that is while the patient has been maintained on coumadin and his inr is 3.22. we are going to watch him and discharge him from the medical center area on his current flecainide of 200 mg in the morning and 100 mg in the evening, atenolol 25 mg once a day, coumadin _____ as currently being diagnosed. i had previously discussed with the patient and he was agreeable with meeting with his electrophysiologist again, dr. x, at electrophysiology unit at general hospital and i will be planning to place a call for dr. x myself. again, he has no ischemia on this most recent stress test and i suppose in the future it may be reasonable to get obstructive sleep apnea evaluation and that may be one issue promulgating his symptoms.,i had previously discussed the case with dr. y who is the patient's general cardiologist as well as updated his wife at the patient's bedside regarding our findings.

indication for operation:, right coronal synostosis with left frontal compensatory bossing causing plagiocephaly.,preoperative diagnosis:, syndromic craniosynostosis.,postoperative diagnosis: , syndromic craniosynostosis.,title of operation: , anterior cranial vault reconstruction with fronto-orbital bar advancement.,specimens: , none.,drains: , one subgaleal drain exiting from the left posterior aspect of wound.,description of procedure:, after satisfactory general endotracheal tube anesthesia was started, the patient was placed on the operating table in supine position with the head held on a horseshoe-shaped headrest and the head was prepped and draped down the routine manner. here, the proposed scalp incision was infiltrated with 1% xylocaine and then a zigzag scalp incision was made from one ear to the other ear, posterior to the coronal suture. scalp incision was reflected anteriorly and then the periosteum was taken off of the bone and then the temporalis muscles were reflected anterolaterally until the anterior cranial vault was exposed and then the periorbital rim, nasion and orbital part of the zygomatic arch were all dissected out as well as the pterion. using a craniotome, several bur holes were made; two on the either side of the midline posteriorly and then two posterolaterally. the two posterior bur holes were then connected with a punch over the superior sagittal sinus and then the craniotome was used to fashion a flap first on the left and then on the right, going paramedian along the superior sagittal sinus in the midline and then curving over the fronto-orbital bar. we then dissected superior sagittal sinus off of the inner table of the right bundle flap and then connected the right bundle flap going across the pterion on the right, which was abnormal. the pterion on the right was then run short down after removing both bone flaps and then the dura was dissected off from the orbital roofs. on the right, the orbital roof was jagged and abnormal and we had to repair a csf leak from where the dura was punctured by the orbital roof. the orbital rim was then dissected out and then using the saw and chisels, we were able to make the releasing cuts to free up the orbital rims, zygomatic arch and then remove the orbital bar going posteriorly and then the distal bar was split in the middle and then reapproximated with a bone graft in the middle to move the orbits out a little bit and the orbital bar was held together using absorbable plate. it was then replaced and advanced and then relaxing, barrel-staving incisions were made in the bone flaps and the orbital rim and it was held on the right side with an absorbable plate to fix it in the proper position. the bone flaps were then reapproximated using absorbable plates and screws, as well as #2-0 vicryl to secure back into place. some of the places were also secured in the midline posteriorly, as well as off to the right where the bony defects were in place. the periosteum was then brought over the skull and fastened in place and the temporalis muscles were tacked up to the periosteum. the wounds were irrigated out. a drain was left in posteriorly and then the wounds were closed in a routine manner using vicryl for the galea and fast-absorbing gut for the skin followed by sterile dressings. the patient tolerated the procedure well and did receive blood transfusions.

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

reason for consultation: , antibiotic management for a right foot ulcer and possible osteomyelitis.,history of present illness:, the patient is a 68-year-old caucasian male with past medical history of diabetes mellitus. he was doing fairly well until last week while mowing the lawn, he injured his right foot. he presented to the hospital emergency room. cultures taken from the wound on 06/25/2008, were reported positive for methicillin-sensitive staphylococcus aureus (mssa). the patient was started on intravenous antibiotic therapy with levaquin and later on that was changed to oral formulation. the patient underwent debridement of the wound on 07/29/2008. apparently, mri and a bone scan was performed at that facility, which was reported negative for osteomyelitis. the patient was then referred to the wound care center at general hospital. from there, he has been admitted to long-term acute care facility for wound care with wound vac placement. on exam, he has a lacerated wound on the plantar aspect of the right foot, which extends from the second metatarsal area to the fifth metatarsal area, closed with the area of the head of these bones. the wound itself is deep and stage iv and with exam of her gloved finger in my opinion, the third metatarsal bone is palpable, which leads to the clinical diagnosis of osteomyelitis. the patient has serosanguineous drainage in this wound and it tracks under the skin in all directions except distal.,past medical history: , positive for:,1. diabetes mellitus.,2. osteomyelitis of the right fifth toe, which was treated with intravenous antibiotic therapy for 6 weeks about 5 years back.,family history: , positive for mother passing away in her late 60s from heart attack, father had liver cancer, and passed away from that. one of his children suffers from hypothyroidism, 2 grandchildren has cerebral palsy secondary to being prematurely born.,allergies: , no known drug allergies.,review of systems: , positive findings of the foot that have been mentioned above. all other systems reviewed were negative.,physical examination:,general: a 68-year-old caucasian male who was not in any acute hemodynamic distress at present.,vital signs: show a maximum recorded temperature of 98, pulse is rating between 67 to 80 per minute, respiratory rate is 20 per minute, blood pressure is varying between 137/63 to 169/75.,heent: pupils equal, round, reactive to light. extraocular movements intact. head is normocephalic. external ear exam is normal.,neck: supple. there is no palpable lymphadenopathy.,cardiovascular: regular rate and rhythm of the heart without any appreciable murmur, rub or gallop.,lungs: clear to auscultation and percussion bilaterally.,abdomen: soft, nontender, and nondistended without any organomegaly and bowel sounds are positive. there is no palpable lymphadenopathy in the inguinal and femoral area.,extremities: there is no cyanosis, clubbing or edema. there is no peripheral stigmata of endocarditis. on the plantar aspect of the distal part of the right foot, the patient has a lacerated wound, which extends from the second metatarsal area to the fifth metatarsal area. tracking under the skin is palpable with a gloved finger in all direction except the distal one. on the proximal tracking, the area of the wound, the third metatarsal bone is palpable. therefore, clinically, the patient has diagnoses of osteomyelitis.,central nervous system: the patient is alert, oriented x3. cranial nerves ii through xii are intact. there is no focal deficit appreciated.,laboratory data:, no laboratory or radiological data is available at present in the chart.,impression/plan: , a 68-year-old caucasian male with history of diabetes mellitus who had an accidental lawn mower-associated injury on the right foot. he has undergone debridement on 07/29/2008. culture results from the debridement procedure are not available. wound cultures from 07/25/2008 showed methicillin-sensitive staphylococcus aureus.,from the infectious disease point of view, the patient has the following problems, and i would recommend following treatments strategy.,1. right foot infected ulcer with clinical evidence of osteomyelitis. even if the mri and bone scan are negative, the treatment should be guided with diagnosis on clinical counts in my opinion. cultures have been reported positive for methicillin-sensitive staphylococcus aureus. therefore, i would discontinue the current antibiotic regimen of oral levaquin, zyvox, and intravenous zosyn, and start the patient on intravenous ancef 2 g q.8 h. we will need to continue this treatment for 6 weeks for treatment of osteomyelitis and deep wound infection. i would also recommend continuation of wound care and wound vac placement that would start tomorrow. we will get a picc line placed to complete the 6-week course of intravenous antibiotic therapy.,2. we would check labs including cbc with differential, chemistry 7 panel, lfts, esr, and c-reactive protein levels every monday and chemistry 7 panel and cbc every thursday for the duration of antibiotic therapy.,3. i will continue to monitor wound healing 2 to 3 times a week. wound care will be managed by the wound care team at the long-term acute care facility.,4. the treatment plan was discussed in detail with the patient and his daughter who was visiting him when i saw him.,5. other medical problems will continue to be followed and treated by dr. x's group during this hospitalization.,6. i appreciate the opportunity of participating in this patient's care. if you have any questions please feel free to call me at any time. i will continue to follow the patient along with you for the next few days during this hospitalization. we would also try to get the results of the deep wound cultures from 07/29/2008, mri, and bone scan from hospital.

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.

reason for consult: , a patient with non-q-wave myocardial infarction.,history of present illness: , the patient is a pleasant 52-year-old gentleman with a history of diabetes mellitus, hypertension, and renal failure, on dialysis, who presented with emesis, dizziness, and nausea for the last few weeks. the patient reports having worsening emesis and emesis a few times. no definite chest pains. the patient is breathing okay. the patient denies orthopnea or pnd.,past medical history:,1. diabetes mellitus.,2. hypertension.,3. renal failure, on dialysis.,medications:, aspirin, coreg, doxazosin, insulin, metoclopramide, simvastatin, and starlix.,allergies: ,no known drug allergies.,social history: , the patient denies tobacco, alcohol or drug use.,family history: , negative for early atherosclerotic heart disease.,review of systems: , general: the patient denies fever or chills. pulmonary: the patient denies hemoptysis. cardiovascular: refer to hpi. gi: the patient denies hematemesis or melena. the rest of systems review is negative.,physical examination:,vital signs: pulse 71, blood pressure 120/70, and respiratory rate 18.,general: a well-nourished, well-developed male in no acute distress.,heent: normocephalic, atraumatic. pupils seem to be equal, round, and reactive. extraocular muscles are full, but the patient has left eye ptosis.,neck: supple without jvd or lymphadenopathy.,lungs: clear to auscultation bilaterally.,cardiovascular: pmi is displaced 0.5 cm lateral to the midclavicular line. regular rate and rhythm, s1, s2. no definite s3, 2/6 holosystolic murmur at the apex radiating to the axilla.,abdomen: positive bowel sounds, nondistended and nontender. no hepatosplenomegaly.,extremities: trace pedal edema.,ekg shows atrial fibrillation with rapid ventricular response at 164 with old anteroseptal myocardial infarction and old inferior wall myocardial infarction. subsequent ekg in sinus rhythm shows sinus rhythm with old inferior wall myocardial infarction and probable anteroseptal myocardial infarction with q-waves in v1, v2, and up to v3.,laboratory exam: , wbc 28,800, hemoglobin 13.6, hematocrit 40, and platelets 266,000. pt 11.3, inr 1.1, and ptt 24.1. sodium 126, potassium 4.3, chloride 86, co2 26, glucose 371, bun 80, and creatinine 8.4. ck was 261, then 315, and then 529 with ck-mb of 8.06, then 8.69, and then 24.6. troponin was 0.051, then 0.46, and then 19.8 this morning.,impression:,1. paroxysmal atrial fibrillation. the heart rate was slowed down with iv cardizem, the patient converted to sinus rhythm. the patient is currently in sinus rhythm.,2. emesis. the etiology is unclear. the patient reports that the emesis is better. the patient is just having some nausea.,3. non-q-wave myocardial infarction. ekg shows atrial fibrillation with old anteroseptal myocardial infarction and old inferior wall myocardial infarction.,4. diabetes mellitus.,5. renal failure.,6. hypertension.,7. hypercholesterolemia.,plan:,1. we will start amiodarone to keep from going back into atrial fibrillation.,2. echocardiogram.,3. aspirin and iv heparin.,4. serial ck-mb and troponin.,5. cardiac catheterization, possible percutaneous coronary intervention. the risks, benefits, and alternatives were explained to the patient through a translator. the patient understands and wishes to proceed.,6. iv integrilin.

preoperative diagnoses:, empyema of the left chest and consolidation of the left lung.,postoperative diagnoses:, empyema of the left chest, consolidation of the left lung, lung abscesses of the left upper lobe and left lower lobe.,operative procedure: , left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses, and multiple biopsies of pleura and lung.,anesthesia:, general.,findings: , the patient has a complex history, which goes back about four months ago when she started having respiratory symptoms and one week ago she was admitted to another hospital with hemoptysis and on her evaluation there which included two cat scans of chest she was found to have marked consolidation of the left lung with a questionable lung abscess or cavity with hydropneumothorax. there was also noted to be some mild infiltrates of the right lung. the patient had a 30-year history of cigarette smoking. a chest tube was placed at the other hospital, which produced some brownish fluid that had foul odor, actually what was thought to be a fecal-like odor. then an abdominal ct scan was done, which did not suggest any communication of the bowel into the pleural cavity or any other significant abnormalities in the abdomen on the abdominal ct. the patient was started on antibiotics and was then taken to the operating room, where there was to be a thoracoscopy performed. the patient had a flexible fiberoptic bronchoscopy that showed no endobronchial lesions, but there was bloody mucous in the left main stem bronchus and this was suctioned out. this was suctioned out with the addition of the use of saline ***** in the bronchus. following the bronchoscopy, a double lumen tube was placed, but it was not possible to secure the double lumen to the place so we did not proceed with the thoracoscopy on that day.,the patient was transferred for continued evaluation and treatment. today, the double lumen tube was placed and there was some erythema of the mucosa noted in the airways in the bronchi and also remarkably bloody secretions were also noted. these were suctioned, but it was enough to produce a temporary obstruction of the left mainstem bronchus. eventually, the double lumen tube was secured and an attempt at a left thoracoscopy was performed after the chest tube was removed and digital dissection was carried out through that. the chest tube tract, which was about in the sixth or seventh intercostal space, but it was not possible to dissect enough down to get a acceptable visualization through this tract. a second incision for thoracoscopy was made about on the sixth intercostal space in the midaxillary line and again some digital dissection was carried out but it was not enough to be able to achieve an opening or space for satisfactory inspection of the pleural cavity. therefore the chest was opened and remarkable findings included a very dense consolidation of the entire lung such that it was very hard and firm throughout. remarkably, the surface of the lower lobe laterally was not completely covered with a fibrotic line, but it was more the line anterior and posterior and more of it over the left upper lobe. there were many pockets of purulent material, which had a gray-white appearance to it. there was quite a bit of whitish fibrotic fibrinous deposit on the parietal pleura of the lung especially the upper lobe. the adhesions were taken down and they were quite bloody in some areas indicating that the process had been present for some time. there seemed to be an abscess that was about 3 cm in dimension, all the lateral basilar segment of the lower lobe near the area where the chest tube was placed. many cultures were taken from several areas. the most remarkable finding was a large cavity, which was probably about 11 cm in dimension, containing grayish pus and also caseous-like material, it was thought to be perhaps necrotic lung tissue, perhaps a deposit related to tuberculosis in the cavity.,the apex of the lung was quite densely adhered to the parietal pleura there and the adhesions were quite thickened and firm.,procedure and technique:, with the patient lying with the right side down on the operating table the left chest was prepped and draped in sterile manner. the chest tube had been removed and initially a blunt dissection was carried out through the old chest tube tract, but then it was necessary to enlarge it slightly in order to get the thoracoport in place and this was done and as mentioned above we could not achieve the satisfactory visualization through this. therefore, the next incision for thoracoport and thoracoscopy insertion through the port was over the sixth intercostal space and a little bit better visualization was achieved, but it was clear that we would be unable to complete the procedure by thoracoscopy. therefore posterolateral thoracotomy incision was made, entering the pleural space and what is probably the sixth intercostal space. quite a bit of blunt and sharp and electrocautery dissection was performed to take down adhesions to the set of the fibrinous deposit on the pleural cavity. specimens for culture were taken and specimens for permanent histology were taken and a frozen section of one of the most quite dense. suture ligatures of prolene were required. when the cavity was encountered it was due to some compression and dissection of some of the fibrinous deposit in the upper lobe laterally and anterior and this became identified as a very thin layer in one area over this abscess and when it was opened it was quite large and we unroofed it completely and there was bleeding down in the depths of the cavity, which appeared to be from pulmonary veins and these were sutured with a "tissue pledget" of what was probably intercostal nozzle and endothoracic fascia with prolene sutures.,also as the upper lobe was retracted in caudal direction the tissue was quite dense and the superior branch of the pulmonary artery on the left side was torn and for hemostasis a 14-french foley catheter was passed into the area of the tear and the balloon was inflated, which helped establish hemostasis and suturing was carried out again with utilizing a small pledget what was probably intercostal muscle and endothoracic fascia and this was sutured in place and the foley catheter was removed. the patch was sutured onto the pulmonary artery tear. a similar maneuver was utilized on the pulmonary vein bleeding site down deep in the cavity. also on the pulmonary artery repair some ***** material was used and also thrombin, gelfoam and surgicel. after reasonably good hemostasis was established pleural cavity was irrigated with saline. as mentioned, biopsies were taken from multiple sites on the pleura and on the edge and on the lung. then two #24 blake chest tubes were placed, one through a stab wound above the incision anteriorly and one below and one in the inferior pleural space and tubes were brought out through stab wounds necked into the skin with 0 silk. one was positioned posteriorly and the other anteriorly and in the cephalad direction of the apex. these were later connected to water-seal suction at 40 cm of water with negative pressure.,good hemostasis was observed. sponge count was reported as being correct. intercostal nerve blocks at probably the fifth, sixth, and seventh intercostal nerves was carried out. then the sixth rib had been broken and with retraction the fractured ends were resected and rongeur used to smooth out the end fragments of this rib. metallic clip was passed through the rib to facilitate passage of an intracostal suture, but the bone was partially fractured inferiorly and it was very difficult to get the suture out through the inner cortical table, so that pericostal sutures were used with #1 vicryl. the chest wall was closed with running #1 vicryl and then 2-0 vicryl subcutaneous and staples on the skin. the chest tubes were connected to water-seal drainage with 40 cm of water negative pressure. sterile dressings were applied. the patient tolerated the procedure well and was turned in the supine position where the double lumen endotracheal tube was switched out with single lumen. the patient tolerated the procedure well and was taken to the intensive care unit in satisfactory condition.

chief complaint:, left wrist pain.,history of present problem:,

the patient's home regimen includes duragesic patch at 125 mcg every 3 days. she is currently on a dilaudid pca of 1 mg every 10 minutes lockout, dilaudid boluses 2 mg q.3 h. p.r.n., ativan 2 mg q.4 h., tylenol per rectum. the patient was offered multiple procedures to help with her abdominal pain including a thoracic epidural placement for sympathetic block for pain control and a celiac plexuses/neurolytic block. the patient's family and she will continue to think about these pain procedures and let us know if they are interested in either. for the moment, we will not make any further recommendations on her current medical management. we did ask dr. x, a psychiatrist, who works for the pain service to come in and see ms. a as anxiety is a large component of her suffering at this time.,

chief complaint: , decreased ability to perform daily living activities secondary to exacerbation of chronic back pain.,history of present illness:, the patient is a 45-year-old white male who was admitted with acute back pain. the patient reports that he had chronic problem with back pain for approximately 20 years, but it has gotten progressively worse over the last 3 years. on 08/29/2007, the patient had awoken and started his day as he normally does, but midday, he reports that he was in such severe back pain and he was unable to walk or stand upright. he was seen at abcd hospital emergency room, was evaluated and admitted. he was treated with iv analgesics as well as decadron, after being evaluated by dr. a. it was decided that the patient could benefit from physical therapy, since he was unable to perform adls, and was transferred to tcu at st. joseph health services on 08/30/2007. he had been transferred with diagnosis of a back pain secondary to intravertebral lumbar disk disease, secondary to degenerative changes. the patient reports that he has had a " bulging disk" for approximately 1 year. he reports that he has history of testicular cancer in the distant past and the most recent bone scan was negative. the bone scan was done at xyz hospital, ordered by dr. b, the patient's oncologist.,allergies: , penicillin, amoxicillin, cephalosporin, doxycycline, ivp dye, iodine, and sulfa, all cause hives.,additionally, the patient reports that he has hives when he comes in contact with sap from the mango tree, and therefore, he avoids any mango product at all.,past medical history: , status post right orchiectomy secondary to his testicular cancer 18 years ago approximately 1989, gerd, irritable bowel syndrome, seasonal asthma (fall and spring) triggered by postnasal drip, history of bilateral carpal tunnel syndrome, and status post excision of abdominal teratoma and incisional hernia.,family history:, noncontributory.,social history: , the patient is employed in the finance department. he is a nonsmoker. he does consume alcohol on the weekend as much as 3 to 4 alcoholic beverages per day on the weekends. he denies any iv drug use or abuse.,review of systems: , no chills, fever, shakes or tremors. denies chest pain palpitations, hemoptysis, shortness of breath, nausea, vomiting, diarrhea, constipation or hematemesis. the patient reports that his last bowel movement was on 08/30/2007. no urological symptoms such as dysuria, frequency, incomplete bladder emptying or voiding difficulties. the patient does report that he has occasional intermittent "numbness and tingling" of his hands bilaterally as he has a history of bilateral carpal tunnel syndrome. he denies any history of seizure disorders, but he did report that he had some momentary dizziness earlier, but that has since resolved.,physical examination:,vital signs: at the time of admission, temperature 98, blood pressure 176/97, pulse 86, respirations 20, and 95% o2 saturation on room air. the patient weighs 260 pounds and is 5 feet and 10 inches tall by his report.,general: the patient appears to be comfortable, in no acute distress.,heent: normocephalic. sclerae are nonicteric. eomi. tongue is at midline and no evidence of thrush.,neck: trachea is at the midline.,lymphatics: no cervical or axillary nodes palpable.,lungs: clear to auscultation bilaterally.,heart: regular rate and rhythm. normal s1 and s2.,abdomen: obese, softly protuberant, and nontender.,extremities: there is no clubbing, cyanosis or edema. there is no calf tenderness bilaterally. bilateral strength is 5/5 for the upper extremities bilaterally and he has 5/5 of left lower extremity. the right lower extremity is 4-5/5.,mental status: he is alert and oriented. he was pleasant and cooperative during the examination.,assessment:,1. acute on chronic back pain. the patient is admitted to the tcu at st. joseph health services for rehabilitation therapy. he will be seen in consultation by physical therapy and occupational therapy. he will continue a tapering dose of decadron over the next 10 to 14 days and a tapering schedule has been provided, also percocet 5/325 mg 1 to 2 tablets q.i.d. p.r.n. for pain.,2. status post right orchiectomy secondary to testicular cancer, stable at this time. we will attempt to obtain copy of the most recent bone scan performed at xyz hospital ordered by dr. b.,3. gastroesophageal reflux disease, irritable bowel syndrome, and gastrointestinal prophylaxis. colace 100 mg b.i.d., lactulose will be used on a p.r.n. basis, and protonix 40 mg daily.,4. deep vein thrombosis prophylaxis will be maintained by the patient, continue to engage in his therapies including ambulating in the halls and doing leg exercises as well.,5. obesity. as mentioned above, the patient's weighs 260 pounds with a height of 5 feet and 10 inches, and we had discussed possible weight loss plan, which he is interested in pursuing and a dietary consult has been requested.

operation,1. right upper lung lobectomy.,2. mediastinal lymph node dissection.,anesthesia,1. general endotracheal anesthesia with dual-lumen tube.,2. thoracic epidural.,operative procedure in detail: , after obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room, and general endotracheal anesthesia was administered with a dual-lumen tube. next, the patient was placed in the left lateral decubitus position, and his right chest was prepped and draped in the standard surgical fashion. we used a #10-blade scalpel to make an incision in the skin approximately 1 fingerbreadth below the angle of the scapula. dissection was carried down in a muscle-sparing fashion using bovie electrocautery. the 5th rib was counted, and the 6th interspace was entered. the lung was deflated. we identified the major fissure. we then began by freeing up the inferior pulmonary ligament, which was done with bovie electrocautery. next, we used bovie electrocautery to dissect the pleura off the lung. the pulmonary artery branches to the right upper lobe of the lung were identified. of note was the fact that there was a visible, approximately 4 x 4-cm mass in the right upper lobe of the lung without any other metastatic disease palpable. as mentioned, a combination of bovie electrocautery and sharp dissection was used to identify the pulmonary artery branches to the right upper lobe of the lung. next, we began by ligating the pulmonary artery branches of the right upper lobe of the lung. this was done with suture ligature in combination with clips. after taking the pulmonary artery branches of the right upper lobe of the lung, we used a combination of blunt dissection and sharp dissection with metzenbaum scissors to separate out the pulmonary vein branch of the right upper lobe of the lung. this likewise was ligated with a 0 silk. it was stick-tied with a 2-0 silk. it was then divided. next we dissected out the bronchial branch to the right upper lobe of the lung. a curved glover was placed around the bronchus. next a ta-30 stapler was fired across the bronchus. the bronchus was divided with a #10-blade scalpel. the specimen was handed off. we next performed a mediastinal lymph node dissection. clips were applied to the base of the feeding vessels to the lymph nodes. we inspected for any signs of bleeding. there was minimal bleeding. we placed a #32-french anterior chest tube, and a #32-french posterior chest tube. the rib space was closed with #2 vicryl in an interrupted figure-of-eight fashion. a flat jackson-pratt drain, #10 in size, was placed in the subcutaneous flap. the muscle layer was closed with a combination of 2-0 vicryl followed by 2-0 vicryl, followed by 4-0 monocryl in a running subcuticular fashion. sterile dressing was applied. the instrument and sponge count was correct at the end of the case. the patient tolerated the procedure well and was transferred to the pacu in good condition.

preoperative diagnosis: , left medial compartment osteoarthritis of the knee.,postoperative diagnosis:, left medial compartment osteoarthritis of the knee.,procedure performed:, left unicompartmental knee replacement.,components used:, biomet size medium femoral component size b tibial tray and a 3 mm polyethylene component.,complications:, none.,tourniquet time: , 59 minutes.,blood loss: , minimal.,indications for procedure: , a 55-year-old female who had previously undergone a biomet oxford unicompartmental knee replacement on the right side. she has done quite well with this. she now has had worsening left knee pain predominantly on the inside of her knee and has consented for unicompartmental knee replacement on the left.,description of procedure in detail: , the patient was brought to the operating room and placed supine on the operating room table. after appropriate anesthesia, the left lower extremity was identified with a time out procedure. preoperative antibiotics were given. left lower extremity was then prepped and draped in usual sterile fashion after applying a thigh tourniquet. the tourniquet was insufflated after elevation of the limb, and a standard medial parapatellar incision was used. soft tissue dissection was carried down the retinaculum, was opened sharply to expose the joint, meniscus that was visible along the tibia was removed. the anterior fat pad was removed. the knee was then examined. the acl was found to be intact. the lateral compartment had very minimal arthritis. there were some osteoarthritic changes of the patellofemoral joint, but these were felt to be mild. following this, the tibial external alignment guide was placed and pinned into place in the appropriate place. tibial bone cut was made and checked with a feeler gauge and felt to be an adequate resection. following this resection, the femoral intramedullary guide was placed without difficulty. the femoral cutting guide was then placed and referenced off of this femoral intramedullary guide. once in the appropriate position, it was pinned and drilled. this was removed, and the posterior cutting block was inserted. it was impacted into place. posterior bone cut was made for the medium femoral component. next, a zero spigot was used and the distal femur was reamed. following this, the check of the extension and flexion gaps revealed that an additional 1 mm needed to be reamed, so 1 spigot was used and this was reamed as well. next, trial components were placed into the knee and the knee was taken through range of motion and felt to come out to full extension with a 3 mm poly with a good fit. next, the tibia was prepared. the tibial tray was pinned into place, and the cuts for the keel of the tibia were made. these were removed with a small osteotome from the set. following this, a trial tibial with the keel was placed and it did fit nicely. after this, all trial components were removed. the knee was copiously irrigated. cement was begun mixing. drill holes were used along the femur for cement interdigitation. the wound was cleaned and dried. cement was placed on the tibia. tibial tray was impacted into place. excess cement was removed. tibia was placed in the femur. femoral component was impacted into place. excess cement was removed. it was held with a 4 mm trial insert and approximately 30 degrees of knee flexion until the cement had hardened. following this, it was again trialed with a meniscal bearing implant and it was felt that 3 mm would be the appropriate size. a 3 mm polyethylene was chosen and inserted in the knee without difficulty, taken through range of motion and found to come out to full extension with no impingement and full flexion. the intramedullary rod removed from the femur. the wound was irrigated with normal saline. the retinaculum was closed with #1 pds, 2-0 monocryl was used for the subcutaneous tissue and staples used for the skin. a sterile dressing was placed. tourniquet was then desufflated. sponge and needle counts were correct at the end of the procedure. dr. jinnah was present for the surgery. the patient was transferred to the recovery room in stable condition. she will be weightbearing as tolerated in the left lower extremity and will be maintained on lovenox for dvt prophylaxis. prior to closure, the posterior capsule was injected with the joint cocktail.

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

preoperative diagnoses:,1. nasopharyngeal mass.,2. right upper lid skin lesion.,postoperative diagnoses:,1. nasopharyngeal tube mass.,2. right upper lid skin lesion.,procedures performed:,1. functional endoscopic sinus surgery.,2. excision of nasopharyngeal mass via endoscopic technique.,3. excision of right upper lid skin lesion 1 cm in diameter with adjacent tissue transfer closure.,anesthesia: , general endotracheal.,estimated blood loss: , less than 30 cc.,complications: , none.,indications for procedure: , the patient is a 51-year-old caucasian female with a history of a nasopharyngeal mass discovered with patient's chief complaint of nasal congestion and chronic ear disease. the patient had a fiberoptic nasopharyngoscopy performed in the office which demonstrated the mass and confirmed also on ct scan. the patient also has had this right upper lid skin lesion which appears to be a cholesterol granuloma for numerous months. it appears to be growing in size and is irregularly bordered. after risks, complications, consequences, and questions were addressed to the patient, a written consent was obtained for the procedure.,procedure: , the patient was brought to the operating suite by anesthesia and placed on the operating table in supine position. after this, the patient was turned to 90 degrees by the department of anesthesia. the right upper eyelid skin lesion was injected with 1% lidocaine with epinephrine 1:100,000 approximately 1 cc total. after this, the patient's bilateral nasal passages were then packed with cocaine-soaked cottonoids of 10% solution of 4 cc total. the patient was then prepped and draped in usual sterile fashion and the right upper lid skin was then first cut around the skin lesion utilizing a superblade. after this, the skin lesion was then grasped with a ________ in the superior aspect and the skin lesion was cut and removed in the subcutaneous plane utilizing westcott scissors. after this, the ________ was then hemostatically controlled with monopolar cauterization. the patient's skin was then reapproximated with a running #6-0 prolene suture. a mastisol along with a single steri-strip was in place followed maxitrol ointment. attention then was drawn to the nasopharynx. the cocaine-soaked cottonoids were removed from the nasal passages bilaterally and zero-degree otoscope was placed all the way to the patient's nasopharynx. the patient had a severely deviated nasal septum more so to the right than the left. there appeared to be a spur on the left inferior aspect and also on the right posterior aspect. the nasopharyngeal mass appeared polypoid in nature almost lymphoid tissue looking. it was then localized with 1% lidocaine with epinephrine 1:100,000 of approximately 3 cc total. after this, the lesion was then removed on the right side with the xps blade. the torus tubarius was noted on the left side with the polypoid lymphoid tissue involving this area completely. this area was taken down with the xps blade. prior to taking down this lesion with the xps, multiple biopsies were taken with a straight biter. after this, a cocaine-soaked cottonoid was placed back in the patient's left nasal passage region and the nasopharynx and the attention was then drawn to the right side. the zero-degree otoscope was placed in the patient's right nasal passage and all the way to the nasopharynx. again, the xps was then utilized to take down the nasopharyngeal mass in its entirety with some involvement overlying the torus tubarius. after this, the patient was then hemostatically controlled with suctioned bovie cauterization. a floseal was then placed followed by bilateral merocels and bacitracin-coated ointment. the patient's meroceles were then tied together to the patient's forehead and the patient was then turned back to the anesthesia. the patient was extubated in the operating room and was transferred to the recovery room in stable condition. the patient tolerated the procedure well and sent home and with instructions to followup approximately in one week. the patient will be sent home with a prescription for keflex 500 mg one p.o. b.i.d, and tylenol #3 one to two p.o. q.4-6h. pain #30.

preoperative diagnosis: , retained hardware in left elbow.,postoperative diagnosis:, retained hardware in left elbow.,procedure: , hardware removal in the left elbow.,anesthesia: , procedure done under general anesthesia. the patient also received 4 ml of 0.25% marcaine of local anesthetic.,tourniquet: ,there is no tourniquet time.,estimated blood loss: ,minimal.,complications: ,no intraoperative complications.,history and physical: ,the patient is a 5-year, 8-month-old male who presented to me direct from ed with distracted left lateral condyle fracture. he underwent screw compression for the fracture in october 2007. the fracture has subsequently healed and the patient presents for hardware removal. the risks and benefits of surgery were discussed. the risks of surgery include the risk of anesthesia, infection, bleeding, changes in sensation and motion of extremity, failure of removal of hardware, failure to relieve pain or improved range of motion. all questions were answered and the family agreed to the above plan.,procedure: , the patient was taken to the operating room, placed supine on the operating table. general anesthesia was then administered. the patient's left upper extremity was then prepped and draped in standard surgical fashion. using his previous incision, dissection was carried down through the screw. a guide wire was placed inside the screw and the screw was removed without incident. the patient had an extension lag of about 15 to 20 degrees. elbow is manipulated and his arm was able to be extended to zero degrees dorsiflex. the washer was also removed without incident. wound was then irrigated and closed using #2-0 vicryl and #4-0 monocryl. wound was injected with 0.25% marcaine. the wound was then dressed with steri-strips, xeroform, 4 x4 and bias. the patient tolerated the procedure well and subsequently taken to the recovery in stable condition.,discharge note: , the patient will be discharged on date of surgery. he is to follow up in one week's time for a wound check. this can be done at his primary care physician's office. the patient should keep his postop dressing for about 4 to 5 days. he may then wet the wound, but not scrub it. the patient may resume regular activities in about 2 weeks. the patient was given tylenol with codeine 10 ml p.o. every 3 to 4 hours p.r.n.

admitting diagnoses:,1. bradycardia.,2. dizziness.,3. diabetes.,4. hypertension.,5. abdominal pain.,discharge diagnosis:, sick sinus syndrome. the rest of her past medical history remained the same.,procedures done: , permanent pacemaker placement after temporary internal pacemaker.,hospital course: , the patient was admitted to the intensive care unit. dr. x was consulted. a temporary intracardiac pacemaker was placed. consultation was requested to dr. y. he considered the need to have a permanent pacemaker after reviewing electrocardiograms and telemetry readings. the patient remained in sinus rhythm with severe bradycardias, but all of them one to one transmission. this was considered to be a sick sinus syndrome. permanent pacemaker was placed on 09/05/2007 with right atrium appendage and right ventricular apex electrode placement. this is a medtronic pacemaker. after this, the patient remained with pain in the left side of the chest in the upper area as expected, but well controlled. right femoral artery catheter was removed. the patient remained with good pulses in the right lower extremity with no hematoma. other problem was the patient's blood pressure, which on 09/05/2007 was found at 180/90. medication was adjusted to benazepril 20 mg a day. norvasc 5 mg was added as well. her blood pressure has remained better, being today 144/74 and 129/76.,final diagnoses: ,sick sinus syndrome. the rest of her past medical history remained without change, which are:,1. diabetes mellitus.,2. history of peptic ulcer disease.,3. hypertension.,4. insomnia.,5. osteoarthritis.,plan: , the patient is discharged home to continue her previous home medications, which are:,1. actos 45 mg a day.,2. bisacodyl 10 mg p.o. daily p.r.n. constipation.,3. cosopt eye drops, 1 drop in each eye 2 times a day.,4. famotidine 20 mg 1 tablet p.o. b.i.d.,5. lotemax 0.5% eye drops, 1 drop in each eye 4 times a day.,6. lotensin (benazepril) increased to 20 mg a day.,7. triazolam 0.125 mg p.o. at bedtime.,8. milk of magnesia suspension 30 ml daily for constipation.,9. tylenol no. 3, one to two tablets every 6 hours p.r.n. pain.,10. promethazine 25 mg im every 6 hours p.r.n. nausea or vomiting.,11. tylenol 325 mg tablets every 4 to 6 hours as needed for pain.,12. the patient will finish cefazolin 1 g iv every 6 hours, total 5 dosages after pacemaker placement.,discharge instructions: , follow up in the office in 10 days for staple removal. resume home activities as tolerated with no starch, sugar-free diet.

preoperative diagnosis: , cervical spondylosis at c3-c4 with cervical radiculopathy and spinal cord compression.,postoperative diagnosis:, cervical spondylosis at c3-c4 with cervical radiculopathy and spinal cord compression.,operation performed,1. anterior cervical discectomy of c3-c4.,2. removal of herniated disc and osteophytes.,3. bilateral c4 nerve root decompression.,4. harvesting of bone for autologous vertebral bodies for creation of arthrodesis.,5. grafting of fibular allograft bone for creation of arthrodesis.,6. creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies.,7. placement of anterior spinal instrumentation using the operating microscope and microdissection technique.,indications for procedure: , this 62-year-old man has progressive and intractable right c4 radiculopathy with neck and shoulder pain. conservative therapy has failed to improve the problem. imaging studies showed severe spondylosis of c3-c4 with neuroforaminal narrowing and spinal cord compression.,a detailed discussion ensued with the patient as to the nature of the procedure including all risks and alternatives. he clearly understood it and had no further questions and requested that i proceed.,procedure in detail: , the patient was placed on the operating room table and was intubated using a fiberoptic technique. the methylprednisolone spinal cord protocol was instituted with bolus and continuous infusion doses. the neck was carefully prepped and draped in the usual sterile manner.,a transverse incision was made on a skin crease on the left side of the neck. dissection was carried down through the platysmal musculature and the anterior spine was exposed. the medial borders of the longus colli muscles were dissected free from their attachments to the spine. a needle was placed and it was believed to be at the c3-c4 interspace and an x-ray properly localized this space. castoff self-retaining pins were placed into the body of the c3 and c4. self-retaining retractors were placed in the wound keeping the blades of the retractors underneath the longus colli muscles.,the annulus was incised and a discectomy was performed. quite a bit of overhanging osteophytes were identified and removed. as i worked back to the posterior lips of the vertebral body, the operating microscope was utilized.,there was severe overgrowth of spondylitic spurs. a high-speed diamond bur was used to slowly drill these spurs away. i reached the posterior longitudinal ligament and opened it and exposed the underlying dura.,slowly and carefully i worked out towards the c3-c4 foramen. the dura was extremely thin and i could see through it in several areas. i removed the bony compression in the foramen and identified soft tissue and veins overlying the root. all of these were not stripped away for fear of tearing this very tissue-paper-thin dura. however, radical decompression was achieved removing all the bony compression in the foramen, out to the pedicle, and into the foramen. an 8-mm of the root was exposed although i left the veins over the root intact.,the microscope was angled to the left side where a similar procedure was performed.,once the decompression was achieved, a high-speed cortisone bur was used to decorticate the body from the greater posterior shelf to prevent backward graft migration. bone thus from the drilling was preserved for use for the arthrodesis.,attention was turned to creation of the arthrodesis. as i had drilled quite a bit into the bodies, i selected a large 12-mm graft and distracted the space maximally. under distraction the graft was placed and fit well. an x-ray showed good graft placement.,attention was turned to spinal instrumentation. a synthes short stature plate was used with four 3-mm screws. holes were drilled with all four screws were placed with pretty good purchase. next, the locking screws were then applied. an x-ray was obtained which showed good placement of graft, plate, and screws. the upper screws were near the upper endplate of c3. the c3 vertebral body that remained was narrow after drilling off the spurs. rather than replace these screws and risk that the next holes would be too near the present holes i decided to leave these screws intact because their position is still satisfactory as they are below the disc endplate.,attention was turned to closure. a hemovac drain was placed in the anterior vertebral body space and brought out through a separate stab wound incision in the skin. the wound was then carefully closed in layers. sterile dressings were applied along with a rigid philadelphia collar. the operation was then terminated.,the patient tolerated the procedure well and left for the recovery room in excellent condition. the sponge and needle counts were reported as correct and there were no intraoperative complications.,specimens were sent to pathology consisted of bone and soft tissue as well as c3-c4 disc material.

preoperative diagnosis: , bilateral chronic serous otitis media.,postoperative diagnosis: , bilateral chronic serous otitis media.,operation performed:,1. bilateral myringotomies.,2. insertion of shepard grommet draining tubes.,anesthesia: , general, by mask.,estimated blood loss: , less than 1 ml.,complications:, none.,findings: ,the patient had a long history of persistent recurrent infections and was placed on antibiotics for the same. at this point in time, he had a small amount of thick mucoid material in both middle ear spaces with middle ear mucosa somewhat inflamed, but no active acute infection at this point in time.,procedure:, with the patient under adequate general anesthesia with the mask delivery of anesthesia, he had his ear canals cleaned utilizing an operating microscope and all foul cerumen had been removed from both sides. bilateral inferior radial myringotomies were performed, first on the right and then on the left. middle ear spaces were suctioned of small amount of thick mucoid material on both sides and then shepard grommet draining tubes were inserted on either side. floxin drops were then instilled bilaterally to decrease any clotting within the tubes, and then cotton ball was placed in the external meatus bilaterally. at this point, the patient was awakened and returned to the recovery room, satisfactory, with no difficulty encountered.

s:, abc is in today for a followup of her atrial fibrillation. they have misplaced the cardizem. she is not on this and her heart rate is up just a little bit today. she does complain of feeling dizziness, some vertigo, some lightheadedness, and has attributed this to the coumadin therapy. she is very adamant that she wants to stop the coumadin. she is tired of blood draws. we have had a difficult time getting her regulated. no chest pains. no shortness of breath. she is moving around a little bit better. her arm does not hurt her. her back pain is improving as well.,o:, vital signs as per chart. respirations 15. exam: nontoxic. no acute distress. alert and oriented. heent: tms are clear bilaterally without erythema or bulging. clear external canals. clear tympanic. conjunctivae are clear. clear nasal mucosa. clear oropharynx with moist mucous membranes. neck is soft and supple. lungs are clear to auscultation. heart is irregularly irregular, mildly tachycardic. abdomen is soft and nontender. extremities: no cyanosis, no clubbing, no edema.,ekg shows atrial fibrillation with a heart rate of 104.,a:,1.

chief complaint:, bright red blood per rectum ,history of present illness: ,this 73-year-old woman had a recent medical history significant for renal and bladder cancer, deep venous thrombosis of the right lower extremity, and anticoagulation therapy complicated by lower gastrointestinal bleeding. colonoscopy during that admission showed internal hemorrhoids and diverticulosis, but a bleeding site was not identified. five days after discharge to a nursing home, she again experienced bloody bowel movements and returned to the emergency department for evaluation. ,review of symptoms: ,no chest pain, palpitations, abdominal pain or cramping, nausea, vomiting, or lightheadedness. positive for generalized weakness and diarrhea the day of admission. ,prior medical history:, long-standing hypertension, intermittent atrial fibrillation, and hypercholesterolemia. renal cell carcinoma and transitional cell bladder cancer status post left nephrectomy, radical cystectomy, and ileal loop diversion 6 weeks prior to presentation, postoperative course complicated by pneumonia, urinary tract infection, and retroperitoneal bleed. deep venous thrombosis 2 weeks prior to presentation, management complicated by lower gastrointestinal bleeding, status post inferior vena cava filter placement. ,medications: ,diltiazem 30 mg tid, pantoprazole 40 mg qd, epoetin alfa 40,000 units weekly, iron 325 mg bid, cholestyramine. warfarin discontinued approximately 10 days earlier. ,allergies: ,celecoxib (rash).,social history:, resided at nursing home. denied alcohol, tobacco, and drug use. ,family history:, non-contributory.,physical exam: ,temp = 38.3c bp =146/52 hr= 113 rr = 18 sao2 = 98% room air ,general: pale, ill-appearing elderly female. ,heent: pale conjunctivae, oral mucous membranes moist. ,cvs: irregularly irregular, tachycardia. ,lungs: decreased breath sounds at the bases. ,abdomen: positive bowel sounds, soft, nontender, nondistended, gross blood on rectal exam. ,extremities: no cyanosis, clubbing, or edema. ,skin: warm, normal turgor. ,neuro: alert and oriented. nonfocal. ,labs: ,cbc: ,wbc count: 6,500 per ml ,hemoglobin: 10.3 g/dl ,hematocrit:31.8% ,platelet count: 248 per ml ,mean corpuscular volume: 86.5 fl ,rdw: 18% ,chem 7: ,sodium: 131 mmol/l ,potassium: 3.5 mmol/l ,chloride: 98 mmol/l ,bicarbonate: 23 mmol/l ,bun: 11 mg/dl ,creatinine: 1.1 mg/dl ,glucose: 105 mg/dl ,coagulation studies: ,pt 15.7 sec ,inr 1.6 ,ptt 29.5 sec ,hospital course: ,the patient received 1 liter normal saline and diltiazem (a total of 20 mg intravenously and 30 mg orally) in the emergency department. emergency department personnel made several attempts to place a nasogastric tube for gastric lavage, but were unsuccessful. during her evaluation, the patient was noted to desaturate to 80% on room air, with an increase in her respiratory rate to 34 breaths per minute. she was administered 50% oxygen by nonrebreadier mask, with improvement in her oxygen saturation to 89%. computed tomographic angiography was negative for pulmonary embolism.

preoperative diagnosis: , gross hematuria.,postoperative diagnosis: ,gross hematuria.,operations: ,cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder.,anesthesia: , spinal.,findings: ,significant amount of bladder clots measuring about 150 to 200 ml, two cupful of clots were removed. there was papillary tumor on the left wall right at the bladder neck and one on the right dome near the bladder neck on the right side. the right ureteral opening was difficult to visualize, the left one was normal.,brief history: , the patient is a 78-year-old male with history of gross hematuria and recurrent utis. the patient had hematuria. cystoscopy revealed atypical biopsy. the patient came in again with gross hematuria. the first biopsy was done about a month ago. the patient was to come back and have repeat biopsies done, but before that came into the hospital with gross hematuria. the options of watchful waiting, removal of the clots and biopsies were discussed. risk of anesthesia, bleeding, infection, pain, mi, dvt and pe were discussed. morbidity and mortality of the procedure were discussed. consent was obtained from the daughter-in-law who has the power of attorney in florida.,description of procedure: ,the patient was brought to the or. anesthesia was applied. the patient was placed in the dorsal lithotomy position. the patient was prepped and draped in the usual sterile fashion. the patient had been off of the coumadin for about 4 days and inr had been reversed. the patient has significant amount of clot upon entering the bladder. there was a tight bladder neck contracture. the prostate was not enlarged. using acmi 24-french sheath, using ellick irrigation about 2 cupful of clots were removed. it took about half an hour to just remove the clots. after removing the clots, using 24-french cutting loop resectoscope, tumor on the left upper wall near the dome or near the 2 o'clock position was resected. this was lateral to the left ureteral opening. the base was coagulated for hemostasis. same thing was done at 10 o'clock on the right side where there was some tumor that was visualized. the back wall and the rest of the bladder appeared normal. using 8-french cone-tip catheter, left-sided pyelogram was normal. the right-sided pyelogram was very difficult to obtain and there was some mucosal irritation from the clots. the contrast did go up to what appeared to be the right ureteral opening, but the mucosa seemed to be very much irritated and it was very difficult to actually visualize the opening. a little bit of contrast went out, but the force was not made just to avoid any secondary stricture formation. the patient did have ct with contrast, which showed that the kidneys were normal. at this time, a #24 three-way irrigation was started. the patient was brought to recovery room in stable condition.

exam: , ultrasound abdomen, complete.,history: , 38-year-old male admitted from the emergency room 04/18/2009, decreased mental status and right upper lobe pneumonia. the patient has diffuse abdominal pain. there is a history of aids.,technique:, an ultrasound examination of the abdomen was performed.,findings:, the liver has normal echogenicity. the liver is normal sized. the gallbladder has a normal appearance without gallstones or sludge. there is no gallbladder wall thickening or pericholecystic fluid. the common bile duct has a normal caliber at 4.6 mm. the pancreas is mostly obscured by gas. a small portion of the head of pancreas is visualized which has a normal appearance. the aorta has a normal caliber. the aorta is smooth walled. no abnormalities are seen of the inferior vena cava. the right kidney measures 10.8 cm in length and the left kidney 10.5 cm. no masses, cysts, calculi, or hydronephrosis is seen. there is normal renal cortical echogenicity. the spleen is somewhat prominent with a maximum diameter of 11.2 cm. there is no ascites. the urinary bladder is distended with urine and shows normal wall thickness without masses. the prostate is normal sized with normal echogenicity.,impression: ,1. spleen size at the upper limits of normal.,2. except for small portions of pancreatic head, the pancreas could not be visualized because of bowel gas. the visualized portion of the head had a normal appearance.,3. the gallbladder has a normal appearance without gallstones. there are no renal calculi.

pre-operative diagnosis:, superior gluteal neuralgia/neurapraxia-impingement syndrome.,post-operative diagnosis:, same,procedure:, superior gluteal nerve block, left.,after verbal informed consent, whereby the patient is made aware of the risks of the procedure, the patient was placed in the standing position with the arms flaccid by the side. alcohol was used to prep the skin 3 times, and a 27-gauge needle was advanced deep to the attachment of the gluteus medius muscle near its attachment on the psis. the needle entered the plane between the gluteus medius and gluteus maximus muscle, in close proximity to the superior gluteal nerve. aspiration was negative, and the mixture was easily injected. aseptic technique was observed at all times, and there were no complications noted.,injectate included:,methyl prednisolone (depomedrol): 20 mg,ketorolac (toradol): 6 mg,sarapin: 1 cc,bupivacaine (marcaine): q.s. 2 cc.,the procedures, above were performed for diagnostic, as well as therapeutic purposes. this treatment plan is medically necessary to decrease pain and suffering, increase activities of daily living and improve sleep.,zung self-rating depression scale© (sds) results:, the patient scored as 'mildly depressed.,note:, the pain was gone post procedure, consistent with the diagnosis, as well as with adequacy of medication placement.

preoperative diagnosis: , thrombosed arteriovenous shunt left forearm.,postoperative diagnosis: ,thrombosed arteriovenous shunt, left forearm with venous anastomotic stenosis.,procedure: ,thrombectomy av shunt, left forearm and patch angioplasty of the venous anastomosis.,anesthesia: , local.,skin prep: , betadine.,drains: , none.,procedure technique: ,the left arm was prepped and draped. xylocaine 1% was administered and a transverse antecubital incision was made over the venous limb of the graft, which was dissected out and encircled with a vessel loop. the runoff vein was dissected out and encircled with the vessel loop as well. a longitudinal incision was made over the venous anastomosis. there was a narrowing in the area and slightly the incision was extended more proximally. there was good back bleeding from the vein as well as bleeding from the more distal vein. these were occluded with noncrushing debakey clamps and the patient was given 5000 units of heparin intravenously. a #4 fogarty was used to extract thrombus from the graft systematically until the arterial plug was removed and excellent inflow was established. there was a narrowing in the mid portion of the venous limb of the graft, which was dilated with a #5 coronary dilator. the fogarty catheter was then passed up the vein, but no clot was obtained. a patch ptfe material was fashioned and was sutured over the graftotomy with running 6-0 gore-tex suture. clamps were removed and flow established. a thrill was easily palpable. hemostasis was achieved and the wound was irrigated and closed with 3-0 vicryl subcutaneous suture followed by 4-0 nylon on the skin. a sterile dressing was applied. the patient was taken to the recovery room in satisfactory condition having tolerated the procedure well. sponge, instrument and needle counts were reported as correct.

general review of systems,general: no fevers, chills, or sweats. no weight loss or weight gain.,cardiovascular: no exertional chest pain, orthopnea, pnd, or pedal edema. no palpitations.,neurologic: no paresis, paresthesias, or syncope.,eyes: no double vision or blurred vision.,ears: no tinnitus or decreased auditory acuity.,ent: no allergy symptoms, such as rhinorrhea or sneezing.,gi: no indigestion, heartburn, or diarrhea. no blood in the stools or black stools. no change in bowel habits.,gu: no dysuria, hematuria, or pyuria. no polyuria or nocturia. denies slow urinary stream.,psych: no symptoms of depression or anxiety.,pulmonary: no wheezing, cough, or sputum production.,skin: no skin lesions or nonhealing lesions.,musculoskeletal: no joint pain, bone pain, or back pain. no erythema at the joints.,endocrine: no heat or cold intolerance. no polydipsia.,hematologic: no easy bruising or easy bleeding. no swollen lymph nodes.,physical exam,vital: blood pressure today was *, heart rate *, respiratory rate *.,ears: tms intact bilaterally. throat is clear without hyperemia.,mouth: mucous membranes normal. tongue normal.,neck: supple; carotids 2+ bilaterally without bruits; no lymphadenopathy or thyromegaly.,chest: clear to auscultation; no dullness to percussion.,heart: revealed a regular rhythm, normal s1 and s2. no murmurs, clicks or gallops.,abdomen: soft to palpation without guarding or rebound. no masses or hepatosplenomegaly palpable. bowel sounds are normoactive.,extremities: bilaterally symmetrical. peripheral pulses 2+ in all extremities. no pedal edema.,neurologic examination: essentially intact including cranial nerves ii through xii intact bilaterally. deep tendon reflexes 2+ and symmetrical.,genitalia: bilaterally descended testes without tenderness or masses. no hernias palpable. rectal examination revealed normal sphincter tone, no rectal mass. prostate was *. stool was hemoccult negative.

discharge diagnoses:,1. chest pain. the patient ruled out for myocardial infarction on serial troponins. result of nuclear stress test is pending.,2. elevated liver enzymes, etiology uncertain for an outpatient followup.,3. acid reflux disease.,test done: , nuclear stress test, results of which are pending.,hospital course: , this 32-year-old with family history of premature coronary artery disease came in for evaluation of recurrent chest pain, o2 saturation at 94% with both atypical and typical features of ischemia. the patient ruled out for myocardial infarction with serial troponins. nuclear stress test has been done, results of which are pending. the patient is stable to be discharged pending the results of nuclear stress test and cardiologist's recommendations. he will follow up with cardiologist, dr. x, in two weeks and with his primary physician in two to four weeks. discharge medications will depend on results of nuclear stress test.

procedure: , thoracic epidural steroid injection without fluoroscopy.,anesthesia: , local sedation.,vital signs: , see nurse's notes.,complications: , none.,details of procedure: , int was placed. the patient was in the sitting position and the back was prepped with betadine. lidocaine 1.5% was used for skin wheal made between __________. an 18-gauge tuohy needle was then placed into the epidural space using loss of resistance technique with no cerebrospinal fluid or blood noted. after negative aspiration, a mixture of 7 cc preservative free normal saline and 160 mg preservative free depo-medrol was injected. neosporin and band-aid were applied over the puncture site. the patient was discharged to recovery room in stable condition.

chief complaint:, non-healing surgical wound to the left posterior thigh.,history of present illness: , this is a 49-year-old white male who sustained a traumatic injury to his left posterior thighthis past year while in abcd. he sustained an injury from the patellar from a boat while in the water. he was air lifted actually up to xyz hospital and underwent extensive surgery. he still has an external fixation on it for the healing fractures in the leg and has undergone grafting and full thickness skin grafting closure to a large defect in his left posterior thigh, which is nearly healed right in the gluteal fold on that left area. in several areas right along the graft site and low in the leg, the patient has several areas of hypergranulation tissue. he has some drainage from these areas. there are no signs and symptoms of infection. he is referred to us to help him get those areas under control.,past medical history:, essentially negative other than he has had c. difficile in the recent past.,allergies:, none.,medications: , include cipro and flagyl.,past surgical history: , significant for his trauma surgery noted above.,family history: , his maternal grandmother had pancreatic cancer. father had prostate cancer. there is heart disease in the father and diabetes in the father.,social history:, he is a non-cigarette smoker and non-etoh user. he is divorced. he has three children. he has an attorney.,review of systems:,cardiac: he denies any chest pain or shortness of breath.,gi: as noted above.,gu: as noted above.,endocrine: he denies any bleeding disorders.,physical examination:,general: he presents as a well-developed, well-nourished 49-year-old white male who appears to be in no significant distress.,heent: unremarkable.,neck: supple. there is no mass, adenopathy, or bruit.,chest: normal excursion.,lungs: clear to auscultation and percussion.,cor: regular. there is no s3, s4, or gallop. there is no murmur.,abdomen: soft. it is nontender. there is no mass or organomegaly.,gu: unremarkable.,rectal: deferred.,extremities: his right lower extremity is unremarkable. peripheral pulse is good. his left lower extremity is significant for the split thickness skin graft closure of a large defect in the posterior thigh, which is nearly healed. the open areas that are noted above __________ hypergranulation tissue both on his gluteal folds on the left side. there is one small area right essentially within the graft site, and there is one small area down lower on the calf area. the patient has an external fixation on that comes out laterally on his left thigh. those pin sites look clean.,neurologic: without focal deficits. the patient is alert and oriented.,impression: , several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg.,plan:, plan would be for chemical cauterization of these areas. series of treatment with chemical cauterization till these are closed.

preoperative diagnosis:, right middle lobe lung cancer.,postoperative diagnosis: , right middle lobe lung cancer.,procedures performed:,1. vats right middle lobectomy.,2. fiberoptic bronchoscopy thus before and after the procedure.,3. mediastinal lymph node sampling including levels 4r and 7.,4. tube thoracostomy x2 including a 19-french blake and a 32-french chest tube.,5. multiple chest wall biopsies and excision of margin on anterior chest wall adjacent to adherent tumor.,anesthesia: ,general endotracheal anesthesia with double-lumen endotracheal tube.,disposition of specimens: , to pathology both for frozen and permanent analysis.,findings:, the right middle lobe tumor was adherent to the anterior chest wall. the adhesion was taken down, and the entire pleural surface along the edge of the adhesion was sent for pathologic analysis. the final frozen pathology on this entire area returned as negative for tumor. additional chest wall abnormalities were biopsied and sent for pathologic analysis, and these all returned separately as negative for tumor and only fibrotic tissue. several other biopsies were taken and sent for permanent analysis of the chest wall. all of the biopsy sites were additionally marked with hemoclips. the right middle lobe lesion was accompanied with distal pneumonitis and otherwise no direct involvement of the right upper lobe or right lower lobe.,estimated blood loss: , less than 100 ml.,condition of the patient after surgery: , stable.,history of procedure:, this patient is well known to our service. he was admitted the night before surgery and given hemodialysis and had close blood sugar monitoring in control. the patient was subsequently taken to the operating room on april 4, 2007, was given general anesthesia and was endotracheally intubated without incident. although, he had markedly difficult airway, the patient had fiberoptic bronchoscopy performed all the way down to the level of the subsegmental bronchi. no abnormalities were noted in the entire tracheobronchial tree, and based on this, the decision was made to proceed with the surgery. the patient was kept in the supine position, and the single-lumen endotracheal tube was removed and a double-lumen tube was placed. following this, the patient was placed into the left lateral decubitus position with the right side up and all pressure points were padded. sterile duraprep preparation on the right chest was placed. a sterile drape around that was also placed. the table was flexed to open up the intercostal spaces. a second bronchoscopy was performed to confirm placement of the double-lumen endotracheal tube. marcaine was infused into all incision areas prior to making an incision. the incisions for the vats right middle lobectomy included a small 1-cm incision for the auscultatory incision approximately 4 cm inferior to the inferior tip of the scapula. the camera port was in the posterior axillary line in the eighth intercostal space through which a 5-mm 30-degree scope was used. third incision was an anterior port, which was approximately 2 cm inferior to the inframammary crease and the midclavicular line in the anterior sixth intercostal space, and the third incision was a utility port, which was a 4 cm long incision, which was approximately one rib space below the superior pulmonary vein. all of these incisions were eventually created during the procedure. the initial incision was the camera port through which, under direct visualization, an additional small 5-mm port was created just inferior to the anterior port. these two ports were used to identify the chest wall lesions, which were initially thought to be metastatic lesions. multiple biopsies of the chest wall lesions were taken, and the decision was made to also insert the auscultatory incision port. through these three incisions, the initial working of the diagnostic portion of the chest wall lesion was performed. multiple biopsies were taken of the entire chest wall offers and specimens came back as negative. the right middle lobe was noted to be adherent to the anterior chest wall. this area was taken down and the entire pleural surface along this area was taken down and sent for frozen pathologic analysis. this also returned as negative with only fibrotic tissue and a few lymphocytes within the fibrotic tissue, but no tumor cells. based on this, the decision was made to not proceed with chest wall resection and continue with right middle lobectomy. following this, the anterior port was increased in size and the utility port was made and meticulous dissection from an anterior to posterior direction was performed. the middle lobe branch of the right superior pulmonary vein was initially dissected and stapled with vascular load 45-mm endogia stapler. following division of the right superior pulmonary vein, the right middle lobe bronchus was easily identified. initially, this was thought to be the main right middle lobe bronchus, but in fact it was the medial branch of the right middle lobe bronchus. this was encircled and divided with a blue load stapler with a 45-mm endogia. following division of this, the pulmonary artery was easily identified. two branches of the pulmonary artery were noted to be going into the right middle lobe. these were individually divided with a vascular load after encircling with a right angle clamp. the vascular staple load completely divided these arterial branches successfully from the main pulmonary artery trunk, and following this, an additional branch of the bronchus was noted to be going to the right middle lobe. a fiberoptic bronchoscopy was performed intraoperatively and confirmed that this was in fact the lateral branch of the right middle lobe bronchus. this was divided with a blue load stapler 45 mm endogia. following division of this, the minor and major fissures were completed along the edges of the right middle lobe separating the right upper lobe from the right middle lobe as well as the right middle lobe from the right lower lobe. following complete division of the fissure, the lobe was put into an endogia bag and taken out through the utility port. following removal of the right middle lobe, a meticulous lymph node dissection sampling was performed excising the lymph node package in the 4r area as well as the 7 lymph node package. node station 8 or 9 nodes were easily identified, therefore none were taken. the patient was allowed to ventilate under water on the right lung with no obvious air leaking noted. a 19-french blake was placed into the posterior apical position and a 32-french chest tube was placed in the anteroapical position. following this, the patient's lung was allowed to reexpand fully, and the patient was checked for air leaking once again. following this, all the ports were closed with 2-0 vicryl suture used for the deeper tissue, and 3-0 vicryl suture was used to reapproximate the subcutaneous tissue and 4-0 monocryl suture was used to close the skin in a running subcuticular fashion. the patient tolerated the procedure well, was extubated in the operating room and taken to the recovery room in stable condition.

preoperative diagnosis: , left hip degenerative arthritis.,postoperative diagnosis: , left hip degenerative arthritis.,procedure performed: ,total hip arthroplasty on the left.,anesthesia: ,general.,blood loss: , 800 cc.,the patient was positioned with the left hip exposed on the beanbag.,implant specification: , a 54 mm trilogy cup with cluster holes 3 x 50 mm diameter with a appropriate liner, a 28 mm cobalt-chrome head with a zero neck length head, and a 12 mm porous proximal collared femoral component.,gross intraoperative findings: ,severe degenerative changes within the femoral head as well as the acetabulum, anterior as well as posterior osteophytes. the patient also had a rent in the attachment of the hip abductors and a partial rent in the vastus lateralis. this was revealed once we removed the trochanteric bursa.,history: ,this is a 56-year-old obese female with a history of bilateral degenerative hip arthritis. she underwent a right total hip arthroplasty by dr. x in the year of 2000, and over the past three years, the symptoms in her left hip had increased tremendously especially in the past few months.,because of the increased amount of pain as well as severe effect on her activities of daily living and uncontrollable pain with narcotic medication, the patient has elected to undergo the above-named procedure. all risks as well complications were discussed with the patient including but not limited to infection, scar, dislocation, need for further surgery, risk of anesthesia, deep vein thrombosis, and implant failure. the patient understood all these risks and was willing to continue further on with the procedure.,procedure: , the patient was wheeled back to the operating room #2 at abcd general hospital on 08/27/03. the general anesthetic was first performed by the department of anesthesia. the patient was then positioned with the left hip exposed on the beanbag in the lateral position. kidney rests were also used because of the patient's size. an axillary roll was also inserted for comfort in addition to a foley catheter, which was inserted by the or nurse. all her bony prominences were well padded. at this time, the left hip and left lower extremity was then prepped and draped in the usual sterile fashion for this procedure. at this time, an anterolateral approach was then performed, first incising through the skin in approximately 5 to 6 inches of subcutaneous fat. the tensor fascia lata was then identified. a self-retainer was then inserted to expose the operative field. bovie cautery was used for hemostasis. at this time, a fresh blade was then used to incise the tensor fascia lata over the posterior one-third of the greater trochanter. at this time, a blunt dissection was taken proximally. the tensor fascia lata was occluded with a hip retractor. at this time, after hemostasis was obtained, bovie cautery was used to incise the proximal end of the vastus lateralis and removing the partial portion of the hip abductor, the gluteus medius. at this time, a periosteal elevator was used to expose anterior hip capsule. a ________ was then inserted over the femoral head purchasing of the acetabulum underneath the reflected head of the quadriceps muscle. once this was performed, homan retractors were then inserted superiorly and inferiorly underneath the femoral neck. at this time, a capsulotomy was then performed using a bovie cautery and the capsulotomy was ________ and then edged over the acetabulum. at this point, a large bone hook was then inserted over the neck and with gentle traction and external rotation, the femoral head was dislocated out of the acetabulum. at this time, we had an exposure of the femoral head, which did reveal degenerative changes of the femoral head and once the acetabulum was visualized, we did see degenerative changes within the acetabulum as well as osteophyte formation around the rim of the acetabulum. at this time, a femoral stem guide was then used to measure proximal femoral neck cut. we made a cut approximately a fingerbreadth above the lesser trochanter. at this time, with protection of the soft tissues an oscillating saw was used to make femoral neck cut.,the femoral head was then removed. at this time, we removed the leg out of the bag and homan retractors were then used to expose the acetabulum. a long-handle knife was used to cut through the remainder of the capsule and remove the glenoid labrum around the rim of the acetabulum. with better exposure of the acetabulum, we started reaming the acetabulum. we started with a size #44 and progressively reamed to a size #50. at the size #50 mm reamer, we obtained excellent bony bleeding with good remainder of bone stalk both anteriorly and posteriorly as well as superiorly within the acetabulum. we then reamed up to size #52 in order to get bony bleeding around the rim as well as anterior and posterior within the acetabulum. a size 54 mm trilogy cup was then implanted with excellent approaches approximately 45 degrees of abduction and 10 to 15 degrees of anteversion dialed in. once the cup was impacted in place, we did visualize that the cup was well seated on to the internal portion of the acetabulum. at this time, two screws were the placed within the superior table for better approaches securing the acetabular cup. at this time, a plastic liner was then inserted for protection. the leg was then placed back in the bag. a bennett retractor was used to retract the tensor fascia lata and femoral elevator was used to elevate the femur for better exposure and at this time, we began working on the femur. a rongeur was used to lateralize over the greater trochanter. a box osteotome was used to remove the cancellous portion of the femoral neck. a charnley awl was then used to cannulate through the proximal femoral canal. a power reamer was then used to ream the lateral aspect of the greater trochanter in order to provide maximal lateralization and prevent varus implantation of our stem. at this time, we began broaching. we started with a size #10 and progressively worked up to a size #12 mm broach. once the 12 mm broach was inserted in place, it was seated approximately 1 mm below the calcar. a calcar reamer was then placed and the calcar was reamed smoothly. a standard neck as well as a 28 mm plastic head was then placed and a trial reduction was then performed. once this was performed, the hip was taken to range of motion with external rotation, longitudinal traction as well as flexion and revealed good stability with no impingement or dislocation. at this time, we removed 12 mm broach and proceeded with implanting our polyethylene liner within the acetabulum. this was impacted and placed and checked to assure that it was well seated with no loosening. once this was performed, we then exposed the proximal femur one more time. we copiously irrigated within the canal and then suctioned it dry. at this time, a 12 mm porous proximal collared stem, a femoral component was then impacted in place. once it was well seated on the calcar, we double checked to assure that there was no evidence of calcar fractures, which there were none. the 28 mm zero neck length cobalt-chrome femoral head was then impacted in place and the morse taper assured that this was well fixed by ________.,next, the hip was then reduced within the acetabulum and again we checked range of motion as well as ligamentous stability with gentle traction, external rotation, as well as hip flexion. we were satisfied with components as well as the alignment of the components. copious irrigation was then used to irrigate the wound. #1 ethibond was then used to approximate the anterior hip capsule. #1 ethibond in interrupted fashion was used to approximate the vastus lateralis as well as the gluteus medius attachment over the partial gluteus medius attachment which was resected off the greater trochanter. next, a #1 ethibond was then used to approximate the tensor fascia lata with figure-of-eight closure. a tight closure was performed. since the patient did have a lot of subcutaneous fat, multiple #2-0 vicryl sutures were then used to approximate the bed space and then #2-0 vicryl for the subcutaneous skin. staples were then used for skin closure. the patient's hip was then cleansed. sterile dressings consisting of adaptic, 4 x 4, abds, and foam tape were then placed. a drain was placed prior to wound closure for postoperative drainage. after the dressing was applied, the patient was extubated safely and transferred to recovery in stable condition. prognosis is good.

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

nerve conduction studies:, bilateral ulnar sensory responses are absent. bilateral median sensory distal latencies are prolonged with a severely attenuated evoked response amplitude. the left radial sensory response is normal and robust. left sural response is absent. left median motor distal latency is prolonged with attenuated evoked response amplitude. conduction velocity across the forearm is mildly slowed. right median motor distal latency is prolonged with a normal evoked response amplitude and conduction velocity. the left ulnar motor distal latency is prolonged with a severely attenuated evoked response amplitude both below and above the elbow. conduction velocities across the forearm and across the elbow are prolonged. conduction velocity proximal to the elbow is normal. the right median motor distal latency is normal with normal evoked response amplitudes at the wrist with a normal evoked response amplitude at the wrist. there is mild diminution of response around the elbow. conduction velocity slows across the elbow. the left common peroneal motor distal latency evoked response amplitude is normal with slowed conduction velocity across the calf and across the fibula head. f-waves are prolonged.,needle emg: , needle emg was performed on the left arm and lumbosacral and cervical paraspinal muscles as well as middle thoracic muscles using a disposable concentric needle. it revealed spontaneous activity in lower cervical paraspinals, left abductor pollicis brevis, and first dorsal interosseous muscles. there were signs of chronic reinnervation in triceps, extensor digitorum communis, flexor pollicis longus as well first dorsal interosseous and abductor pollicis brevis muscles.,impression: , this electrical study is abnormal. it reveals the following:,1. a sensory motor length-dependent neuropathy consistent with diabetes.,2. a severe left ulnar neuropathy. this is probably at the elbow, although definitive localization cannot be made.,3. moderate-to-severe left median neuropathy. this is also probably at the carpal tunnel, although definitive localization cannot be made.,4. right ulnar neuropathy at the elbow, mild.,5. right median neuropathy at the wrist consistent with carpal tunnel syndrome, moderate.,6. a left c8 radiculopathy (double crush syndrome).,7. there is no evidence for thoracic radiculitis.,the patient has made very good response with respect to his abdominal pain since starting neurontin. he still has mild allodynia and is waiting for authorization to get insurance coverage for his lidoderm patch. he is still scheduled for mri of c-spine and t-spine. i will see him in followup after the above scans.

ears, nose, mouth and throat,ears/nose: , the auricles are normal to palpation and inspection without any surrounding lymphadenitis. there are no signs of acute trauma. the nose is normal to palpation and inspection externally without evidence of acute trauma. otoscopic examination of the auditory canals and tympanic membranes reveals the auditory canals without signs of mass lesion, inflammation or swelling. the tympanic membranes are without disruption or infection. hearing intact bilaterally to normal level speech. nasal mucosa, septum and turbinate examination reveals normal mucous membranes without disruption or inflammation. the septum is without acute traumatic lesions or disruption. the turbinates are without abnormal swelling. there is no unusual rhinorrhea or bleeding. ,lips/teeth/gums: ,the lips are without infection, mass lesion or traumatic lesions. the teeth are intact without obvious signs of infection. the gingivae are normal to palpation and inspection. ,oropharynx: ,the oral mucosa is normal. the salivary glands are without swelling. the hard and soft palates are intact. the tongue is without masses or swelling with normal movement. the tonsils are without inflammation. the posterior pharynx is without mass lesion with good patent oropharyngeal airway.

preoperative diagnosis:, right spermatocele.,postoperative diagnosis: ,right spermatocele.,operations performed:,1. right spermatocelectomy.,2. right orchidopexy.,anesthesia: , local mac.,estimated blood loss:, minimal.,fluids: , crystalloid.,brief history of the patient: ,the patient is a 77-year-old male who comes to the office with a large right spermatocele. the patient says it does bother him on and off, has occasional pain and discomfort with it, has difficulty with putting clothes on etc. and wanted to remove. options such as watchful waiting, removal of the spermatocele or needle drainage were discussed. risk of anesthesia, bleeding, infection, pain, mi, dvt, pe, risk of infection, scrotal pain, and testicular pain were discussed. the patient was told that his scrotum may enlarge in the postoperative period for about a month and it will settle down. the patient was told about the risk of recurrence of spermatocele. the patient understood all the risks, benefits, and options and wanted to proceed with removal.,details of the procedure: ,the patient was brought to the or. anesthesia was applied. the patient's scrotal area was shaved, prepped, and draped in the usual sterile fashion. a midline scrotal incision was made measuring about 2 cm in size. the incision was carried through the dartos through the scrotal sac and the spermatocele was identified. all the layers of the spermatocele were removed. clear layer was visualized, was taken all the way up to the base, the base was tied. entire spermatocele sac was removed. after removing the entire spermatocele sac, hemostasis was obtained. the testicle was not in normal orientation. the testis and epididymis was removed, which is a small appendage on the superior aspect of the testicle. the testicle was placed in a normal orientation. careful attention was drawn not to twist the cord. orchidopexy was done to allow the testes to stay stable in the postoperative period using 4-0 vicryl and was tied at 3 different locations. absorbable sutures were used, so that the patient does not feel the sutures in the postoperative period. the dartos was closed using 2-0 vicryl in running locking fashion. there was excellent hemostasis. the skin was closed using 4-0 monocryl. dermabond was applied. the patient tolerated the procedure well. the patient was brought to the recovery room in stable condition.

1. odynophagia.,2. dysphagia.,3. gastroesophageal reflux disease rule out stricture.,postoperative diagnoses:,1. antral gastritis.,2. hiatal hernia.,procedure performed: egd with photos and biopsies.,gross findings: this is a 75-year-old female who presents with difficulty swallowing, occasional choking, and odynophagia. she has a previous history of hiatal hernia. she was on prevacid currently. at this time, an egd was performed to rule out stricture. at the time of egd, there was noted some antral gastritis and hiatal hernia. there are no strictures, tumors, masses, or varices present.,operative procedure: the patient was taken to the endoscopy suite in the lateral decubitus position. she was given sedation by the department of anesthesia. once adequate sedation was reached, the olympus gastroscope was inserted into oropharynx. with air insufflation entered through the proximal esophagus to the ge junction. the esophagus was without evidence of tumors, masses, ulcerations, esophagitis, strictures, or varices. there was a hiatal hernia present. the scope was passed through the hiatal hernia into the body of the stomach. in the distal antrum, there was some erythema with patchy erythematous changes with small superficial erosions. multiple biopsies were obtained. the scope was passed through the pylorus into the duodenal bulb and duodenal suite, they appeared within normal limits. the scope was pulled back from the stomach, retroflexed upon itself, _____ fundus and ge junction. as stated, multiple biopsies were obtained.,the scope was then slowly withdrawn. the patient tolerated the procedure well and sent to recovery room in satisfactory condition.

procedures performed: , phenol neurolysis right obturator nerve, botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles.,procedure codes: , 64640 times one, 64614 times two, 95873 times two.,preoperative diagnosis: , spastic right hemiparetic cerebral palsy, 343.1.,postoperative diagnosis:, spastic right hemiparetic cerebral palsy, 343.1.,anesthesia:, mac.,complications: , none.,description of technique: , informed consent was obtained from the patient. she was brought to the minor procedure area and sedated per their protocol. the patient was positioned lying supine. skin overlying all areas injected was prepped with chlorhexidine. the right obturator nerve was identified using active emg stimulation lateral to the adductor longus tendon origin and below the femoral pulse. approximately 6 ml of 5% phenol was injected in this location. at all sites of phenol injections, injections were done at the site of maximum hip adduction contraction with least amount of stimulus. negative drawback for blood was done prior to each injection of phenol.,muscles injected with botulinum toxin were identified with active emg stimulation. approximately 100 units was injected in the right pectoralis major and 100 units in the right rectus femoris and vastus intermedius muscles. total amount of botulinum toxin injected was 200 units diluted 25 units to 1 ml. the patient tolerated the procedure well and no complications were encountered.

reason for consult:, depression.,hpi:, the patient is an 87-year-old white female admitted for low back pain status post hip fracture sustained a few days before thanksgiving in 2006. the patient was diagnosed and treated for a t9 compression fraction with vertebroplasty. soon after discharge, the patient was readmitted with severe mid low back pain and found to have a t8 compression fracture. this was also treated with vertebroplasty. the patient is now complaining of back pain that fluctuates at time, acknowledging her pain medication works but not all the time. her pain is in her upper back around her shoulder blades. the patient says lying down with the heated pad lessens the pain and that any physical activity increases it. mri on january 29, 2007, was positive for possible meningioma to the left of anterior box.,the patient reports of many depressive symptoms, has lost all interest in things she used to do (playing cards, reading). has no energy to do things she likes, but does participate in physical therapy, cries often and what she believes for no reason. does not see any future for herself. reports not being able to concentrate on anything saying she gets distracted by thoughts of how she does not want to live anymore. admits to decreased appetite, feeling depressed, and always wanting to be alone. claims that before her initial hospitalization for her hip fracture, she was highly active, enjoyed living independently at terrace. denies suicidal ideations and homicidal ideations, but that she did not mind dying, and denies any manic symptoms including decreased need to sleep, inflated self-worth, and impulsivity. denies auditory and visual hallucinations. no paranoid, delusions, or other abnormalities of thought content. denies panic attacks, flashbacks, and other feelings of anxiety. does admit to feeling restless at times. is concerned with her physical appearance while in the hospital, i.e., her hair looking "awful.",past medical history:, hypertension, cataracts, hysterectomy, mi, osteoporosis, right total knee replacement in april 2004, hip fracture, and newly diagnosed diabetes. no history of thyroid problems, seizures, strokes, or head injuries.,current medications:, norvasc 10 mg p.o. daily, aspirin 81 mg p.o. daily, lipitor 20 mg p.o. daily, klonopin 0.5 mg p.o. b.i.d., digoxin 0.125 mg p.o. daily, lexapro 10 mg p.o. daily, tricor 145 mg p.o. each bedtime, lasix 20 mg p.o. daily, ismo 20 mg p.o. daily, lidocaine patch, zestril, prinivil 40 mg p.o. daily, lopressor 75 mg p.o. b.i.d., starlix 120 mg p.o. t.i.d., pamelor 25 mg p.o. each bedtime, polyethylene glycol 17 g p.o. every other day, potassium chloride 20 meq p.o. t.i.d., norco one tablet p.o. q.4h. p.r.n., zofran 4 mg iv q.6h.,home medications:, unknown.,allergies:, codeine (hallucinations).,family medical history:, unremarkable.,past psychiatric history:, unremarkable. never taken any psychiatric medications or have ever had a family member with psychiatric illness.,social/developmental history:, unremarkable childhood. married for 40 plus years, widowed in 1981. worked as administrative assistant in utmb hospitals vp's office. two children. before admission, lived in the terrace independent living center. was happy and very active while living there. had friends in the terrace and would not mind going back there after discharge. occasional glass of wine at dinner. denies ever using illicit drugs and tobacco.,mental status exam:, the patient is an 87-year-old white female with appropriate appearance, wearing street clothes while lying in bed with her eyes tightly closed. slight decrease in motor activity. normal eye contact. speech, low volume and rate. good articulation and inflexion. normal concentration. mood, labile, tearful at times, depressed, then euthymic. affect, mood congruent, full range. thought process, logical and goal directed. thought content, no delusions, suicidal or homicidal ideations. perception, no auditory or visual hallucinations. sensorium, alert, and oriented x3. memory, fair. information and intelligence, average. judgment and insight, fair.,mini mental status exam,: a 28/30. could not remember two out of the three recalled words.,assessment:, the patient is an 87-year-old white female with recent history of hip fracture and two thoracic compression fractures. the patient reports being high functioning prior to admission and says her depression symptoms have occurred while being in the hospital.,axis i: major depression disorder.,axis ii: deferred.,axis iii: osteoporosis, hypertension, hip fracture, possible diabetes, meningioma, mi, and right total knee replacement.,axis iv: lives independently at terrace, difficulty walking, hospitalization.,axis v: 45.,plan:, continue lexapro 10 mg daily and pamelor 25 mg each bedtime monitor for adverse effects of tca and worsening of depressive symptoms. discussed about possible inpatient psychiatric care.,thank you for the consultation.

history of present illness: , this is a followup for this 69-year-old african american gentleman with stage iv chronic kidney disease secondary to polycystic kidney disease. his creatinine has ranged between 4 and 4.5 over the past 6 months, since i have been following him. i have been trying to get him educated about end-stage kidney disease and we have been unsuccessful in getting him into classes. on his last visit, i really stressed the importance of him taking his medications adequately and not missing some of the doses, and he returns today with much better blood pressure control. he has also brought a machine at home, and states his blood pressure readings have been better. he has not gone to the transplant orientation class yet and has not been to dialysis education yet, and both of these i have discussed with him in the past. he also needs followup for his elevated psa in the past, which has not been done for over 2 years and will likely need cardiac clearance if we ever are able to evaluate him for transplant.,review of systems: , really negative. he continues to feel well. he denies any problems with shortness of breath, chest pain, swelling in his legs, nausea or vomiting, and his appetite remains good.,current medications:,1. vytorin 10/40 mg one a day.,2. rocaltrol 0.25 micrograms a day.,3. carvedilol 12.5 mg twice a day.,4. cozaar 50 mg twice a day.,5. lasix 40 mg a day.,physical examination:,vital signs: on exam, his blood pressure is 140/57, pulse 58, current weight is 67.1 kg, and again his blood pressure is markedly improved over his previous readings. general: he is a thin african american gentleman in no distress. lungs: clear. cardiovascular: regular rate and rhythm. normal s1 and s2. i did not appreciate a murmur. abdomen: soft. he has a very soft systolic murmur at the left lower sternal border. no rubs or gallops. extremities: no significant edema.,laboratory data: , today indicates that his creatinine is 4.5 and stable, ionized calcium 8.5, intact pth 458, and hemoglobin stable at 10.9. he is not on epo yet. his ua has been negative.,impression:,1. chronic kidney disease, stage iv, secondary to polycystic kidney disease. his estimated gfr is 16 ml per minute. he has no uremic symptoms.,2. hypertension, which is finally better controlled.,3. metabolic bone disease.,4. anemia.,recommendation:, he needs a number of things done in terms of followup and education. i gave him more information again about dialysis education and transplant, and instructed him he needs to go to these classes. i also gave him websites that he can get on to find out more information. i have not made any changes in his medications. he is getting blood work done prior to his next visit with me. i will check a psa on him but he needs to get back into see urology, as his last psa that i see was 37 and this was from 02/05. he will see me back in about 4 to 6 weeks.

chief complaint:, confusion and hallucinations.,history of present illness:, the patient was a 27-year-old hispanic man who presented to st. luke's episcopal hospital with a five day history of confusion and hallucinations. the patient was doing well until three months prior to admission when he developed wheezing and shortness of breath upon exertion. he was seen by his primary care physician and was prescribed salmeterol and fluticasone nasal inhaler for presumed asthma. his wheezing improved with treatment.,over the five days prior to admission, his family noticed the patient's increasing confusion and bizarre behavior. the patient was intermittently unable to recognize his family members or surroundings. he was restless and anxious, paced the floor at night, and complained of insomnia. he stated he was unable to sleep because he feared his family was trying to hurt him. when he did sleep, he described night terrors. he also complained of both auditory and visual hallucinations. he stated the voices "told him to do good things". he denied any previous history of depression or manic episodes. the patient denied suicidal or homicidal ideation. he admitted he had recently lost weight although he was unable to quantify how much. he stated his appetite was good, but he had not been eating for fear of being poisoned.,the patient denied having headaches or a history of trauma. he denied fevers or chills but he complained of recent night sweats. he denied nausea, vomiting, diarrhea, or dysuria. he denied chest pain, palpitations, or episodic flushing; but he complained of lightheadedness. he denied orthopnea or paroxysmal nocturnal dyspnea. the shortness of breath symptoms had resolved.,past medical history:, none. no history of hypertension or of cardiac, renal, lung, or liver disease.,past surgical history:, none,past psychological history: none,social history:, the patient was from brazil. he moved to the united states one year ago. he denied any history of tobacco, alcohol, or illicit drug use. he was married and monogamous. he worked as an engineer/manager, and stated that his job was "very stressful". he had recently been admitted to an mba program. the patient denied recent travel or exposures of any kind.,family history:, the patient had a second-degree relative with a history of depression and "nervous breakdown".,allergies:, there were no known drug allergies.,medications:, prescribed medications were salmeterol inhaler, prn; and fluticasone nasal inhaler. the patient was taking no over the counter or alternative medicines.,physical examination:, the patient was a 27-year-old hispanic man who presented with symptoms of confusion and hallucinations. he was a thin man but appeared to be well developed and well nourished. the patient paced the room during the examination. he appeared anxious and distracted. he was coherent, yet he had poor concentration and was unable to cooperate fully with the examination. the patient had a pulse rate of 110 beats per minute and blood pressure of 186/101 mm hg when reclining; and a pulse rate of 122 beats per minute and blood pressure of 166/92 mm hg when standing. his oral temperature was 100.8 degrees fahrenheit, and his respiratory rate was 12 breaths per minute.,heent: conjunctivae were pink; sclerae anicteric; mucous membranes moist and pink without lesions.,neck: the neck was supple, normal jugular venous pressure, no carotid bruits, no thyromegaly.,lungs: the lungs were clear to auscultation bilaterally; no wheezes, rales or rhonchi.,heart: the heart had a regular rhythm, tachycardic, ii/vi systolic ejection murmur lusb, no rubs or gallops, pmi nondisplaced, hyperdynamic precordium.,abdomen: the abdomen was soft, nontender and nondistended; normoactive bowel sounds, no hepatosplenomegaly, no masses; positive bruit heard throughout mid-abdomen, positive bilateral femoral bruits.,extremities: no clubbing, cyanosis, or edema; 2+ pulses.,genitourinary: normal male phallus, no testicular masses.,rectal: guaiac negative, no masses.,lymph nodes: negative in the anterior and posterior clavicular, supraclavicular, axillary, and inguinal regions.,skin: acneiform eruption over back and trunk, no papules or vesicles.,neurological examination: the patient was alert and oriented to self and year, but not to month or place. he had difficulty with mathematics and following commands (when asked to stand on his heels, the patient stood on his toes and turned on the television). cranial nerves ii-xii intact, motor 5/5 throughout all extremities; reflexes 2+ and symmetrical throughout. sensory: intact to light touch, vibration, proprioception, and temperature. cerebellar: intact finger to nose, no ataxia. romberg negative.,psychological examination: the patient's mood was elevated and euphoric; affect was appropriate; his speech was normal in rate, volume, and tone.,hospital course:, the patient was admitted to st. luke's episcopal hospital and a workup for his altered mental status was begun. the following studies were performed:,twelve-lead ekg: sinus tachycardia.,cxr (pa/lat): normal cardiac silhouette and normal lung fields.,ct scan of head without contrast: ventricles were normal in size and position. there was no evidence of mass or hemorrhage.,lumbar puncture: clear, colorless; wbc--0; rbc--56; protein--45; glucose--126; vdrl--negative; cryptococcal ag--negative; cultures--negative.,mri with gadolinium: no discrete areas of abnormal signal intensity.,eeg: no focal or epileptiform activity.,the patient was treated with haldol and risperidone for his agitation, and further diagnostic testing was performed.

preoperative diagnosis:, right frontotemporal chronic subacute subdural hematoma.,postoperative diagnosis:, right frontotemporal chronic subacute subdural hematoma.,title of the operation: , right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques.,assistant: , none.,indications: , the patient is a 75-year-old man with a 6-week history of decline following a head injury. he was rendered unconscious by the head injury. he underwent an extensive syncopal workup in mississippi. this workup was negative. the patient does indeed have a heart pacemaker. the patient was admitted to abcd three days ago and yesterday underwent a ct scan, which showed a large appearance of subdural hematoma. there is a history of some bladder tumors and so a scan with contrast was obtained that showed some enhancement in the membranes. i decided to perform a craniotomy rather than burr hole drainage because of the enhancing membranes and the history of a bladder tumor undefined as well as layering of the blood within the cavity. the patient and the family understood the nature, indications, and risk of the surgery and agreed to go ahead.,description of procedure: ,the patient was brought to the operating room where general and endotracheal anesthesia was obtained. the head was turned over to the left side and was supported on a cushion. there was a roll beneath the right shoulder. the right calvarium was shaved and prepared in the usual manner with betadine-soaked scrub followed by betadine paint. markings were applied. sterile drapes were applied. a linear incision was made more or less along the coronal suture extending from just above the ear up to near the midline. sharp dissection was carried down into subcutaneous tissue and bovie electrocautery was used to divide the galea and the temporalis muscle and fascia. weitlaner retractors were inserted. a single bur hole was placed underneath the temporalis muscle. i placed the craniotomy a bit low in order to have better cosmesis. a cookie cutter type craniotomy was then carried out in dimensions about 5 cm x 4 cm. the bone was set aside. the dura was clearly discolored and very tense. the dura was opened in a cruciate fashion with a #15 blade. there was immediate flow of a thin motor oil fluid under high pressure. literally the fluid shot out several inches with the first nick in the membranous cavity. the dura was reflected back and biopsy of the membranes was taken and sent for permanent section. the margins of the membrane were coagulated. the microscope was brought in and it was apparent there were septations within the cavity and these septations were for the most part divided with bipolar electrocautery. the wound was irrigated thoroughly and was inspected carefully for any sites of bleeding and there were none. the dura was then closed in a watertight fashion using running locking 4-0 nurolon. tack-up sutures had been placed at the beginning of the case and the bone flap was returned to the wound and fixed to the skull using the lorenz plating system. the wound was irrigated thoroughly once more and was closed in layers. muscle fascia and galea were closed in separate layers with interrupted inverted 2-0 vicryl. finally, the skin was closed with running locking 3-0 nylon.,estimated blood loss for the case was less than 30 ml. sponge and needle counts were correct.,findings: , chronic subdural hematoma with multiple septations and thickened subdural membrane.,i might add that the arachnoid was not violated at all during this procedure. also, it was noted that there was no subarachnoid blood but only subdural blood.

summary of clinical history:, the patient was a 35-year-old african-american male with no significant past medical history who called ems with shortness of breath and chest pain. upon ems arrival, patient was tachypneic at 40 breaths per minute with oxygen saturation of 90%. at the scene, ems administered breathing treatments and checked lung sounds that did not reveal any evidence of fluid in the lung fields. ems also reports patient was agitated upon their arrival at his residence. two minutes after arrival at utmb at 1500, the patient became unresponsive, apneic, and had oxygen saturations from 80-90%. the patient's heart rate decreased to asystole, was intubated with good breath sounds and air movement. patient then had wide complex bradycardia and acls protocol for pulseless electrical activity was followed for 45 minutes. the patient was administered tpa with no improvement. bedside echocardiogram showed no pericardial effusion. the patient was administered d5w, narcan, and multiple rounds of epinephrine and atropine, calcium chloride, and sodium bicarbonate. the patient had three episodes of ventricular tachycardia/fibrillation with cardioversion/defibrillation resulting in asystole. the patient was pronounced dead at 1605 with fixed, dilated pupils, no heart sounds, no pulse and no spontaneous respirations.,description of gross lesions,external examination:, the body is that of a 35-year-old well-developed, well-nourished male. there is no peripheral edema of the extremities. there is an area of congestion/erythema on the upper chest and anterior neck. there are multiple small areas of hemorrhage bilaterally in the conjunctiva. a nasogastric tube and endotracheal tube are in place. there is an intravenous line in the right hand and left femoral region. the patient has multiple lead pads on the thorax. the patient has no other major surgical scars.,internal examination (body cavities):, the right and left pleural cavity contains 10 ml of clear fluid with no adhesions. the pericardial sac is yellow, glistening without adhesions or fibrosis and contains 30 ml of a straw colored fluid. there is minimal fluid in the peritoneal cavity.,heart:, the heart is large with a normal shape and a weight of 400 grams. the pericardium is intact. the epicardial fat is diffusely firm. as patient was greater than 48 hours post mortem, no ttc staining was utilized. upon opening the heart was grossly normal without evidence of infarction. there were slightly raised white plaques in the left ventricle wall lining. the left ventricle measures 2.2 cm, the right ventricle measures 0.2 cm, the tricuspid ring measures 11 cm, the pulmonic right measures 8 cm, the mitral ring measures 10.2 cm, and the aortic ring measures 7 cm. the foramen ovale is closed. the circulation is left dominant. examination of the great vessels of the heart reveals minimal atherosclerosis with the area of greatest stenosis (20% stenosis) at the bifurcation of the lad.,aorta:, there is minimal atherosclerosis with no measurable plaques along the full length of the ascending and descending aorta.,lungs: , the right lung weighed 630 grams, the left weighed 710 grams. the lung parenchyma is pink without evidence of congestion of hemorrhage. the bronchi are grossly normal. in the right lung, there are two large organizing thrombo-emboli. the first is located at the first branch of the pulmonary artery with an older, organizing area adherent to the vessel wall measuring 1.0 x 1.0 x 2.5 cm. surrounding this organizing area is a newer area of apparent thrombosis completely occluding the bifurcation. the other large organizing, adherent embolus is located further in out in the vasculature measuring approximately 1.0 x 1.0 x 1.5 cm. there are multiple other emboli located in smaller pulmonary vessels that show evidence of distending the vessels they are located inside.,gastrointestinal system:, the esophagus and stomach are normal in appearance without evidence of ulcers or varices. the stomach contains approximately 800 ml, without evidence of any pills or other non-foodstuff material. the pancreas shows a normal lobular cut surface with evidence of autolysis. the duodenum, ileum, jejunum and colon are all grossly normal without evidence of abnormal vasculature or diverticula. an appendix is present and is unremarkable. the liver weighs 2850 grams and the cut surface reveals a normal liver with no fibrosis present grossly. the gallbladder is in place with a probe patent bile duct through to the ampulla of vater.,reticuloendothelial system:, the spleen is large weighing 340 grams, the cut surface reveals a normal appearing white and red pulp. no abnormally large lymph nodes were noted.,genitourinary system:, the right kidney weighs 200 grams, the left weighs 210 grams. the left kidney contains a 1.0 x 1.0 x 1.0 simple cyst containing a clear fluid. the cut surface reveals a normal appearing cortex and medulla with intact calyces. the prostate and seminal vessels were cut revealing normal appearing prostate and seminal vesicle tissue without evidence of inflammation or embolus.,endocrine system:, the adrenal glands are in the normal position and weigh 8.0 grams on the right and 11.6 grams on the left. the cut surface of the adrenal glands reveals a normal appearing cortex and medulla. the thyroid gland weighs 12.4 grams and is grossly normal.,extremities:, both legs and calves were measured and found to be very similar in circumference. both legs were also milked and produced no clots in the venous system.,clinicopathologic correlation,this patient died shortly after a previous pulmonary embolus completely occluded the right pulmonary artery vasculature., ,the most significant finding on autopsy was the presence of multiple old and new thromboemboli in the pulmonary vasculature of the right lung. the autopsy revealed evidence of multiple emboli in the right lung that were at least a few days old because the emboli that were organizing were adherent to the vessel wall. in order to be adherent to the vessel wall, the emboli must be in place long enough to evoke a fibroblast response, which takes at least a few days. the fatal event was not the old emboli in the right lung, but rather the thrombosis on top of the large saddle thrombus residing in the pulmonary artery. this created a high-pressure situation that the right ventricle could not handle resulting in cardiac dysfunction and ultimately the patient's demise.,although this case is fairly straight forward in terms of what caused the terminal event, perhaps the more interesting question is why a relatively healthy 35-year-old man would develop a fatal pulmonary embolism. virchow's triad suggests we should investigate endothelial injury, stasis and a hypercoagulable state as possible etiologies. the age of the patient probably precludes venous stasis as the sole reason for the embolus although it could have certainly contributed. the autopsy revealed no evidence of endothelial damage in the pulmonary vasculature that would have caused the occlusion. the next logical reason would be a hypercoagulable state. some possibilities include obesity, trauma, surgery, cancer, factor v leiden deficiency (as well as other inherited disorders-prothrombin gene mutation, deficiencies in protein c, protein s, or antithrombin iii, and disorders of plasminogen), and lupus anticoagulant. of these risks factors, obesity was the only risk factor the patient was known to have. the patient had no evidence of trauma, surgery, cancer or the stigmata of sle, therefore these are unlikely. perhaps the most fruitful search would be an examination of the genetic possibilities for a hypercoagulable state (factor v leiden being the most common).,in summary, this patient died of a pulmonary embolism, the underlying cause of which is currently undetermined. a definitive diagnosis may be ascertained with either genetic or other laboratory tests and a more detailed history.,summary and reflection,what i learned from this autopsy:, i learned that although a cause of death may sometimes be obvious, the underlying mechanism for the death may still be elusive. this patient was an otherwise completely healthy 35-year-old man with one known risk factor for a hypercoagulable state.,remaining unanswered questions:, basically the cause of the hypercoagulable state is undetermined. once that question is answered i believe this autopsy will have done a great service for the patient's family.

operation,1. insertion of a left subclavian tesio hemodialysis catheter.,2. surgeon-interpreted fluoroscopy.,operative procedure in detail: , after obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and mac anesthesia was administered. next, the patient's chest and neck were prepped and draped in the standard surgical fashion. lidocaine 1% was used to infiltrate the skin in the region of the procedure. next a #18-gauge finder needle was used to locate the left subclavian vein. after aspiration of venous blood, seldinger technique was used to thread a j wire through the needle. this process was repeated. the 2 j wires and their distal tips were confirmed to be in adequate position with surgeon-interpreted fluoroscopy. next, the subcutaneous tunnel was created. the distal tips of the individual tesio hemodialysis catheters were pulled through to the level of the cuff. a dilator and sheath were passed over the individual j wires. the dilator and wire were removed, and the distal tip of the tesio hemodialysis catheter was threaded through the sheath, which was simultaneously withdrawn. the process was repeated. both distal tips were noted to be in good position. the tesio hemodialysis catheters were flushed and aspirated without difficulty. the catheters were secured at the cuff level with a 2-0 nylon. the skin was closed with 4-0 monocryl. sterile dressing was applied. the patient tolerated the procedure well and was transferred to the pacu in good condition.

preoperative diagnosis: , cervical spondylosis at c3-c4 with cervical radiculopathy and spinal cord compression.,postoperative diagnosis:, cervical spondylosis at c3-c4 with cervical radiculopathy and spinal cord compression.,operation performed,1. anterior cervical discectomy of c3-c4.,2. removal of herniated disc and osteophytes.,3. bilateral c4 nerve root decompression.,4. harvesting of bone for autologous vertebral bodies for creation of arthrodesis.,5. grafting of fibular allograft bone for creation of arthrodesis.,6. creation of arthrodesis via an anterior technique with fibular allograft bone and autologous bone from the vertebral bodies.,7. placement of anterior spinal instrumentation using the operating microscope and microdissection technique.,indications for procedure: , this 62-year-old man has progressive and intractable right c4 radiculopathy with neck and shoulder pain. conservative therapy has failed to improve the problem. imaging studies showed severe spondylosis of c3-c4 with neuroforaminal narrowing and spinal cord compression.,a detailed discussion ensued with the patient as to the nature of the procedure including all risks and alternatives. he clearly understood it and had no further questions and requested that i proceed.,procedure in detail: , the patient was placed on the operating room table and was intubated using a fiberoptic technique. the methylprednisolone spinal cord protocol was instituted with bolus and continuous infusion doses. the neck was carefully prepped and draped in the usual sterile manner.,a transverse incision was made on a skin crease on the left side of the neck. dissection was carried down through the platysmal musculature and the anterior spine was exposed. the medial borders of the longus colli muscles were dissected free from their attachments to the spine. a needle was placed and it was believed to be at the c3-c4 interspace and an x-ray properly localized this space. castoff self-retaining pins were placed into the body of the c3 and c4. self-retaining retractors were placed in the wound keeping the blades of the retractors underneath the longus colli muscles.,the annulus was incised and a discectomy was performed. quite a bit of overhanging osteophytes were identified and removed. as i worked back to the posterior lips of the vertebral body, the operating microscope was utilized.,there was severe overgrowth of spondylitic spurs. a high-speed diamond bur was used to slowly drill these spurs away. i reached the posterior longitudinal ligament and opened it and exposed the underlying dura.,slowly and carefully i worked out towards the c3-c4 foramen. the dura was extremely thin and i could see through it in several areas. i removed the bony compression in the foramen and identified soft tissue and veins overlying the root. all of these were not stripped away for fear of tearing this very tissue-paper-thin dura. however, radical decompression was achieved removing all the bony compression in the foramen, out to the pedicle, and into the foramen. an 8-mm of the root was exposed although i left the veins over the root intact.,the microscope was angled to the left side where a similar procedure was performed.,once the decompression was achieved, a high-speed cortisone bur was used to decorticate the body from the greater posterior shelf to prevent backward graft migration. bone thus from the drilling was preserved for use for the arthrodesis.,attention was turned to creation of the arthrodesis. as i had drilled quite a bit into the bodies, i selected a large 12-mm graft and distracted the space maximally. under distraction the graft was placed and fit well. an x-ray showed good graft placement.,attention was turned to spinal instrumentation. a synthes short stature plate was used with four 3-mm screws. holes were drilled with all four screws were placed with pretty good purchase. next, the locking screws were then applied. an x-ray was obtained which showed good placement of graft, plate, and screws. the upper screws were near the upper endplate of c3. the c3 vertebral body that remained was narrow after drilling off the spurs. rather than replace these screws and risk that the next holes would be too near the present holes i decided to leave these screws intact because their position is still satisfactory as they are below the disc endplate.,attention was turned to closure. a hemovac drain was placed in the anterior vertebral body space and brought out through a separate stab wound incision in the skin. the wound was then carefully closed in layers. sterile dressings were applied along with a rigid philadelphia collar. the operation was then terminated.,the patient tolerated the procedure well and left for the recovery room in excellent condition. the sponge and needle counts were reported as correct and there were no intraoperative complications.,specimens were sent to pathology consisted of bone and soft tissue as well as c3-c4 disc material.

chief complaint: ,the patient does not have any chief complaint.,history of present illness:, this is a 93-year-old female who called up her next-door neighbor to say that she was not feeling well. the next-door neighbor came over and decided that she should go to the emergency room to be check out for her generalized complaint of not feeling well. the neighbor suspects that this may have been due to the patient taking too many of her tylenol pm, which the patient has been known to do. the patient was a little somnolent early this morning and was found only to be oriented x1 with ems upon their arrival to the patient's house. the patient states that she just simply felt funny and does not give any more specific details than this. the patient denies any pain at any time. she did not have any shortness of breath. no nausea or vomiting. no generalized weakness. the patient states that all that has gone away since arrival here in the hospital, that she feels at her usual self, is not sure why she is here in the hospital, and thinks she should go. the patient's primary care physician, dr. x reports that the patient spoke with him yesterday and had complained of shortness of breath, nausea, dizziness, as well as generalized weakness, but the patient states that all this has resolved. the patient was actually seen here two days ago for those same symptoms and was found to have exacerbation of her copd and chf. the patient was discharged home after evaluation in the emergency room. the patient does use home o2.,review of systems: , constitutional: the patient had complained of generalized fatigue and weakness two days ago in the emergency room and yesterday to her primary care physician. the patient denies having any other symptoms today. the patient denies any fever or chills. has not had any recent weight change. heent: the patient denies any headache. no neck pain. no rhinorrhea. no sinus congestion. no sore throat. no any vision or hearing change. no eye or ear pain. cardiovascular: the patient denies any chest pain. respirations: no shortness of breath. no cough. no wheeze. the patient did report having shortness of breath and wheeze with her presentation to the emergency room two days ago and shortness of breath to her primary care physician yesterday, but the patient states that all this has resolved. gastrointestinal: no abdominal pain. no nausea or vomiting. no change in the bowel movements. there has not been any diarrhea or constipation. no melena or hematochezia. genitourinary: no dysuria, hematuria, urgency, or frequency. musculoskeletal: no back pain. no muscle or joint aches. no pain or abnormalities to any portion of the body. skin: no rashes or lesions. neurologic: the patient reported dizziness to her primary care physician yesterday over the phone, but the patient denies having any problems with dizziness over the past few days. the patient denies any dizziness at this time. no syncope or no near-syncope. the patient denies any focal weakness or numbness. no speech change. no difficulty with ambulation. the patient has not had any vision or hearing change. psychiatric: the patient denies any depression. endocrine: no heat or cold intolerance.,past medical history:, copd, chf, hypertension, migraines, previous history of depression, anxiety, diverticulitis, and atrial fibrillation.,past surgical history:, placement of pacemaker and hysterectomy.,current medications: , the patient takes tylenol pm for insomnia, lasix, coumadin, norvasc, lanoxin, diovan, atenolol, and folic acid.,allergies:, no known drug allergies.,social history: , the patient used to smoke, but quit approximately 30 years ago. the patient denies any alcohol or drug use although her son reports that she has had a long history of this in the past and the patient has abused prescription medication in the past as well according to her son.,physical examination: , vital signs: temperature 99.1 oral, blood pressure 139/65, pulse is 72, respirations 18, and oxygen saturation is 92% on room air and interpreted as low normal. constitutional: the patient is well nourished and well developed. the patient appears to be healthy. the patient is calm, comfortable, in no acute distress, and looks well. the patient is pleasant and cooperative. heent: head is atraumatic, normocephalic, and nontender. eyes are normal with clear sclerae and cornea bilaterally. nose is normal without rhinorrhea or audible congestion. mouth and oropharynx are normal without any sign of infection. mucous membranes are moist. neck: supple and nontender. full range of motion. there is no jvd. no cervical lymphadenopathy. no carotid artery or vertebral artery bruits. cardiovascular: heart is regular rate and rhythm without murmur, rub or gallop. peripheral pulses are +2. the patient does have +1 bilateral lower extremity edema. respirations: the patient has coarse breath sounds bilaterally, but no dyspnea. good air movement. no wheeze. no crackles. the patient speaks in full sentences without any difficulty. the patient does not exhibit any retractions, accessory muscle use or abdominal breathing. gastrointestinal: abdomen is soft, nontender, and nondistended. no rebound or guarding. no hepatosplenomegaly. normal bowel sounds. no bruits, no mass, no pulsatile mass, and no inguinal lymphadenopathy. musculoskeletal: no abnormalities noted to the back, arms or legs. skin: no rashes or lesions. neurological: cranial nerves ii through xii are intact. motor is 5/5 and equal to bilateral arms and legs. sensory is intact to light touch. the patient has normal speech and normal ambulation. psychiatric: the patient is awake, alert, and oriented x3 although the patient first stated that the year was 1908, but did manage to correct herself up on addressing this with her. the patient has normal mood and affect. hematologic and lymphatic: there is no evidence of lymphadenopathy.,emergency department testing: , ekg is a rate of 72 with evidence of a pacemaker that has good capture. there is no evidence of acute cardiac disease on the ekg and there is no apparent change in the ekg from 03/17/08. cbc has no specific abnormalities of issue. chemistry has a bun of 46 and creatinine of 2.25, glucose is 135, and an estimated gfr is 20. the rest of the values are normal and unremarkable. lfts are all within normal limits. cardiac enzymes are all within normal limits. digoxin level is therapeutic at 1.6. chest x-ray noted cardiomegaly and evidence of congestive heart failure, but no acute change from her chest x-ray done two days ago. cat scan of the head did not identify any acute abnormalities. i spoke with the patient's primary care physician, dr. x who stated that he would be able to follow up with the patient within the next day. i spoke with the patient's neighbor who contacted the ambulance service who stated that the patient just reported not feeling well and appeared to be a little somnolent and confused at the time, but suspected that she may have taken too many of her tylenol pm as she often has done in the past. the neighbor is xyz and he says that he checks on her three times a day every day. abc is the patient's son and although he lives out of town he calls and checks on her every day as well. he states that he spoke to her yesterday. she sounded fine, did not express any other problems that she had apparently been in contact with her primary care physician. she sounded her usual self to him. mr. abc also spoke to the patient while she was here in the emergency room and she appears to be her usual self and has her normal baseline mental status to him. he states that he will be able to check on her tomorrow as well. although it is of some concern that there may be problems with development of some early dementia, the patient is adamant about not going to a nursing home and has been placed in a nursing home in the past, but dr. y states that she has managed to be discharged after two previous nursing home placements. the patient does have home health that checks on her as well as housing care in between the two services they share visits every single day by them as well as the neighbor who checks on her three times a day and her son who calls her each day as well. the patient although she lives alone, does appear to have good followup and the patient is adamant that she wishes to return home.,diagnoses,1. early dementia.,2.

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

indications:, atrial fibrillation, coronary disease.,stress technique:, the patient was infused with dobutamine to a maximum heart rate of 142. ecg exhibits atrial fibrillation.,image technique:, the patient was injected with 5.2 millicuries of thallous chloride and subsequently imaged on the gated tomographic spect system.,image analysis:, it should be noted that the images are limited slightly by the patient's obesity with a weight of 263 pounds. there is normal lv myocardial perfusion. the lv systolic ejection fraction is normal at 65%. there is normal global and regional wall motion.,conclusions:,1. basic rhythm of atrial fibrillation with no change during dobutamine stress, maximum heart rate of 142.,2. normal lv myocardial perfusion.,3. normal lv systolic ejection fraction of 65%.,4. normal global and regional wall motion.