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physical examination:, this 71-year-old man went to his primary care physician for a routine physical. his only complaints were nocturia times two and a gradual "slowing down" feeling. the physical examination on 1/29 was within normal limits except for the digital rectal exam which revealed an asymmetric prostate gland with nodularity, r>l. psa was elevated. the differential diagnosis for the visit was abnormal prostate, suggestive of ca.,imaging: ,ct pelvis: irregular indentation of bladder. seminal vesicles enlarged. streaky densities in periprostatic fat consistent with transcapular spread to periprostatic plexus. impression: prostatic malignancy with extracapsular extension and probable regional node metastasis.,bone scan: negative for distant metastasis.,laboratory:, psa 32.1,procedures:, transrectal needle biopsy of prostate. pelvic lymphadenectomy and radical prostatectomy.,pathology: ,prostate biopsy: moderate to poorly differentiated adenocarcinoma in the right lobe and poorly differentiated tubular adenocarcinoma in the left lobe of prostate.,lymphadenectomy and prostatectomy: frozen section of removed pelvic lymph nodes demonstrated metastatic adenocarcinoma in one lymph node in the right obturator fossa. therefore, the radical prostatectomy was canceled. ,final pathology diagnosis: pelvic lymphadenectomy; left obturator fossa, single negative lymph node. right obturator fossa; metastatic adenocarcinoma in 1/5 lymph nodes. largest involved node 1.5 cm.,treatment: , patient began external beam radiation therapy to the pelvis.

findings:,high resolution computerized tomography was performed from t12-l1 to the s1 level with reformatted images in the sagittal and coronal planes and 3d reconstructions performed. comparison: previous mri examination 10/13/2004.,there is minimal curvature of the lumbar spine convex to the left.,t12-l1, l1-2, l2-3: there is normal disc height with no posterior annular disc bulging or protrusion. normal central canal, intervertebral neural foramina and facet joints.,l3-4: there is normal disc height and non-compressive circumferential annular disc bulging eccentrically greater to the left. normal central canal and facet joints (image #255).,l4-5: there is normal disc height, circumferential annular disc bulging, left l5 hemilaminectomy and posterior central/right paramedian broad-based disc protrusion measuring 4mm (ap) contouring the rightward aspect of the thecal sac. orthopedic hardware is noted posteriorly at the l5 level. normal central canal, facet joints and intervertebral neural foramina (image #58).,l5-s1: there is minimal decreased disc height, postsurgical change with intervertebral disc spacer, posterior lateral orthopedic hardware with bilateral pedicle screws in good postsurgical position. the orthopedic hardware creates mild streak artifact which mildly degrades images. there is a laminectomy defect, spondylolisthesis with 3.5mm of anterolisthesis of l5, posterior annular disc bulging greatest in the left foraminal region lying adjacent to the exiting left l5 nerve root. there is fusion of the facet joints, normal central canal and right neural foramen (image #69-70, 135).,there is no bony destructive change noted.,there is no perivertebral soft tissue abnormality.,there is minimal to mild arteriosclerotic vascular calcifications noted in the abdominal aorta and right proximal common iliac artery.,impression:,minimal curvature of the lumbar spine convex to the left.,l3-4 posterior non-compressive annular disc bulging eccentrically greater to the left.,l4-5 circumferential annular disc bulging, non-compressive central/right paramedian disc protrusion, left l5 laminectomy.,l5-s1 postsurgical change with posterolateral orthopedic fusion hardware in good postsurgical position, intervertebral disc spacer, spondylolisthesis, laminectomy defect, posterior annular disc bulging greatest in the left foraminal region adjacent to the exiting left l5 nerve root with questionable neural impingement.,minimal to mild arteriosclerotic vascular calcifications.

reason for referral: , ms. a is a 60-year-old african-american female with 12 years of education who was referred for neuropsychological evaluation by dr. x after she demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment with him for stroke in july. a comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,relevant background information:, historical information was obtained from a review of available medical records and clinical interview with ms. a. a summary of pertinent information is presented below. please refer to the patient's medical chart for a more complete history.,history of presenting problem:, ms. a presented to the abc hospital emergency department on 07/26/2009 reporting that after she had woken up that morning she noticed numbness and weakness in her left hand, slurred speech, and left facial droop. neurological evaluation with dr. x confirmed left hemiparesis. brain ct showed no evidence of intracranial hemorrhage or mass effect and that she received tpa and had moderate improvement in left-sided weakness. these symptoms were thought to be due to a right middle cerebral artery stroke. she was transferred to the icu for monitoring. ultrasound of the carotids showed 20% to 30% stenosis of the right ica and 0% to 19% stenosis of the left ica. on 07/29/2009, she was admitted for acute inpatient rehabilitation for the treatment of residual functional deficits of her acute ischemic right mca/cva. at discharge on 08/06/2009, she was mainly on supervision for all adls and walking with a rolling walker, but tolerating increased ambulation with a cane. she was discharged home with recommendations for outpatient physical therapy. she returned to the sinai er on 08/2009/2009 due to reported left arm pain, numbness, and weakness, which lasted 10 to 15 minutes and she reported that it felt "just like the stroke." brain ct on 08/2009/2009 was read as showing "mild chronic microvascular ischemic change of deep white matter," but no acute or significant interval change compared to her previous scan. neurological examination with dr. y was within normal limits, but she was admitted for a more extensive workup. due to left arm pain an ultrasound was completed on her left upper extremity, but it did not show deep vein thrombosis.,followup ct on 08/10/2009 showed no significant interval change. mri could not be completed due to the patient's weight. she was discharged on 08/11/2009 in stable condition after it was determined that this event was not neurological in origin; however, note that ms. a referred to this as a second stroke.,ms. a presented for a followup outpatient neurological evaluation with dr. x on 09/22/2009, at which time a brief neuropsychological screening was also conducted. she demonstrated significant impairments in confrontation naming, abstract verbal reasoning, and visual and verbal memory and thus a more comprehensive evaluation was suggested due to her intent to return to her full-time work duty. during the current interview, ms. a reported that she noticed mild memory problems including some difficultly remembering conversations, events, and at times forgetting to take her medications. she also reported mild difficulty finding words in conversation, solving novel problems and tasks (e.g. difficulty learning to use her camcorder), but overall denied significant cognitive deficits in attention, concentration, language or other areas of cognitive functioning. when asked about her return to work, she said that she was still on light duty due to limited physical activity because of residual left leg weakness. she reported that no one had indicated to her that she appeared less capable of performing her job duties, but said that she was also receiving fewer files to process and enter data into the computer at the social security agency that she works at. note also that she had some difficulty explaining exactly what her job involved. she also reported having problems falling asleep at work and that she is working full-time although on light duty.,other medical history: ,as mentioned, ms. a continues to have some residual left leg weakness and continues to use a rolling walker for ambulation, but she reported that her motor functioning had improved significantly. she was diagnosed with sleep apnea approximately two years ago and was recently counseled by dr. x on the need to use her cpap because she indicated she never used it at night. she reported that since her appointment with dr. x, she has been using it "every other night." when asked about daytime fatigue, ms. a initially denied that she was having any difficulties, but repeatedly indicated that she was falling asleep at work and thought that it was due to looking at a computer screen. she reported at times "snoring" and forgetting where she is at and said that a supervisor offered to give her coffee at one point. she receives approximately two to five hours of sleep per night. other current untreated risk factors include obesity and hypercholesterolemia. her medical history is also significant for hypertension, asthma, abdominal adenocarcinoma status post hysterectomy with bilateral salpingo-oophorectomy, colonic benign polyps status post resection, benign lesions of the breast status post lumpectomy, and deep vein thrombosis in the left lower extremity status post six months of anticoagulation (which she had discontinued just prior to her stroke).,current medications: , aspirin 81 mg daily, colace 100 mg b.i.d., lipitor 80 mg daily, and albuterol mdi p.r.n.,substance use:, ms. a denied drinking alcohol or using illicit drugs. she used to smoke a pack of cigarettes per day, but quit five to six years ago.,family medical history: , ms. a had difficulty providing information on familial medical history. she reported that her mother died three to four years ago from lung cancer. her father has gout and blood clots. siblings have reportedly been treated for asthma and gi tumors. she was unsure of familial history of other conditions such as hypertension, high cholesterol, stroke, etc.,social history: , ms. a completed high school degree. she reported that she primarily obtained b's and c's in school. she received some tutoring for algebra in middle school, but denied ever having been held back a grade failing any classes or having any problems with attention or hyperactivity.,she currently works for the social security administration in data processing. as mentioned, she has returned to full-time work, but continues to perform only light duties due to her physical condition. she is now living on her own. she has never driven. she reported that she continues to perform adls independently such as cooking and cleaning. she lost her husband in 2005 and has three adult daughters. she previously reported some concerns that her children wanted her to move into assisted living, but she did not discuss that during this current evaluation. she also reported number of other family members who had recently passed away. she has returned to activities she enjoys such as quire, knitting, and cooking and plans to go on a cruise to the bahamas at the end of october.,psychiatric history: , ms. a did not report a history of psychological or psychiatric treatment. she reported that her current mood was good, but did describe some anxiety and nervousness about various issues such as her return to work, her upcoming trip, and other events. she reported that this only "comes and goes.",tasks administered:,clinical interview,adult history questionnaire,wechsler test of adult reading (wtar),mini mental status exam (mmse),cognistat neurobehavioral cognitive status examination,repeatable battery for the assessment of neuropsychological status (rbans; form xx),mattis dementia rating scale, 2nd edition (drs-2),neuropsychological assessment battery (nab),wechsler adult intelligence scale, third edition (wais-iii),wechsler adult intelligence scale, fourth edition (wais-iv),wechsler abbreviated scale of intelligence (wasi),test of variables of attention (tova),auditory consonant trigrams (act),paced auditory serial addition test (pasat),ruff 2 & 7 selective attention test,symbol digit modalities test (sdmt),multilingual aphasia examination, second edition (mae-ii), token test, sentence repetition, visual naming, controlled oral word association, spelling test, aural comprehension, reading comprehension,boston naming test, second edition (bnt-2),animal naming test

preoperative diagnoses:,1. enlarging dark keratotic lesion of the left temple measuring 1 x 1 cm.,2. enlarging keratotic neoplasm of the left nasolabial fold measuring 0.5 x 0.5 cm.,3. enlarging seborrheic keratotic neoplasm of the right temple measuring 1 x 1 cm.,postoperative diagnoses:,1. enlarging dark keratotic lesion of the left temple measuring 1 x 1 cm.,2. enlarging keratotic neoplasm of the left nasolabial fold measuring 0.5 x 0.5 cm.,3. enlarging seborrheic keratotic neoplasm of the right temple measuring 1 x 1 cm.,title of procedures:,1. excision of the left temple keratotic neoplasm, final defect 1.8 x 1.5 cm with two layer plastic closure.,2. excision of the left nasolabial fold defect 0.5 x 0.5 cm with single layer closure.,3. excision of the right temple keratotic neoplasm, final defect measuring 1.5 x 1.5 cm with two layer plastic closure.,anesthesia: , local using 3 ml of 1% lidocaine with 1:100,000 epinephrine.,estimated blood loss: , less than 30 ml.,complications:, none.,procedure: , the patient was evaluated preoperatively and noted to be in stable condition. informed consent was obtained from the patient. all risks, benefits and alternatives regarding the surgery have been reviewed in detail with the patient. this includes risks of bleeding, infection, scarring, recurrence of lesion, need for further procedures, etc. each of the areas was cleaned with a sterile alcohol swab. planned excision site was marked with a marking pen. local anesthetic was infiltrated. sterile prep and drape were then performed.,we began first with excision of the left temple followed by the left nasolabial and right temple lesions. the left temple lesion is noted to be a dark black what appears to be a keratotic or possible seborrheic keratotic neoplasm. however, it is somewhat deeper than the standard seborrheic keratosis. the incision for removal of this lesion was placed within the relaxed skin tension line of the left temple region. once this was removed, wide undermining was performed and the wound was closed in a two layer fashion using 5-0 myochromic for the deep subcutaneous and 5-0 nylon for the skin.,excision of left cheek was a keratotic nevus. it was excised with a defect 0.5 x 0.5 cm. it was closed in a single layer fashion 5-0 nylon.,the lesion of the right temple also dark black keratotic neoplasm was excised with the incision placed within the relaxed skin tension. once it was excised full-thickness, the defect measure 1.5 x 1.5 cm. wide undermine was performed and it was closed in a two layer fashion using 5-0 myochromic for the deep subcutaneous, 5-0 nylon that was used to close skin. sterile dressing was applied afterwards. the patient was discharged in stable condition. postop care instructions reviewed in detail. she is scheduled with me in one week and we will make further recommendations at that time.

preoperative diagnosis:, recurring bladder infections with frequency and urge incontinence, not helped with detrol la.,postoperative diagnosis: , normal cystoscopy with atrophic vaginitis.,procedure performed: , flexible cystoscopy.,findings:, atrophic vaginitis.,procedure: ,the patient was brought in to the procedure suite, prepped and draped in the dorsal lithotomy position. the patient then had flexible scope placed through the urethral meatus and into the bladder. bladder was systematically scanned noting no suspicious areas of erythema, tumor or foreign body. significant atrophic vaginitis is noted.,impression: , atrophic vaginitis with overactive bladder with urge incontinence.,plan: , the patient will try vesicare 5 mg with estrace and follow up in approximately 4 weeks.

discharge diagnoses: ,1. suspected mastoiditis ruled out.,2. right acute otitis media.,3. severe ear pain resolving.,history of present illness: , the patient is an 11-year-old male who was admitted from the er after a ct scan suggested that the child had mastoiditis. the child has had very severe ear pain and blood draining from the right ear. the child had a temperature maximum of 101.4 in the er. the patient was admitted and started on iv unasyn, which he tolerated well and required morphine and vicodin for pain control. in the first 12 hours after admission, the patient's pain decreased and also swelling of his cervical area decreased. the patient was evaluated by dr. x from the ent while in house. after reviewing the ct scan, it was felt that the ct scan was not consistent with mastoiditis. the child was continued on iv fluid and narcotics for pain as well as unasyn until the time of discharge. at the time of discharge his pain is markedly decreased about 2/10 and swelling in the area has improved. the patient is also able to take p.o. well.,discharge physical examination:,general: the patient is alert, in no respiratory distress.,vital signs: his temperature is 97.6, heart rate 83, blood pressure 105/57, respiratory rate 16 on room air.,heent: right ear shows no redness. the area behind his ear is nontender. there is a large posterior chains node that is nontender and the swelling in this area has decreased markedly.,neck: supple.,chest: clear breath sounds.,cardiac: normal s1, s2 without murmur.,abdomen: soft. there is no hepatosplenomegaly or tenderness.,skin: warm and well perfused.,discharge weight: , 38.7 kg.,discharge condition: , good.,discharge diet:, regular as tolerated.,discharge medications: ,1. ciprodex otic solution in the right ear twice daily.,2. augmentin 500 mg three times daily x10 days.,follow up: ,1. dr. y in one week (ent).,2. the primary care physician in 2 to 3 days.,time spent: , approximate discharge time is 28 minutes.

pre and postoperative diagnosis:, left cervical radiculopathy at c5, c6,operation: , left c5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root.,after informed consent was obtained from the patient, he was taken to the or. after general anesthesia had been induced, ted hose stockings and pneumatic compression stockings were placed on the patient and a foley catheter was also inserted. at this point, the patient's was placed in three point fixation with a mayfield head holder and then the patient was placed on the operating table in a prone position. the patient's posterior cervical area was then prepped and draped in the usual sterile fashion. at this time the patient's incision site was infiltrated with 1 percent lidocaine with epinephrine. a scalpel was used to make an approximate 3 cm skin incision cephalad to the prominent c7 spinous processes, which could be palpated. after dissection down to a spinous process using bovie cautery, a clamp was placed on this spinous processes and cross table lateral x-ray was taken. this showed the spinous process to be at the c4 level. therefore, further soft tissue dissection was carried out caudally to this level after the next spinous processes presumed to be c5 was identified. after the muscle was dissected off the lamina laterally on the left side, self retaining retractors were placed and after hemostasis was achieved, a penfield probe was placed in the interspace presumed to be c5-6 and another cross table lateral x-ray of the c spine was taken. this film confirmed our position at c5-6 and therefore the operating microscope was brought onto the field at this time. at the time the kerrison rongeur was used to perform a hemilaminotomy by starting with the inferior margin of the superior lamina. the superior margin of the inferior lamina of c6 was also taken with the kerrison rongeur after the ligaments had been freed by using a woodson probe. this was then extended laterally to perform a medial facetectomy also using the kerrison rongeur. however, progress was limited because of thickness of the bone. therefore at this time the midas-rex drill, the am8 bit was brought onto the field and this was used to thin out the bone around our laminotomy and medial facetectomy area. after the bone had been thinned out, further bone was removed using the kerrison rongeur. at this point the nerve root was visually inspected and observed to be decompressed. however, there was a layer of fibrous tissue overlying the exiting nerve root which was removed by placing a woodson resector in a plane between the fibrous sheath and the nerve root and incising it with a 15 blade. hemostasis was then achieved by using gelfoam as well as bipolar electrocautery. after hemostasis was achieved, the surgical site was copiously irrigated with bacitracin. closure was initiated by closing the muscle layer and the fascial layer with 0 vicryl stitches. the subcutaneous layer was then reapproximated using 000 dexon. the skin was reapproximated using a running 000 nylon. sterile dressings were applied. the patient was then extubated in the or and transferred to the recovery room in stable condition.,estimated blood loss:, minimal.

cc:, ha and vision loss.,hx: ,71 y/o rhm developed a cataclysmic headache on 11/5/92 associated with a violent sneeze. the headache lasted 3-4 days. on 11/7/92, he had acute pain and loss of vision in the left eye. over the following day his left pupil enlarged and his left upper eyelid began to droop. he was seen locally and a brain ct showed no sign of bleeding, but a tortuous left middle cerebral artery was visualized. the patient was transferred to uihc 11/12/92.,fhx:, htn, stroke, coronary artery disease, melanoma.,shx:, quit smoking 15 years ago.,meds:, lanoxin, capoten, lasix, kcl, asa, voltaren, alupent mdi,pmh: ,chf, atrial fibrillation, obesity, anemia, duodenal ulcer, spinal avm resection 1986 with residual t9 sensory level, hyperreflexia and bilateral babinski signs, copd.,exam: ,35.5c, bp 140/91, p86, rr20. alert and oriented to person, place, and time. cn: no light perception os, pupils: 3/7 decreasing to 2/7 on exposure to light (i.e., fixed/dilated pupil os). upon neutral gaze the left eye deviated laterally and inferiorly. there was complete ptosis os. on downward gaze their was intorsion os. the left eye could not move superiorly, medially or effectively downward, but could move laterally. eom were full od. the rest of the cn exam was unremarkable. motor, coordination, station and gait testing were unremarkable. sensory exam revealed decreased pinprick and light touch below t9 (old). muscle stretch reflexes were increased (3+/3+) in both lower extremities and there were bilateral babinski signs (old). the upper extremity reflexes were symmetrical (2/2). cardiovascular exam revealed an irregularly irregular rhythm and lung sounds were coarse bilaterally. the rest of the general exam was unremarkable.,lab:, cbc, pt/ptt, general screen were unremarkable except for a bun 21mg/dl. csf: protein 88mg/dl, glucose 58mg/dl, rbc 2800/mm3, wbc 1/mm3. ana, rf, tsh, ft4 were wnl.,impression:, cn3 palsy and loss of vision. differential diagnosis: temporal arteritis, aneurysm, intracranial mass.,course:, the outside brain ct revealed a tortuous left mca. a four-vessel cerebral angiogram revealed a dolichoectatic basilar artery and tortuous lica. there was no evidence of aneursym. transesophageal echocardiogram revealed atrial enlargement only. neuroopthalmologic evaluation revealed: loss of color vision and visual acuity os, rapd os, bilateral optic disk pallor (os > od), cn3 palsy and bilateral temporal field loss, os >> od . esr, crp, mri were recommended to rule out temporal arteritis and intracranial mass. esr 29mm/hr, crp 4.3mg/dl (high) , the patient was placed on prednisone. temporal artery biopsy showed no evidence of vasculitis. mri scan could not be obtained due to patient weight. sellar ct was done instead: coronal sections revealed sellar enlargement and upward bowing of the diaphragm sella suggesting a pituitary mass. in retrospect sellar enlargement could be seen on the angiogram x-rays. differential consideration was given to cystic pituitary adenoma, noncalcified craniopharyngioma, or rathke's cleft cyst with solid component. the patient refused surgery. he was seen in neuroopthalmology clinic 2/18/93 and was found to have mild recovery of vision os and improved visual fields. aberrant reinnervation of the 3rd nerve was noted as there was constriction of the pupil (os) on adduction, downgaze and upgaze. the upper eyelid, os, elevated on adduction and down gaze, os. eom movements were otherwise full and there was no evidence of ptosis. in retrospect he was felt to have suffered pituitary apoplexy in 11/92.

the patient presented in the early morning hours of february 12, 2007, with contractions. the patient was found to be in false versus early labor and managed as an outpatient. the patient returned to labor and delivery approximately 12 hours later with regular painful contractions. there was minimal cervical dilation, but 80% effacement by nurse examination. the patient was admitted. expected management was utilized initially. stadol was used for analgesia. examination did not reveal vulvar lesions. epidural was administered. membranes ruptured spontaneously. cervical dilation progressed. acceleration-deceleration complexes were seen. overall, fetal heart tones remained reassuring during the progress of labor. the patient was allowed to "labor down" during second stage. early decelerations were seen as well as acceleration-deceleration complexes. overall, fetal heart tones were reassuring. good maternal pushing effort produced progressive descent.,spontaneous controlled sterile vaginal delivery was performed without episiotomy and accomplished without difficulty. fetal arm was wrapped at the level of the neck with the fetal hand and also at the level of the neck. there was no loop or coil of cord. infant was vigorous female sex. oropharynx was aggressively aspirated. cord blood was obtained. placenta delivered spontaneously.,following delivery, uterus was explored without findings of significant tissue. examination of the cervix did not reveal lacerations. upper vaginal lacerations were not seen. multiple first-degree lacerations were present. specific locations included the vestibula at 5 o'clock, left labia minora with short extension up the left sulcus, right anterior labia minora at the vestibule, and midline of the vestibule. all mucosal lacerations were reapproximated with interrupted simple sutures of 4-0 vicryl with the knots being buried. post-approximation examination of the rectum showed smooth, intact mucosa. blood loss with the delivery was 400 ml.,plans for postpartum care include routine postpartum orders. nursing personnel will be notified of gilbert's syndrome.

diagnosis: , bilateral hypomastia.,name of operation:, bilateral transaxillary subpectoral mammoplasty with saline-filled implants.,anesthesia:, general.,procedure: , after first obtaining a suitable level of general anesthesia with the patient in the supine position, the breasts were prepped with betadine scrub and solution. sterile towels, sheets, and drapes were placed in the usual fashion for surgery of the breasts. following prepping and draping, the anterior axillary folds and the inframammary folds were infiltrated with a total of 20 cc of 0.5% xylocaine with 1:200,000 units of epinephrine.,after a suitable hemostatic waiting period, transaxillary incisions were made, and dissection was carried down to the edge of the pectoralis fascia. blunt dissection was then used to form a bilateral subpectoral pocket. through the subpectoral pocket a sterile suction tip was introduced, and copious irrigation with sterile saline solution was used until the irrigant was clear.,following completion of irrigation, 350-cc saline-filled implants were introduced. they were first filled with 60 cc of saline and checked for gross leakage; none was evident. they were over filled to 400 cc of saline each. the patient was then placed in the seated position, and the left breast needed 10 cc of additional fluid for symmetry.,following completion of the filling of the implants and checking the breasts for symmetry, the patient's wounds were closed with interrupted vertical mattress sutures of 4-0 prolene. flexan dressings were applied followed by the patient's bra.,she seemed to tolerate the procedure well.

preoperative diagnosis: , leaking anastomosis from esophagogastrectomy. ,postoperative diagnosis: , leaking anastomosis from esophagogastrectomy. ,procedure: , exploratory laparotomy and drainage of intra-abdominal abscesses with control of leakage. ,complications:, none. ,anesthesia: , general oroendotracheal intubation. ,procedure: , after adequate general anesthesia was administered, the patient's abdomen was prepped and draped aseptically. sutures and staples were removed. the abdomen was opened. the were some very early stage adhesions that were easy to separate. dissection was carried up toward the upper abdomen where the patient was found to have a stool filled descended colon. this was retracted caudally to expose the stomach. there were a number of adhesions to the stomach. these were carefully dissected to expose initially the closure over the gastrotomy site. initially this looked like this was leaking but it was actually found to be intact. the pyloroplasty was identified and also found to be intact with no evidence of leakage. further dissection up toward the hiatus revealed an abscess collection. this was sent for culture and sensitivity and was aspirated and lavaged. cavity tracked up toward the hiatus. stomach itself appeared viable, there was no necrotic sections. upper apex of the stomach was felt to be viable also. i did not pull the stomach and esophagus down into the abdomen from the mediastinum, but placed a sucker up into the mediastinum where additional turbid fluid was identified. carefully placed a 10 mm flat jackson-pratt drain into the mediastinum through the hiatus to control this area of leakage. two additional jackson-pratt drains were placed essentially through the gastrohepatic omentum. this was the area that most of the drainage had collected in. as i had previously discussed with dr. sageman i did not feel that mobilizing the stomach to redo the anastomosis in the chest would be a recoverable situation for the patient. i therefore did not push to visualize any focal areas of the anastomosis with the intent of repair. once the drains were secured, they were brought out through the anterior abdominal wall and secured with 3-0 silk sutures and secured to bulb suction. the midline fascia was then closed using running #2 prolene sutures bolstered with retention sutures. subcutaneous tissue was copiously lavaged and then the skin was closed with loosely approximated staples. dry gauze dressing was placed. the patient tolerated the procedure well, there were no complications.

preoperative diagnosis: , multiple pelvic adhesions.,postoperative diagnosis: , multiple pelvic adhesions.,procedure performed: ,lysis of pelvic adhesions.,anesthesia: , general with local.,specimen: , none.,complications: , none.,history: , the patient is a 32-year-old female who had an 8 cm left ovarian mass, which was evaluated by dr. x. she had a ultrasound, which demonstrated the same. the mass was palpable on physical examination and was tender. she was scheduled for an elective pelvic laparotomy with left salpingooophorectomy. during the surgery, there were multiple pelvic adhesions between the left ovarian cyst and the sigmoid colon. these adhesions were taken down sharply with metzenbaum scissors.,procedure: , a pelvic laparotomy had been performed by dr. x. upon exploration of the abdomen, multiple pelvic adhesions were noted as previously stated. a 6 cm left ovarian cyst was noted with adhesions to the sigmoid colon and mesentery. these adhesions were taken down sharply with metzenbaum scissors until the sigmoid colon was completely freed from the ovarian cyst. the ureter had been identified and isolated prior to the adhesiolysis. there was no evidence of bleeding. the remainder of the case was performed by dr. x and this will be found in a separate operative report.

preoperative diagnosis: , possible inflammatory bowel disease.,postoperative diagnosis: , polyp of the sigmoid colon.,procedure performed: ,total colonoscopy with photography and polypectomy.,gross findings: , the patient had a history of ischiorectal abscess. he has been evaluated now for inflammatory bowel disease. upon endoscopy, the colon prep was good. we were able to reach the cecum without difficulty. there are no diverticluli, inflammatory bowel disease, strictures, or obstructing lesions. there was a pedunculated polyp approximately 4.5 cm in size located in the sigmoid colon at approximately 35 cm. this large polyp was removed using the snare technique.,operative procedure: ,the patient was taken to the endoscopy suite, prepped and draped in left lateral decubitus position. iv sedation was given by anesthesia department. the olympus videoscope was inserted into anus. using air insufflation, the colonoscope was advanced through the anus to the rectum, sigmoid colon, descending colon, transverse colon, ascending colon and cecum, the above gross findings were noted. the colonoscope was slowly withdrawn and carefully examined the lumen of the bowel. when the polyp again was visualized, the snare was passed around the polyp. it required at least two to three passes of the snare to remove the polyp in its totality. there was a large stalk on the polyp. ________ the polyp had been removed down to the junction of the polyp in the stalk, which appeared to be cauterized and no residual adenomatous tissue was present. no bleeding was identified. the colonoscope was then removed and patient was sent to recovery room in stable condition.

preoperative diagnosis: , cataract, right eye.,postoperative diagnosis:, cataract, right eye.,title of operation: ,phacoemulsification with intraocular lens insertion, right eye.,anesthesia: , retrobulbar block.,complications: , none.,procedure in detail: ,the patient was brought to the operating room where retrobulbar anesthesia was induced. the patient was then prepped and draped using standard procedure. a wire lid speculum was inserted to keep the eye open and the eye rotated downward with a 0.12. the anterior chamber was entered by making a small superior limbal incision with a crescent blade and then entering the anterior chamber with a keratome. the chamber was then filled with viscoelastic and a continuous-tear capsulorrhexis performed. the phacoemulsification was then instilled in the eye and a linear incision made in the lens. the lens was then cracked with a mcpherson forceps, and the remaining lens material removed with the phacoemulsification tip. the remaining cortex was removed with an i&a. the capsular bag was then inflated with viscoelastic and the wound extended slightly with the keratome. the folding posterior chamber lens was then inserted in the capsular bag and rotated into position. the remaining viscoelastic was removed from the eye with the i&a. the wound was checked for watertightness and found to be watertight. tobramycin drops were instilled in the eye and a shield placed over it. the patient tolerated the procedure well.

preliminary diagnoses:,1. contusion of the frontal lobe of the brain.,2. closed head injury and history of fall.,3. headache, probably secondary to contusion.,final diagnoses:,1. contusion of the orbital surface of the frontal lobes bilaterally.,2. closed head injury.,3. history of fall.,course in the hospital: , this is a 29-year-old male, who fell at home. he was seen in the emergency room due to headache. ct of the brain revealed contusion of the frontal lobe near the falx. the patient did not have any focal signs. he was admitted to abcd. neurology consultation was obtained. neuro checks were done. the patient continued to remain stable, although he had some frontal headache. he underwent an mri to rule out extension of the contusion or the possibility of a bleed and the mri of the brain without contrast revealed findings consistent with contusion of the orbital surface of the frontal lobes bilaterally near the interhemispheric fissure. the patient remained clinically stable and his headache resolved. he was discharged home on 11/6/2008.,plan: , discharge the patient to home.,activity: ,as tolerated.,the patient has been advised to call if the headache is recurrent and tylenol 650 mg 1 p.o. q.6 h. p.r.n. headache. the patient has been advised to follow up with me as well as the neurologist in about 1 week.

preprocedure diagnosis: , history of colon polyps and partial colon resection, right colon.,postprocedure diagnoses: ,1. normal operative site. ,2. mild diverticulosis of the sigmoid colon. ,3. hemorrhoids.,procedure: ,total colonoscopy.,procedure in detail: ,the patient is a 60-year-old of dr. abc's being evaluated for the above. the patient also apparently had an x-ray done at the hospital and it showed a dark spot, and because of this, a colonoscopy was felt to be needed. she was prepped the night before and on the morning of the test with oral fleet's, brought to the second floor and sedated with a total of 50 mg of demerol and 3.75 mg of versed iv push. digital rectal exam was done, unremarkable. at that point, the pentax video colonoscope was inserted. the rectal vault appeared normal. the sigmoid showed diverticula throughout, mild to moderate in nature. the scope was then passed through the descending and transverse colon over to the hepatic flexure area and then the anastomosis site was visualized. the scope was passed a short distance up the ileum, which appeared normal. the scope was then withdrawn through the transverse, descending, sigmoid, and rectal vault area. the scope was then retroflexed, and anal verge visualized showed some hemorrhoids. the scope was then removed. the patient tolerated the procedure well.,recommendations: ,repeat colonoscopy in three years.

discharge diagnoses: ,1. suspected mastoiditis ruled out.,2. right acute otitis media.,3. severe ear pain resolving.,history of present illness: , the patient is an 11-year-old male who was admitted from the er after a ct scan suggested that the child had mastoiditis. the child has had very severe ear pain and blood draining from the right ear. the child had a temperature maximum of 101.4 in the er. the patient was admitted and started on iv unasyn, which he tolerated well and required morphine and vicodin for pain control. in the first 12 hours after admission, the patient's pain decreased and also swelling of his cervical area decreased. the patient was evaluated by dr. x from the ent while in house. after reviewing the ct scan, it was felt that the ct scan was not consistent with mastoiditis. the child was continued on iv fluid and narcotics for pain as well as unasyn until the time of discharge. at the time of discharge his pain is markedly decreased about 2/10 and swelling in the area has improved. the patient is also able to take p.o. well.,discharge physical examination:,general: the patient is alert, in no respiratory distress.,vital signs: his temperature is 97.6, heart rate 83, blood pressure 105/57, respiratory rate 16 on room air.,heent: right ear shows no redness. the area behind his ear is nontender. there is a large posterior chains node that is nontender and the swelling in this area has decreased markedly.,neck: supple.,chest: clear breath sounds.,cardiac: normal s1, s2 without murmur.,abdomen: soft. there is no hepatosplenomegaly or tenderness.,skin: warm and well perfused.,discharge weight: , 38.7 kg.,discharge condition: , good.,discharge diet:, regular as tolerated.,discharge medications: ,1. ciprodex otic solution in the right ear twice daily.,2. augmentin 500 mg three times daily x10 days.,follow up: ,1. dr. y in one week (ent).,2. the primary care physician in 2 to 3 days.,time spent: , approximate discharge time is 28 minutes.

reason for consultation:, breast reconstruction post mastectomy.,history of present illness: , the patient is a 51-year-old lady, who had gone many years without a mammogram when she discovered a lump in her right breast early in february of this year. she brought this to the attention of her primary care doctor and she soon underwent ultrasound and mammogram followed by needle biopsy, which revealed that there was breast cancer. this apparently was positive in two separate locations within the suspicious area. she also underwent mri, which suggested that there was significant size to the area involved. her contralateral left breast appeared to be uninvolved. she has had consultation with dr. abc and they are currently in place to perform a right mastectomy.,past medical history: , positive for hypertension, which is controlled on medications. she is a nonsmoker and engages in alcohol only moderately.,past surgical history: , surgical history includes uterine fibroids, some kind of cyst excision on her foot, and cataract surgery.,allergies: , none known.,medications: , lipitor, ramipril, lasix, and potassium.,physical examination: , on examination, the patient is a healthy looking 51-year-old lady, who is moderately overweight. breast exam reveals significant breast hypertrophy bilaterally with a double d breast size and significant shoulder grooving from her bra straps. there are no any significant scars on the right breast as she has only undergone needle biopsy at this point. exam also reveals abdomen where there is moderate excessive fat, but what i consider a good morphology for a potential tram flap.,impression:, a 51-year-old lady for mastectomy on the right side, who is interested in the possibility of breast reconstruction. we discussed the breast reconstruction options in some detail including immediate versus delayed reconstruction and autologous tissue versus implant reconstruction. i think for a lady of this physical size and breast morphology that the likelihood of getting a good result with a tissue expander reconstruction is rather slim. a further complicating factor is the fact that she may well be undergoing radiation after her mastectomy. i would think this would make a simple tissue expander reconstruction virtually beyond the balance of consideration. i have occasionally gotten away with tissue expanders with reasonable results in irradiated patients when they are thinner and smaller breasted, but in a heavier lady with large breasts, i think it virtually deemed to failure. we therefore, mostly confine our discussion to the relative merits of tram flap breast reconstruction and latissimus dorsi reconstruction with implant. in either case, the contralateral breast reduction would be part of the overall plan., ,the patient understands that the tram flap although not much more lengthy of a procedure is a little comfortable recovery. since we are sacrificing a rectus abdominus muscle that can be more discomfort and difficulties in healing both due to it being a respiratory muscle and to its importance in sitting up and getting out of bed. in any case, she does prefer this option in order to avoid the need for an implant. we discussed pros and cons of the surgery, including the risks such as infection, bleeding, scarring, hernia, or bulging of the donor site, seroma of the abdomen, and fat necrosis or even the skin slough in the abdomen. we also discussed some of the potential flap complications including partial or complete necrosis of the tram flap itself.,plan: , the patient is definitely interested in undergoing tram flap reconstruction. at the moment, we are planning to do it as an immediate reconstruction at the time of the mastectomy. for this reason, i have made arrangements to do initial vascular delay procedure within the next couple of days. we may cancel this if the chance of postoperative irradiation is high. if this is the case, i think we can do a better job on the reconstruction if we defer it. the patient understands this and will proceed according to the recommendations from dr. abc and from the oncologist.

social history, family history, and past medical history:, reviewed. there are no changes, otherwise.,review of systems:, fatigue, pain, difficulty with sleep, mood fluctuations, low stamina, mild urgency frequency and hesitancy, preponderance of lack of stamina, preponderance of pain particularly in the left shoulder.,examination: , the patient is alert and oriented. extraocular movements are full. the face is symmetric. the uvula is midline. speech has normal prosody. today there is much less guarding of the left shoulder. in the lower extremities, iliopsoas, quadriceps, femoris and tibialis anterior are full. the gait is narrow based and noncircumductive. rapid alternating movements are slightly off bilaterally. the gait does not have significant slapping characteristics. sensory examination is largely unremarkable. heart, lungs, and abdomen are within normal limits.,impression: , mr. abc is doing about the same. we discussed the issue of adherence to copaxone. in order to facilitate this, i would like him to take copaxone every other day, but on a regular rhythm. his wife continues to inject him. he has not been able to start himself on the injections.,greater than 50% of this 40-minute appointment was devoted to counseling.

preoperative diagnosis: , right trigger thumb.,postoperative diagnosis:, right trigger thumb.,surgery: , release of a1 pulley, cpt code 26055.,anesthesia:, general lma.,tourniquet time: ,9 minutes at 200 torr.,findings:, the patient was found to have limitations to extension at the ip joint to the right thumb. he was found to have full extension after release of a1 pulley.,indications:, the patient is 2-1/2-year-old. he has a history of a trigger thumb. this was evaluated in the office. he was indicated for release of a1 pulley to allow for full excursion. risks and benefits including recurrence, infection, and problems with anesthesia were discussed at length with the family. they wanted to proceed.,procedure:, the patient was brought into the operating room and placed on the operating table in supine position. general anesthesia was induced without incident. he was given a weight-adjusted dose of antibiotics. the right upper extremity was then prepped and draped in a standard fashion. limb was exsanguinated with an esmarch bandage. tourniquet was raised to 200 torr. transverse incision was then made at the base of thumb. the underlying soft tissues were carefully spread in line longitudinally. the underlying tendon was then identified. the accompanied a1 pulley was also identified. this was incised longitudinally using #11 blade. inspection of the entire tendon then demonstrated good motion both in flexion and extension. the leaflets of the pulley were easily identified.,the wound was then irrigated and closed. the skin was closed using interrupted #4-0 monocryl simple sutures. the area was injected with 5 ml of 0.25% marcaine. the wound was dressed with xeroform, dry sterile dressings, hand dressing, kerlix, and coban. the patient was awakened from anesthesia and taken to the recovery room in good condition. there were no complications. all instrument, sponge, needle counts were correct at the end of case.,plan: , the patient will be discharged home. he will return in 1-1/2 weeks for wound inspection.

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

history of present illness: ,the patient comes in today because of feeling lightheaded and difficulty keeping his balance. he denies this as a spinning sensation that he had had in the past with vertigo. he just describes as feeling very lightheaded. it usually occurs with position changes such as when he stands up from the sitting position or stands up from a lying position. it tends to ease when he sits down again, but does not totally resolve for another 15 to 30 minutes and he feels shaky and weak all over. lorazepam did not help this sensation. his blood pressure has been up lately and his dose of metoprolol was increased. they feel these symptoms have gotten worse since metoprolol was increased.,past medical history: , detailed on our h&p form. positive for elevated cholesterol, diabetes, glaucoma, cataracts, hypertension, heart disease, vertigo, stroke in may of 2005, congestive heart failure, cabg, and cataract removed right eye.,current medications: , detailed on the h&p form.,physical examination: , his blood pressure sitting down was 180/80 with a pulse rate of 56. standing up blood pressure was 160/80 with a pulse rate of 56. his general exam and neurological exam were detailed on our h&p form. pertinent positives on his neurological exam were decreased sensation in his left face, and left arm and leg.,impression and plan: ,this lightheaded, he exquisitely denies vertigo, the vertigo that he has had in the past. he states this is more of a lightheaded type feeling. he did have a mild blood pressure drop here in the office. we are also concerned that bradycardia might be contributing to his feeling of lightheadedness. we are going to suggest that he gets a holter monitor and he should speak to his general practitioner as well as his cardiologist regarding the lightheaded feeling.,we will schedule him for the holter monitor and refer him back to his cardiologist.

preoperative diagnosis: , need for intravenous access.,postoperative diagnosis: , need for intravenous access.,procedure performed: ,insertion of a right femoral triple lumen catheter.,anesthesia: , includes 4 cc of 1% lidocaine locally.,estimated blood loss: , minimum.,indications:, the patient is an 86-year-old caucasian female who presented to abcd general hospital secondary to drainage of an old percutaneous endoscopic gastrostomy site. the patient is also ventilator-dependent, respiratory failure with tracheostomy in place and dependent on parenteral nutrition secondary to dysphagia and also has history of protein-calorie malnutrition and the patient needs to receive total parenteral nutrition and therefore needs central venous access.,procedure:, the patient's legal guardian was talked to. all questions were answered and consent was obtained. the patient was sterilely prepped and draped. approximately 4 cc of 1% lidocaine was injected into the inguinal site. a strong femoral artery pulse was felt and triple lumen catheter angiocath was inserted at 30-degree angle cephalad and aspirated until a dark venous blood was aspirated. a guidewire was then placed through the needle. the needle was then removed. the skin was ________ at the base of the wire and a dilator was placed over the wire. the triple lumen catheters were then flushed with bacteriostatic saline. the dilator was then removed from the guidewire and a triple lumen catheter was then inserted over the guidewire with the guidewire held at all times.,the wire was then carefully removed. each port of the lumen catheter was aspirated with 10 cc syringe with normal saline till dark red blood was expressed and then flushed with bacteriostatic normal saline and repeated on the remaining two ports. each port was closed off and also kept off. straight needle suture was then used to suture the triple lumen catheter down to the skin. peristatic agent was then placed at the site of the lumen catheter insertion and a tegaderm was then placed over the site. the surgical site was then sterilely cleaned. the patient tolerated the full procedure well. there were no complications. the nurse was then contacted to allow for access of the triple lumen catheter.

preoperative diagnosis: , right acute on chronic slipped capital femoral epiphysis.,postoperative diagnosis: , right acute on chronic slipped capital femoral epiphysis.,procedure: , revision and in situ pinning of the right hip.,anesthesia: , surgery performed under general anesthesia.,complications: ,there were no intraoperative complications.,drains: , none.,specimens: , none.,local: ,10 ml of 0.50% marcaine local anesthetic.,history and physical: , the patient is a 13-year-old girl who presented in november with an acute on chronic right slipped capital femoral epiphysis. she underwent in situ pinning. the patient on followup; however, noted to have intraarticular protrusion of her screw. this was not noted intraoperatively on previous fluoroscopic views. given this finding, i explained to the father and especially the mother that this can cause further joint damage and that the screw would need to be exchanged for a shorter one. risks and benefits of surgery were discussed. risks of surgery include risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, failure to remove the screw, possible continued joint stiffness or damage. all questions were answered and parents agreed to above plan.,procedure in detail: , the patient was taken to the operating room and placed supine on the operating table. general anesthesia was then administered. the patient received ancef preoperatively. a small bump was placed underneath her right buttock. the right upper thigh was then prepped and draped in standard surgical fashion. the upper aspect of the incision was reincised. the dissection was carried down to the crew, which was easily found. a guidewire was placed inside the screw with subsequent removal of the previous screw. the previous screw measured 65 mm. a 60 mm screw was then placed under direct visualization with fluoroscopy. the hip was taken through full range of motion to check on the length of the screw, which demonstrated no intraarticular protrusion. the guidewire was removed. the wound was then irrigated and closed using 2-0 vicryl in the fascial layer as well as the subcutaneous fat. the skin was closed with 4-0 monocryl. the wound was cleaned and dried, dressed with steri-strips, xeroform, 4 x 4s, and tape. the area was infiltrated with total 10 ml of 0.5% marcaine local anesthetic.,postoperative plan: , the patient will be discharged on the day of surgery. she should continue toe touch weightbearing on her leg. the wound may be wet in approximately 5 days. the patient should follow up in clinic in about 10 days. the patient is given vicodin for pain. intraoperative findings were relayed to the mother.

preoperative diagnosis:, medial meniscal tear, left knee.,postoperative diagnosis: , chondromalacia of medial femoral condyle.,procedure performed:,1. arthroscopy of the left knee.,2. left arthroscopic medial meniscoplasty of medial femoral condyle.,3. chondroplasty of the left knee as well.,estimated blood loss: , 80 cc.,total tourniquet time: , 19 minutes.,disposition: , the patient was taken to pacu in stable condition.,history of present illness: ,the patient is a 41-year-old male with left knee pain for approximately two years secondary to hockey injury where he did have a prior mcl sprain. he has had a positive symptomology of locking and pain since then. he had no frank instability to it, however.,gross operative findings: , we did find a tear to the medial meniscus as well as a large area of chondromalacia to the medial femoral condyle.,operative procedure: ,the patient was taken to the operating room. the left lower extremity was prepped and draped in the usual sterile fashion. tourniquet was applied to the left thigh with adequate webril padding, not inflated at this time. after the left lower extremity had been prepped and draped in the usual sterile fashion, we applied an esmarch tourniquet, exsanguinating the blood and inflated the tourniquet to 325 mmhg for a total of 19 minutes. we established the lateral port of the knee with #11 blade scalpel. we put in the arthroscopic trocar, instilled with water and inserted the camera.,on inspection of the patellofemoral joint, it was found to be quite smooth. pictures were taken there. there was no evidence of chondromalacia, cracking, or fissuring of the articular cartilage. the patella was well centered over the trochlear notch. we then directed the arthroscope to the medial compartment of the knee. it was felt that there was a tear to the medial meniscus. we also saw large area of chondromalacia with grade-iv changes to bone over the medial femoral condyle. this area was debrided with forceps and the arthroscopic shaver. the cartilage was also smoothened over the medial femoral condyle. this was curetted after the medial meniscus had been trimmed. we looked into the notch. we saw the acl appeared stable, saw attachments to tibial as well as the femoral insertion with some evidence of laxity, wear and tear. attention then was taken to the lateral compartment with some evidence of tear to the lateral meniscus and the arterial surface of both the tibia as well as the femur were pristine in the lateral compartment. all instruments were removed. all loose cartilaginous pieces were suctioned from the knee and water was suctioned at the end. we removed all instruments. marcaine was injected into the portal sites. we placed a sterile dressing and stockinet on the left lower extremity. he was transferred to the gurney and taken to pacu in stable condition.

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

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

general evaluation:,fetal cardiac activity: normal with a heart rate of 135bpm,fetal presentation: cephalic.,placenta: anterior,placentral grade: ii,previa: ? none.,amniotic fluid: 1.5 + 2.5 + 0.0 + 0.0 = 4cm compatible with oligohydramnios.,biometry:,bpd: 9.0cm consistent with 36weeks, 4days gestation,hc: 34.6cm which equals 40weeks and 1day gestational age.,fl: 6.9cm which equals 35weeks and 3days gestational age.,ac: 34.6cm which equals 38weeks and 4days gestational age.,ci (bpd/ofd): (70-86) 73,fl/bpd: (71-87) 77,fl/hc: (20.8-22.6) 19.9,fl/ac (20-24) 20,hc/ac: (0.92-1.05) 1.00,gestational age by current ultrasound: 37weeks 4days.,fetal weight by current ultrasound: 3289grams (7pounds 4ounces).,estimated fetal weight percentile: 24%.,edd by current ultrasound: 06/04/07.,gestational age by dates: 40weeks 0days.,l m p: unknown.,edd by dates: 05/18/07.,date of previous ultrasound: 03/05/07.,edd by previous ultrasound: 05/24/07.,fetal anatomy:,fetal ventricles: normal,fetal cerebellum: normal,fetal cranium: normal,fetal face: normal nose and mouth,fetal heart (4 chamber view): normal,fetal diaphragm: normal,fetal stomach: normal,fetal cord: normal three-vessel cord,fetal abdominal wall: normal,fetal spine: normal,fetal kidneys: normal,fetal bladder: normal,fetal limbs: normal,impression:,active intrauterine pregnancy with a sonographic gestational age of 37weeks and 4days.,afi=4cm compatible with mild oligohydramnios.,fetal weight equals 3289grams (7pounds 4ounces). efw percentile is 24%.,placental grade is ii.,no evidence of gross anatomical abnormality, with a biophysical profile total equal to 8 out of 8.,

cc:, weakness.,hx:, this 30 y/o rhm was in good health until 7/93, when he began experiencing rue weakness and neck pain. he was initially treated by a chiropractor and, after an unspecified length of time, developed atrophy and contractures of his right hand. he then went to a local neurosurgeon and a cervical spine ct scan, 9/25/92, revealed an intramedullary lesion at c2-3 and an extramedullary lesion at c6-7. he underwent a c6-t1 laminectomy with exploration and decompression of the spinal cord. his clinical condition improved over a 3 month post-operative period, and then progressively worsened. he developed left sided paresthesia and upper extremity weakness (right worse than left). he then developed ataxia, nausea, vomiting, and hyperreflexia. on 8/31/93, mri c-spine showed diffuse enlargement of the cervical and thoracic spine and multiple enhancing nodules in the posterior fossa. on 9/1/93, he underwent suboccipital craniotomy with tumor excision, decompression, and biopsy which was consistent with hemangioblastoma. his symptoms stabilized and he underwent 5040 cgy in 28 fractions to his brain and 3600 cgy in 20 fractions to his cervical and thoracic spinal cord from 9/93 through 1/19/94.,he was evaluated in the neurooncology clinic on 10/26/95 for consideration of chemotherapy. he complained of progressive proximal weakness of all four extremities and dysphagia. he had difficulty putting on his shirt and raising his arms, and he had been having increasing difficulty with manual dexterity (e.g. unable to feed himself with utensils). he had difficulty going down stairs, but could climb stairs. he had no bowel or bladder incontinence or retention.,meds:, none.,pmh:, see above.,fhx:, father with von hippel-lindau disease.,shx:, retired truck driver. smokes 1-3 packs of cigarettes per day, but denied alcohol use. he is divorced and has two sons who are healthy. he lives with his mother.,ros:, noncontributory.,exam:, vital signs were unremarkable.,ms: a&o to person, place and time. speech fluent and without dysarthria. thought process lucid and appropriate.,cn: unremarkable exept for 4+/4+ strength of the trapezeii. no retinal hemangioblastoma were seen.,motor: 4-/4- strength in proximal and distal upper extremities. there is diffuse atrophy and claw-hands, bilaterally. he is unable to manipulate hads to any great extent. 4+/4+ strength throughout ble. there is also diffuse atrophy throughout the lower extremities though not as pronounced as in the upper extremities.,sensory: there was a right t3 and left t8 cord levels to pp on the posterior thorax. decreased lt in throughout the 4 extremities.,coord: difficult to assess due to weakness.,station: bue pronator drift.,gait: stands without assistance, but can only manage to walk a few steps. spastic gait.,reflexes: hyperreflexic on left (3+) and hyporeflexic on right (1). babinski signs were present bilaterally.,gen exam: unremarkable.,course: ,9/8/95, gs normal. by 11/14/95, he required ngt feeding due to dysphagia and aspiration risk confirmed on cookie swallow studies.mri brain, 2/19/96, revealed several lesions (hemangioblastoma) in the cerebellum and brain stem. there were postoperative changes and a cyst in the medulla.,on 10/25/96, he presented with a 1.5 week h/o numbness in ble from the mid- thighs to his toes, and worsening ble weakness. he developed decubitus ulcers on his buttocks. he also had had intermittent urinary retention for month, chronic sob and dysphagia. he had been sitting all day long as he could not move well and had no daytime assistance. his exam findings were consistent with his complaints. he had had no episodes of diaphoresis, headache, or elevated blood pressures. an mri of the c-t spine, 10/26/96, revealed a prominent cervicothoracic syrinx extending down to t10. there was evidence of prior cervical laminectomy of c6-t1 with expansion of the cord in the thecalsac at that region. multiple intradural extra spinal nodular lesions (hyperintense on t2, isointense on t1, enhanced gadolinium) were seen in the cervical spine and cisterna magna. the largest of which measures 1.1 x 1.0 x 2.0cm. there are also several large ring enhancing lesions in cerebellum. the lesions were felt to be consistent with hemangioblastoma. no surgical or medical intervention was initiated. visiting nursing was provided. he has since been followed by his local physician

reason for admission:, penile injury and continuous bleeding from a penile laceration.,history of present illness:, the patient is an 18-year-old detainee who was brought by police officers because of a penile injury and bleeding. he is otherwise healthy. he tried to insert a marble in his penis four days ago. he told me that he grabbed the skin on the top of the penis and moved it away from the penis shaft and then using a toothbrush that he made in to a knife object he pierced the skin through from both sides and then kept moving the toothbrush to dilate and make a way for the marble. then he inserted a heart-shaped marble in one of the puncture wounds and inserted it under the skin and kept it there. he was not significantly bleeding and essentially the bleeding stopped from both puncture wounds that he has. then today four days after that procedure, he was taking a bath today and he thinks because of the weight he felt a gush in his pants and he looked and he saw the bleeding come out. he was bleeding so much that he started dripping to the sides of his legs. so, he was brought to the hospital. actually after being seen by two nurses at the facility where he was at the detention center where he was at and they actually did the dressing twice and it was twice soaked with blood. he came here and was continuously bleeding from that area that we had to change the dressing twice and he is actually still bleeding especially from one of the laceration, the one on the right side of the penis. the marble also still can be felt underneath the skin. there is no urethral bleeding. he did urinate today without difficulty, without hematuria or dysuria. there is pain in the lacerations. no erythema in the skin or swelling in the penis and no other injuries. he did this procedure for sexual pleasure as he said.,past medical history: , unremarkable.,past surgical history: ,tonsillectomy.,medication: , he took only ibuprofen. no regular medication.,allergies: , none.,social history: ,he has been in detention for two months for immigration problems. no drugs. no alcohol. no smoking. he used to work in fast food chain.,family history: , noncontributory to this illness.,review of systems: , aside from the pain in the penis and continuous bleeding, he is basically asymptomatic and review of systems is unremarkable.,physical examination:,general: the patient is a young hispanic male, lying in bed, appear comfortable in no apparent distress.,vital signs: temperature 97.8, heart rate 99, respiratory rate 20, blood pressure 142/100, and saturation is 98% on room air.,ent: sclerae nonicteric. pupils reactive to light. nostrils are normal. oral cavity is clear.,neck: supple. trachea midline. no jvd.,lungs: clear to auscultation bilaterally.,heart: normal s1 and s2. no murmurs or gallops.,abdomen: soft, nontender, and nondistended. positive bowel sounds.,extremities: pulses strong bilaterally. no edema.,genital: testicles appear normal. the penis shaft has two lacerations on both sides, one of them is bleeding. they measure about 5 to 6 mm on the right side, about 3 or 4 mm on the left side. the one on the right side is bleeding much more than the other one. there is a marble that can be felt and it is freely mobile underneath the skin of the dorsum of the penis. there is no bleeding from the meatus or discharge and no other injuries were seen by inspection.,laboratory data:, white count 11.1, hemoglobin 14.5, hematocrit 43.5, and platelets 303,000. coags unremarkable. glucose 106, creatinine 0.8, sodium 141, potassium 4, and calcium 9.7. urinalysis unremarkable.,impression: , the patient with a penile laceration that is continuously bleeding from inserting a marble four days ago, which is still underneath the skin of the shaft of the penis. no other injuries that can be seen and no other evidence of secondary bacterial infection at this time. the patient is currently refusing removal of the marble and insisting on just repairing the laceration and he is having discussion with dr. x.,plan:,1. the patient will be admitted to the hospital and will follow dr. x's recommendation.,2. the patient was offered a repair of those lacerations, to stop the bleeding as well as the removal of the marble and he is currently considering that and discussing that with dr. x.,3. prophylactic antibiotics to prevent infection.,4. he has mild hypertension, which is likely due to stress and pain and also the leukocytosis probably can be explained by that. this will be monitored.,5. monitor h&h to determine if he needs any transfusion at this time. he does not need that.,6. iv fluid for hydration and volume resuscitation at this time.,7. pain management.,8. topical care for the wound vac after repair.,time spent in evaluation and management of this patient including discussions about this procedure and the harm that can happen if he chooses to keep the penis including permanent damage and infection to the penis was 65 minutes.,i had clearly explained to the patient in detail about the possibility of permanent penile damage that could affect erection and future sexual functioning as well as significant infection if a foreign object was retained in the penis under the skin and he verbalized understanding of this.

preoperative diagnosis (es):, cataract, right eye.,postoperative diagnosis (es):, cataract, right eye.,procedure:, right phacoemulsification of cataract with intraocular lens implantation.,description of the operation:, under topical anesthesia with monitored anesthesia care, the patient was prepped, draped and positioned under the operating microscope. a lid speculum was applied to the right eye, and a stab incision into the anterior chamber was done close to the limbus at about the 1 o'clock position with a superblade, and xylocaine 1% preservative free 0.25 ml was injected into the anterior chamber, which was then followed by healon to deepen the anterior chamber. using a keratome, another stab incision was done close to the limbus at about the 9 o'clock position and with the utrata forceps, anterior capsulorrhexis was performed, and the torn anterior capsule was totally removed. hydrodissection and hydrodelineation were performed with the tuberculin syringe filled with bss. the tip of the phaco unit was introduced into the anterior chamber, and anterior sculpting of the nucleus was performed until about more than two-thirds of the nucleus was removed. using the phaco tip and the drysdale hook, the nucleus was broken up into 4 pieces and then phacoemulsified.,the phaco tip was then exchanged for the aspiration/irrigation tip, and cortical materials were aspirated. posterior capsule was polished with a curette polisher, and healon was injected into the capsular bag. using the monarch intraocular lens inserter, the posterior chamber intraocular lens model sn60wf power +19.50 was placed into the inserter after applying some healon, and the tip of the inserter was gently introduced through the cornea tunnel wound, into the capsular bag and then the intraocular lens was then inserted inferior haptic first into the back and the superior haptic was placed into the bag with the same instrument. intraocular lens was then rotated about half a turn with a collar button hook. healon was removed with the aspiration/irrigation tip, and balanced salt solution was injected through the side port to deepen the anterior chamber. it was found that there was no leakage of fluid through the cornea tunnel wound. for this reason, no suture was applied. vigamox, econopred and nevanac eye drops were instilled and the eye was covered with a perforated shield. the patient tolerated the procedure well. there were no complications.

preoperative diagnosis: ,tailor's bunion and neuroma of the second and third interspace of the left foot.,postoperative diagnosis:, tailor's bunion and neuroma of the second and third interspace, left foot.,procedure performed:,1. tailor's bunionectomy with metatarsal osteotomy of the left fifth metatarsal.,2. excision of nerve lesion with implantation of the muscle belly of the left second interspace.,3. excision of nerve lesion in the left third interspace.,anesthesia: ,monitored iv sedation with local.,history: ,this is a 37-year-old female who presents to abcd's preoperative holding area, n.p.o. since mid night, last night for surgery of her painful left second and third interspaces and her left fifth metatarsal. the patient has attempted conservative correction and injections with minimal improvement. the patient desires surgical correction at this time. the patient states that her pain has been increasingly worsening with activity and with time and it is currently difficult for her to ambulate and wear shoes. at this time, the patient desires surgical intervention and correction. the risks versus benefits of the procedure have been explained to the patient in detail by dr. x and consent was obtained.,procedure in detail: , after an iv was instituted by the department of anesthesia in the preoperative holding area, the patient was taken to the operating suite via cart and placed on the operating table in the supine position. a safety strap was placed across her waist for protection.,next, a pneumatic ankle tourniquet was applied around her left ankle over copious amounts of webril for the patient's protection. after adequate iv sedation was administered by the department of anesthesia, a total of 20 cc of a mixture of 4.5 cc of 1% lidocaine plain, 4.5 cc of 0.5% marcaine plain, and 1 cc of solu-medrol per 10 cc dose was administered to the patient for local anesthesia. the foot was then prepped and draped in the usual sterile orthopedic manner. the foot was then elevated and a tourniquet was then placed at 230 mmhg after applying esmarch bandage. the foot was then lowered down the operative field and sterile stockinet was draped. the stockinet was then reflected. attention was then directed to the second intermetatarsal interspace. after testing the anesthesia, a 4 cm incision was placed using a #10 blade over the dorsal surface of the foot in the second intermetatarsal space beginning from proximal third of the metatarsals distally to and beyond the metatarsal head. then, using #15 blade the incision was deepened through the skin into the subcutaneous tissue. care was taken to identify and avoid or to cauterize any local encountered vascular structures. incision was deepened using the combination of blunt and dull dissection using mayo scissors, hemostat, and a #15 blade. the incision was deepened distally down to the level of the deep transverse metatarsal ligament which was reflected and exposure of the intermetatarsal space was appreciated. the individual branches of the plantar digital nerve were identified extending into the second and third digits plantarly. these endings were dissected distally and cut at their most distal portions. following this, the nerve was dissected proximally into the common nerve and dissected proximally into the proximal portion of the intermetatarsal space. using careful meticulous dissection, there was noted to a be a enlarged bulbous mass of fibers and nerve tissue embedded with the adipose tissue. this was also cut and removed. the proximal portion of the nerve stump was identified and care was taken to suture this into the lumbrical muscle to leave no free nerve ending exposed. following this, the interspace was irrigated with copious amounts of sterile saline and interspace explored for any other portions of nerve which may been missed on the previous dissection. it was noted that no other portions of the nerve were detectable and the proximal free nerve ending was embedded and found to be ________ the lumbrical muscle belly. following this, the interspace was packed using iodoform gauze packing and was closed in layers with the packing extruding from the wound. attention was then directed to the third interspace where in a manner as mentioned before. a dorsal linear incision which measured 5 cm was made over the third interspace extending from the proximal portion of the metatarsal distally to the metatarsal head. like before, using a combination of blunt and dull dissection, with sharp dissection the incision was deepened down with care taken to cauterize all retracting vascular structures which were encountered.,the incision was deepened down to the level of the subcutaneous tissue and then down deeper to the interspace of the third and fourth metatarsal. the dissection was deepened distally down to the level of the transverse intermetatarsal ligament, where upon this was reflected and the nerve fibers to the third and fourth digit plantarly were identified. these were once again dissected distally out and transected at their most distal portions. care was then taken to dissect the nerve proximally into the proximal metatarsal region. no other branches of the nerve were identified and the nerve in its entirety along with fibrous tissue encountered in the area was removed. the proximal portion of the nerve which remained was not large enough to suture into lumbrical muscle as was done in the previous interspace. half of the nerve was transected proximally as was feasible and no exposed ending was noted. incision was then flushed and irrigated using sterile saline. following this, the incision wound was packed with iodoform gauze packed and closed in layers using as before #4-0 vicryl and #4-0 nylon suture.,following this, attention was directed to the fifth metatarsal head where a lateral 4 cm incision was placed along the lateral distal shaft and head of the fifth metatarsal using a fresh #10 blade. the incision was then deepened using #15 blade down to the level of the subcutaneous tissue. care was taken to reflect any neurovascular structures which were encountered. following this the incision was deepened down to the level of the periosteum and periosteum was reflected, using the sharp dissection, to expose the head of the metatarsal along with the neck region. after adequate exposure of the fifth metatarsal head was achieved, an oblique incision directed from distal lateral to proximal medial in a sagittal plane was performed and the head of the fifth metatarsal was shifted medially. following this, an orthosorb pin was retrograded through the fifth metatarsal head into the neck of the fifth metatarsal and was cut off first with the lateral surfaces of bone. orthosorb pin was noted to be intact and the fifth metatarsal head was in good alignment and position. following this, the sagittal saw and the #138 blade were used to provide rasping and smoothing of the sharp acute edges of bone laterally. following this, the periosteum was closed using #4-0 vicryl and the skin was closed in layers using #4-0 vicryl and closed with running subcuticular #4-0 monocryl suture. upon completion of this, the foot was noted to be in good position with good visual alignment of the fifth metatarsal head and digit. the incisions in foot were then ________ draped in the normal manner using owen silk, 4 x 4s, kling, and kerlix and covered with coban bandage. the tourniquet was then deflated with the total tourniquet time of 103 minutes at 230 mmhg and immediate hyperemia was noted to end digits one through five of the left foot.,the patient was then transferred to the cart and was escorted to the postanesthesia care unit with vital signs stable and vascular status intact. the patient tolerated the procedure well without any complications. the patient was then given prescriptions for vicoprofen #30 and augmentin #14 to be taken twice daily. the patient was instructed to followup with dr. x after the weekend on tuesday in his office. the patient also given postoperative instructions and was placed in a postoperative shoe and instructed to limit weightbearing to the heel only, ice and elevate her foot 20 minutes every hour as tolerated. the patient also instructed to take her medications and prescriptions as directed. she was given the emergency contact numbers. postoperative x-rays were taken and the patient was discharged home in stable condition upon conclusion of this.

a fluorescein angiogram was ordered at today's visit to rule out macular edema. we have asked her to return in one to two weeks' time to discuss the results of her angiogram and possible intervention and will be sure to keep you apprised of her ongoing progress. a copy of the angiogram is enclosed for your records.

procedure: , colonoscopy.,preoperative diagnoses: , rectal bleeding and perirectal abscess.,postoperative diagnosis: , perianal abscess.,medications:, mac.,description of procedure: ,the olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon into the cecum and then through the ileocecal valve into the terminal ileum. the preparation was excellent and all surfaces were well seen. the mucosa throughout the colon and in the terminal ileum was normal, with no evidence of colitis. special attention was paid to the rectum, including retroflexed views of the distal rectum and the anorectal junction. there was no evidence of either inflammation or a fistulous opening. the scope was withdrawn. a careful exam of the anal canal and perianal area demonstrated a jagged 8-mm opening at the anorectal junction posteriorly (12 o'clock position). some purulent material could be expressed through the opening. there was no suggestion of significant perianal reservoir of inflamed tissue or undrained material. specifically, the posterior wall of the distal rectum and anal canal were soft and unremarkable. in addition, scars were noted in the perianal area. the first was a small dimpled scar, 1 cm from the anal verge in the 11 o'clock position. the second was a dimpled scar about 5 cm from the anal verge on the left buttock's cheek. there were no other abnormalities noted. the patient tolerated the procedure well and was sent to the recovery room.,final diagnoses:,1. normal colonoscopy to the terminal ileum.,2. opening in the skin at the external anal verge, consistent with drainage from a perianal abscess, with no palpable abscess at this time, and with no evidence of fistulous connection to the bowel lumen.,recommendations:,1. continue antibiotics.,2. followup with dr. x.,3. if drainage persists, consider surgical drainage.

procedure performed: , trigger point injections with botox.,preprocedure diagnoses:,1. cervical spondylosis without myelopathy.,2. myofascial pain syndrome.,3. cervical dystonia.,4. status post c5-6 anterior cervical fusion.,5. multilevel degenerative disc disease.,6. cervicogenic migraines.,7. hypertension.,8. hypothyroidism.,postprocedure diagnoses:,1. cervical spondylosis without myelopathy.,2. myofascial pain syndrome.,3. cervical dystonia.,4. status post c5-6 anterior cervical fusion.,5. multilevel degenerative disc disease.,6. cervicogenic migraines.,7. hypertension.,8. hypothyroidism.,complications: , none.,the risks, benefits, complications, and alternatives to the procedure were discussed in detail and informed written consent was obtained.,indications:, the patient is here today after establishing care at my new office. she is a long-term patient of mine at the pain management clinic and has requested transference because of insurance reasons. today, she is here for not only establishment of care, but continued management of her many neck-related complaints. among these are spasms and ongoing pain for which she receives long-acting opioids. she states that she is in fact doing quite well since her cervical fusion. she is requesting that we decrease her medications from 480 mg to 240 mg to 360 mg of morphine per day in the form of avinza. she also is quite pleased with her other medication regimen which has been greatly simplified over the past year.,other treatment modalities that have been helpful have included cervical epidural steroid injections. the patient is requesting that we schedule this as well, as the relief provided by that lasted anywhere from four to six months. i agree that because of intermittent radicular symptoms that this may be helpful particularly in light of her recent surgery. she does complain of hand tingling and numbness, although she is not dropping objects or having difficulties with coordination. i believe that in addition, the steroid injections may help expedite her desire to decrease her reliance on medications which have been oversedating as well as racked with other side effects.,details of procedure: , alcohol prep and sterile technique were used. a total of 6 cc of preservative-free 1% lidocaine was used and injected into eight different sites using a 25-gauge, 1-1/2-inch needle at the trapezius muscles bilaterally as well as the levator scapulae, the splenius capitis, and the semispinalis musculature. the procedure was well tolerated.,treatment plan:,1. the patient is tentatively scheduled for a cervical epidural steroid injection on march 14, 2005.,2. we will begin a weaning schedule for the patient's avinza by decreasing in 60 mg intervals. the patient will have a target of 120 mg p.o. b.i.d., and then be reassessed. this is expected to occur after her cervical epidural steroid injection.

preoperative diagnosis: , persistent pneumonia, right upper lobe of the lung, possible mass.,postoperative diagnosis: , persistent pneumonia, right upper lobe of the lung, possible mass.,procedure:, bronchoscopy with brush biopsies.,description of procedure: , after obtaining an informed consent, the patient was taken to the operating room where he underwent a general endotracheal anesthesia. a time-out process had been followed and then the flexible bronchoscope was inserted through the endotracheal tube after 2 cc of 4% lidocaine had been infused into the endotracheal tube. first the trachea and the carina had normal appearance. the scope was passed into the left side and the bronchial system was found to be normal. there were scars and mucoid secretions. then the scope was passed into the right side where brown secretions were obtained and collected in a trap to be sent for culture and sensitivity of aerobic and anaerobic fungi and tb. first, the basal lobes were explored and found to be normal. then, the right upper lobe was selectively cannulated and no abnormalities were found except some secretions were aspirated. then, the bronchi going to the three segments were visualized and no abnormalities or mass were found. brush biopsy was obtained from one of the segments and sent to pathology.,the procedure had to be interrupted several times because of the patient's desaturation, but after a few minutes of ambu bagging, he recovered satisfactorily.,at the end, the patient tolerated the procedure well and was sent to the recovery room in satisfactory condition.,

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

preoperative diagnosis: , severe degenerative joint disease of the right shoulder.,postoperative diagnosis:, severe degenerative joint disease of the right shoulder.,procedure: , right shoulder hemi-resurfacing using a size 5 biomet copeland humeral head component, noncemented.,anesthesia: , general endotracheal.,estimated blood loss: , less than 100 ml.,complications:, none. the patient was taken to postanesthesia care unit in stable condition. the patient tolerated the procedure well.,indications: , the patient is a 55-year-old female who has had increased pain in to her right shoulder. x-rays as well as an mri showed a severe arthritic presentation of the humeral head with mild arthrosis of the glenoid. she had an intact rotator cuff being at a young age and with potential of glenoid thus it was felt that a hemi-resurfacing was appropriate for her right shoulder focusing in the humeral head. all risks, benefits, expectations and complications of surgery were explained to her in detail including nerve and vessel damage, infection, potential for hardware failure, the need for revision surgery with potential of some problems even with surgical intervention. the patient still wanted to proceed forward with surgical intervention. the patient did receive 1 g of ancef preoperatively.,procedure: , the patient was taken to the operating suite, placed in supine position on the operating table. the department of anesthesia administered a general endotracheal anesthetic, which the patient tolerated well. the patient was moved to a beach chair position. all extremities were well padded. her head was well padded to the table. her right upper extremity was draped in sterile fashion. a saber incision was made from the coracoid down to the axilla. skin was incised down to the subcutaneous tissue, the cephalic vein was retracted as well as all neurovascular structures were retracted in the case. dissecting through the deltopectoral groove, the subscapularis tendon was found as well as the bicipital tendon, 1 finger breadth medial to the bicipital tendon an incision was made. subscapularis tendon was released. the humeral head was brought in to; there were large osteophytes that were removed with an osteotome. the glenoid then was evaluated and noted to just have mild arthrosis, but there was no need for surgical intervention in this region. a sizer was placed. it was felt that size 5 was appropriate for this patient, after which the guide was used to place the stem and pin. this was placed, after which a reamer was placed along the humeral head and reamed to a size 5. all extra osteophytes were excised. the supraspinatus and infraspinatus tendons were intact. next, the excess bone was removed and irrigated after which reaming of the central portion of the humeral head was performed of which a trial was placed and showed that there was adequate fit and appropriate fixation. the arm had excellent range of motion. there are no signs of gross dislocation. drill holes were made into the humeral head after which a size 5 copeland hemi-resurfacing component was placed into the humeral head, kept down in appropriate position, had excellent fixation into the humeral head. excess bone that had been reamed was placed into the copeland metal component, after which this was tapped into position. after which the wound site was copiously irrigated with saline and antibiotics and the humeral head was reduced and taken through range of motion; had adequate range of motion, full internal and external rotation as well as forward flexion and abduction. there was no gross sign of dislocation. wound site once again it was copiously irrigated with saline antibiotics. the subscapularis tendon was approximated back into position with #2 ethibond after which the bicipital tendon did have significant tear to it; therefore it was tenodesed in to the pectoralis major tendon. after which, the wound site again was irrigated with saline antibiotics after which subcutaneous tissue was approximated with 2-0 vicryl. the skin was closed with staples. a sterile dressing was placed. the patient was awakened from general anesthetic and transferred to hospital gurney to the postanesthesia care unit in stable condition.

history:, the patient is a 52-year-old female with a past medical history of diet-controlled diabetes, diffuse arthritis, plantar fasciitis, and muscle cramps who presents with a few-month history of numbness in both big toes and up the lateral aspect of both calves. symptoms worsened considerable about a month ago. this normally occurs after being on her feet for any length of time. she was started on amitriptyline and this has significantly improved her symptoms. she is almost asymptomatic at present. she dose complain of longstanding low back pain, but no pain that radiates from her back into her legs. she has had no associated weakness.,on brief examination, straight leg raising is normal. the patient is obese. there is mild decreased vibration and light touch in distal lower extremities. strength is full and symmetric. deep tendon reflexes at the knees are 2+ and symmetric and absent at the ankles.,nerve conduction studies: , bilateral sural sensory responses are absent. bilateral superficial sensory responses are present, but mildly reduced. the right radial sensory response is normal. the right common peroneal and tibial motor responses are normal. bilateral h-reflexes are absent.,needle emg:, needle emg was performed on the right leg and lumbosacral paraspinal muscles and the left tibialis posterior using a concentric disposable needle. it revealed increased insertional activity in the right tibialis posterior muscle with signs of mild chronic denervation in bilateral peroneus longus muscles and the right tibialis posterior muscle. lumbar paraspinals were attempted, but were too painful to get a good assessment.,impression: ,this electrical study is abnormal. it reveals the following:,1. a very mild, purely sensory length-dependent peripheral neuropathy.,2. mild bilateral l5 nerve root irritation. there is no evidence of active radiculopathy.,based on the patient's history and exam, her new symptoms are consistent with mild bilateral l5 radiculopathies. symptoms have almost completely resolved over the last month since starting elavil. i would recommend mri of the lumbosacral spine if symptoms return. with respect to the mild neuropathy, this is probably related to her mild glucose intolerance/early diabetes. however, i would recommend a workup for other causes to include the following: fasting blood sugar, hba1c, esr, rpr, tsh, b12, serum protein electrophoresis and lyme titer.

principal diagnosis:, knee osteoarthrosis.,principal procedure: , total knee arthroplasty.,history and physical:, a 66-year-old female with knee osteoarthrosis. failed conservative management. risks and benefits of different treatment options were explained. informed consent was obtained.,past surgical history: , right knee surgery, cosmetic surgery, and carotid sinus surgery.,medications: , mirapex, ibuprofen, and ambien.,allergies: , questionable penicillin allergies.,physical examination: , general: female who appears younger than her stated age. examination of her gait reveals she walks without assistive devices.,heent: normocephalic and atraumatic.,chest: clear to auscultation.,cardiovascular: regular rate and rhythm.,abdomen: soft.,extremities: grossly neurovascularly intact.,hospital course: , the patient was taken to the operating room (or) on 03/15/2007. she underwent right total knee arthroplasty. she tolerated this well. she was taken to the recovery room. after uneventful recovery room course, she was brought to regular surgical floor. mechanical and chemical deep venous thrombosis (dvt) prophylaxis were initiated. routine postoperative antibiotics were administered. hemovac drain was discontinued on postoperative day #2. physical therapy was initiated. continuous passive motion (cpm) was also initiated. she was able to spontaneously void. she transferred to oral pain medication. incision remained clean, dry, and intact during the hospital course. no pain with calf squeeze. she was felt to be ready for discharge home on 03/19/2007.,disposition: ,discharged to home.,follow up:, follow up with dr. x in one week. prescriptions were written for percocet and coumadin.,instructions: , home physical therapy and pt and inr to be drawn at home for adjustment of coumadin dosing.,

exam:, bilateral carotid ultrasound.,reason for exam: , headache.,technique: ,color grayscale and doppler analysis is employed.,findings:, on the grayscale images, the right common carotid artery demonstrates patency with mild intimal thickening only. at the level of the carotid bifurcation, there is heterogeneous hard plaque present, but without grayscale evidence of greater than 50% stenosis. right common carotid waveform is normal with a peak systolic velocity of 0.474 m/second and an end-diastolic velocity of 0.131 m/second. the right eca is patent as well with the velocity measurement 0.910 m/second.,the right internal carotid artery at the bifurcation demonstrates plaque formation, but no evidence of greater than 50% stenosis. proximal peak systolic velocity in the internal carotid artery is 0.463 m/second with proximal end-diastolic velocity of 0.170. the mid internal carotid peak systolic velocity is 0.564 m/second, and mid ica end-diastolic velocity is 0.199 m/second. right ica distal psv 0.580 m/second, right ica distal edv 0.204 m/second. vertebral flow is antegrade on the right at 0.469 m/second.,on the left, the common carotid artery demonstrates intimal thickening, but is otherwise patent. at the level of the bifurcation, however, there is more pronounced plaque formation with approximately 50% stenosis by the grayscale analysis. see the velocity measurements below:,left carotid eca measurement 0.938 m/second. left common carotid psv 0.686 m/second, and left common carotid end-diastolic velocity 0.137 m/second.,left internal carotid artery again demonstrates prominent focus of hard plaque with up to at least 50% stenosis. this should be further assessed with cta for more precise measurement. the left proximal ica/psv 0.955 m/second, left proximal ica/edv 0.287 m/second. there is spectral broadening in the proximal aspect of the carotid waveform. the left carotid ica mid psv 0.895, left carotid ica mid edv 0.278 with also spectral broadening present.,the left distal ica/psv 0.561, left distal ica/edv 0.206, again the spectral broadening present. vertebral flow is antegrade at 0.468 m/second.,impression: , the study demonstrates bilateral hard plaque at the bifurcation, left greater than right. there is at least 50% stenosis of the left internal carotid artery at its bifurcation and a followup cta is recommended for further assessment.

indications:, ischemic cardiomyopathy, status post inferior wall myocardial infarction, status post left anterior descending ptca and stenting.,procedure done:, adenosine myoview stress test.,stress ecg results:, the patient was stressed by intravenous adenosine, 140 mcg/kg/minute infused over four minutes. the baseline resting electrocardiogram revealed an electronic pacemaker depolarizing the ventricles regularly at a rate of 70 beats per minute. underlying atrial fibrillation noted, very wide qrs complexes. the heart rate remained unchanged at 70 beats per minute as the blood pressure decreased from 140/80 to 110/70 with adenosine infusion.

discharge diagnosis:,1. epigastric pain. questionable gastritis, questionable underlying myocardial ischemia.,2. congestive heart failure exacerbation.,3. small pericardial effusion with no tamponade.,4. hypothyroidism.,5. questionable subacute infarct versus neoplasm in the pons.,6. history of coronary artery disease, status post angioplasty and stent.,7. hypokalemia.,clinical resume: , this 83 year-old woman who presented to the er with complaints of nausea, vomiting, and epigastric discomfort, ongoing for about 4 to 5 months. she has had extensive work up and had her gallbladder removed on april 22, 2007, and had an endoscopy, which had demonstrative gastric ulcer disease apparently about a year ago. she has had abdominal cat scan and gastric emptying studies which was normal.,a ct scan of the abdomen done on her may 9, 2007, which showed bilateral peripelvic renal cysts and a redundant sigmoid colon. otherwise unremarkable. the patient follows with dr. xyz as an outpatient. the patient had some worsening of her symptoms over the last few days and then came to the er. she was admitted. please refer to dr. xyz initial h&p for complete details.,hospital course:,1. epigastric pain, nausea, and vomiting. the patient was restituted with antiemetics and her symptoms improved. it was not clear whether her nausea and abdominal pain were due to gastritis, peptic ulcer disease/gastric ischemia, or cardiac origin. a brain mri was also done which basically showed a tiny focus of abnormal enhancement in the pons, which could be subacute like infarct. however, brain neoplasm could not be excluded. other workup including a ct angio did not show any evidence of acute pulmonary emboli. it showed some moderate cardiomegaly with bilateral pleural effusions, and a small pericardial effusion. the patient underwent cardiolite stress test but finished only the resting studies, which was inconclusive. she refused to complete the stress test. she was seen by dr. xyz in consultation who recommended that the patient should have a small bowel follow through and eventually angiogram as an outpatient.,2. congestive heart failure exacerbation. the patient was treated with ace inhibitors, diuretics, aldactone, and lasix, and improved. an echocardiogram done showed an ejection fraction of about 30% to 35%, mild water decrease in lv systolic function, with multiple segmental wall motion abnormalities, a small anterior pericardial effusion, but no electrocardiographic signs of cardiac tamponade. there was some pseudo normal pattern of filling, mild mr and global hypokinesis of the lv.,3. small pericardial effusion. the patient did not have any clinical or echocardiographic evidence of tamponade.,4. hypothyroidism. tsh was quite elevated at 19.,5. questionable subacute infarct versus neoplasm in the pons on an mri of the head.,6. history of coronary artery disease/angioplasty and stents.,7. hyperkalemia.,8. patient was doing well. she was back to her baseline and was refusing further workup and the patient was stable and it was felt she could be safely discharged home to have further testing done as an outpatient.,medications and advice on discharge:,1. she is to continue taking coreg 12.5 mg p.o. b.i.d.,2. cozaar 50 mg p.o. daily.,3. aldactone 25 mg p.o. daily.,4. synthroid 0.075 mg p.o. daily.,5. carafate 1 gram p.o. 4 times a day.,6. claritin 10 mg p.o. daily.,7. lasix 20 mg p.o. daily.,8. k-dur 20 meq p.o. daily.,9. prilosec 40 mg p.o. daily.,10. zofran 4 mg p.o. q.4-6 hourly p.r.n.,she is to follow up with her primary care physician, dr. xyz in 2 to 3 days' time. she is to follow up with dr. xyz her cardiologist in 1 to 2 days' time. she is to follow up with dr. xyz from gi as scheduled. the patient was advised that she will need a small bowel follow through with angiogram which can be arranged by her gastroenterologist as an outpatient. she was also advised that she would need a repeat mri of her head in 2 to 3 months' time. she will also need repeat echocardiogram done in one month for a pericardial effusion. this can be arranged by her primary care physician. repeat tsh to be done in 6 weeks' time.,over 35 minutes were spent in the patient discharged.

chief complaint: ,

chief complaint:, headache and pain in the neck and lower back.,history of present illness:, the patient is a 34 year old white man with aids (cd4 -67, vl -341k) and castleman’s disease who presents to the va hospital complaining of headaches, neck pain, and lower back pain over the last 2-3 weeks. he was hospitalized 3 months prior to his current presentation with abdominal pain and diffuse lymphadenopathy. excisional lymph node biopsy during that admission showed multicentric castleman’s disease. he was started on cyclophosphamide and prednisone and his lymphadenopathy dramatically improved. his hospitalization was complicated by the development of acute renal failure from tumor lysis syndrome and he required hemodialysis for only a few sessions. the patient was discharged on haart and later returned for 2 cycles of modified chop chemotherapy.,approximately five weeks prior to his current presentation, the patient was involved in a motor vehicle accident at 40 mph. he said he was not wearing his seatbelt and had hit his head on the roof of the car. he did not lose consciousness. the patient went to the va er but left against medical advice prior to being fully evaluated. records showed that the patient had complained of some neck soreness but he was able to move his neck without any difficulty.,two weeks later, the patient started having headaches, neck and lower back pain during a road trip with his family to mexico . he returned to houston and approximately one week prior to admission, the patient presented to the va er for further evaluation. spinal films were unremarkable and the patient was sent home on pain medications with a diagnosis of muscle strain. the patient followed up with his primary care physician and was admitted for further workup.,on the day of admission, the patient complains of severe pain that is worse in the lower back than in the neck. the pain is 7-8 out of 10 and does not radiate. he also complains of diffuse headaches and intermittent blurriness of his vision. he complains of having a very stiff neck that hurts when he bends it. he denies any fevers, chills, or night sweats. he denies any numbness or tingling of his extremities and he denies any bowel or bladder incontinence. none of the medications that he takes provides adequate relief of his pain.,regarding his aids and castleman’s disease, his lymphadenopathy have completely resolved by physical exam. he no longer has any of the symptoms from his previous hospitalization. he is scheduled to have his next cycle of chemotherapy during the week of his current admission. he has been noncompliant with his haart and has been off the medications for >3 weeks.,past medical history:, hiv diagnosed 11 years ago. no history of opportunistic infections. recently diagnosed with castleman’s disease (9/03) from excisional lymph node biopsy s/p cyclophosphamide/prednisone ( 9/25/03 ) and modified chop ( 10/15/03 , 11/10/03 ). last cd4 count is 67 and viral load is 341k (9/03). currently is off haart x 3 weeks because of noncompliance.,past surgical history:, excisional lymph node biopsy (9/03).,family history:, there was no history of hypertension, coronary artery disease, stroke, cancer or diabetes.,social history:, patient is single and he lives alone. he is heterosexual and has a history of sexual encounter with prostitutes in japan. he works as a plumber over the last 5 years. he smokes and drinks occasionally and denies any history of iv drug use. no blood transfusion. no history of incarceration. recently traveled to mexico .,medication:, tylenol #3 q6h prn, ibuprofen 800 mg q8h prn, methocarbamol 750 mg qid.,allergies:, , sulfa (rash).,review of systems:, the patient complains of feeling weak and fatigued. he has no appetite over the past week and has lost 8 pounds during this period. no chest pain, palpitations, shortness of breath or coughing. he denies any nausea, vomiting, or abdominal pain. no focal neuro deficits. otherwise, as stated in hpi.,physical exam:,vs: t 98 bp 121/89 p 80 r 20 o2 sat 100% on room air.,ht: 5'9" wt: 159 lbs.,gen: well developed man in no apparent distress. alert and oriented x 3.,heent: pupils equally round and reactive to light. extra-ocular movements intact. anicteric. papilledema present bilaterally. moist mucous membranes. no oropharyngeal lesions.,neck: stiff, difficulty with neck flexion; no lymphadenopathy,lungs: clear to auscultation bilaterally.,cv: regular rate and rhythm. no murmurs, gallops, rubs.,abd: soft with active bowel sounds. nontender/nondistended. no rebound or guarding. no hepatosplenomegaly.,ext: no clubbing, cyanosis, or edema. 2+ pulses bilaterally.,back: no point tenderness to spine,neuro: cranial nerves intact. 2+ dtrs bilaterally and symmetrically. motor strength and sensation within the normal limits.,lymph: no cervical, axillary, or inguinal lymph nodes palpated,skin: warm, no rashes, no lesions,studies:,c-spine/lumbosacral spine (11/30): within normal limits.,cxr (12/8): normal heart size, no infiltrate. hila and mediastinum are not enlarged.,ct head with and without contrast (12/8): ventriculomegaly and potentially minor hydrocephalus. otherwise normal ct scan of the brain. no evidence of abnormal enhancement of the brain or mass lesions within the brain or dura.,hospital course:, the patient was admitted to the medicine floor and a lumbar puncture was performed. the opening pressure was greater than 55. the csf results are shown in the table. a diagnostic study was sent.

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

procedure: , cardiac catheterization by:,a. left heart catheterization.,b. left ventriculography.,c. selective coronary angiography.,d. right femoral artery approach.,complications:, none.,medications,1. iv versed.,2. iv fentanyl.,3. intravenous fluid administration.,4. heparin 3000 units iv.,indications: , this 70-year-old asian-american presents with chest pain syndrome, abnormal ekg suggesting an acute st elevation, anterior myocardial infarction, being taken urgently to cardiac catheterization laboratory with possible coronary intervention.,narrative: , after detailed informed consent had been obtained. usual benefits, alternatives, and risks of the procedure had been discussed with the patient, she was agreeable to proceed. the patient was prepped, draped, and anesthetized in the usual manner. using modified seldinger technique a 6 french introducer sheath inserted into the right femoral artery. next, 6 french 3d right coronary catheter was inserted and right coronary angiogram was obtained in various projections. next, a 6 french jl4.0 left coronary catheter was inserted and left coronary angiogram was obtained in various projections. next, 4 french pigtail catheter was inserted into left ventricle under fluoroscopic guidance. left ventricular angiogram was performed. pre and post angiogram lvedp, lv, and aortic pressures were obtained. at the end of the procedure catheters were removed and the introducer sheath was secured. the patient was admitted to the tcu in stable condition.,findings,hemodynamics,left heart pressures:, lvedp of 5, left ventricular systolic pressure of 81, central aortic pressure systolic 70, diastolic 20.,left ventriculography: , left ventricular chamber size is normal. the distal half of the anterior wall of the entire apex and the distal half of the inferior wall are completely akinetic with hypercontractility of the basilar segments of the anterior and inferior wall. calculated ejection fraction of 51%, which probably overestimates the overall effective ejection fraction. no lv thrombus or mitral regurgitation present.,coronary arteriography,1. ,right coronary artery: , the rca gives rise to a posterior descending artery and a small posterolateral branch. angiographically the right coronary artery is normal.,2. ,left main artery:, the left main vessel is angiographically normal, bifurcates into left anterior descending artery and circumflex system.,3. ,left anterior descending artery: , the lad gives rise to a normal complement of septal branches, diagonal branches, and extends around the apex. angiographically the mid left anterior descending artery and distal left anterior descending artery demonstrates systolic compression of the vessel lumen, consistent with myocardial bridging. the degree of myocardial bridging appears moderate in the mid vessel and mild in the distal segment. otherwise, there is no evidence of atherosclerotic obstruction.,4. ,circumflex artery: , the circumflex gives rise to two large extremely tortuous marginal vessels that extend towards the apex. angiographically, the circumflex artery is normal.,conclusion: , this is a 70-year-old female with above clinical and cardiovascular history, who has angiographic evidence of a large anterior apical and inferior apical wall motion abnormality with angiographically patent coronary arteries with two segments of myocardial bridging involving the mid and distal left anterior descending artery. these angiographic findings are consistent with takasubo syndrome, aka apical ballooning syndrome. the patient will be treated medically.

s - ,an 83-year-old diabetic female presents today stating that she would like diabetic foot care.,o - ,on examination, the lateral aspect of her left great toenail is deeply ingrown. her toenails are thick and opaque. vibratory sensation appears to be intact. dorsal pedal pulses are 1/4. there is no hair growth seen on her toes, feet or lower legs. her feet are warm to the touch. all of her toenails are hypertrophic, opaque, elongated and discolored.,a - ,1. onychocryptosis.,

reason for consultation: , hemoptysis.,history of present illness: , the patient is an 80-year-old african-american male, very well known to my service, with a past medical history significant for asbestos exposure. the patient also has a very extensive cardiac history that would be outlined below. he is being admitted with worsening shortness of breath and constipation. he is also complaining of cough and blood mixed with sputum production, but there is no fever.,past medical history,1. benign prostatic hypertrophy.,2. peptic ulcer disease.,3. atrial fibrillation.,4. coronary artery disease.,5. aortic valve replacement in 1991, st. jude mechanical valve #23.,6. icd implantation.,7. peripheral vascular disease.,8. cabg in 1991 and 1998.,9. congestive heart failure, ef 40%.,10. asbestos exposure.,medications,1. coumadin 6 mg alternating with 9 mg.,2. prevacid 30 mg once a day.,3. diovan 160 mg every day.,4. flomax 0.4 mg every day.,5. coreg 25 mg in the morning and 12.5 mg at night.,6. aldactone 25 mg a day.,7. lasix 20 mg a day.,8. zocor 40 mg every day.,allergies,1. darvocet.,2. clonidine.,physical examination,general: the patient is an elderly male; awake, alert, and oriented, in no acute distress.,vital signs: blood pressure is 136/80, pulse is 70, respiratory rate is 20, temperature 99.3, pulse oximetry 96% on 2 l nasal cannula.,heent: significant for peripheral cyanosis.,neck: supple.,lungs: bibasilar crackles with decreased breath sounds in the left base.,cardiovascular: regular rate and rhythm with murmur and metallic click.,abdomen: soft and benign.,extremities: 1+ cyanosis. no clubbing. no edema.,laboratory data:, shows a white count of 6.9, hemoglobin 10.6, hematocrit 31.2, and platelet count 160,000. ck 266, ptt 37, pt 34, and inr 3.7. sodium 141, potassium 4.2, chloride 111, co2 23, bun 18, creatinine 1.7, glucose 91, calcium 8.6, total protein 6.1, albumin 3.3, total bilirubin 1.4, alkaline phosphatase 56, and troponin i 0.085 and 0.074.,diagnostic studies: , chest x-ray shows previous sternotomy with icd implantation and aortic valve mechanical implant with left-sided opacification of the diaphragm worrisome for pleural effusion.,assessment,1. hemoptysis.,2. acute bronchitis.,3. coagulopathy.,4. asbestos exposure.,5. left pleural effusion.,recommendations,1. antibiotics.

history: ,the patient is a 53-year-old male who was seen for evaluation at the request of dr. x regarding recurrent jaw pain. this patient has been having what he described as numbness and tingling along the jaw, teeth, and tongue. this numbness has been present for approximately two months. it seems to be there "all the time." he was seen by his dentist and after dental evaluation was noted to be "okay." he had been diagnosed with a throat infection about a week ago and is finishing a course of avelox at this time. he has been taking cough drops and trying to increase his fluids. he has recently stopped tobacco. he has been chewing tobacco for about 30 years. again, there is concern regarding the numbness he has been having. he has had a loss of sensation of taste as well. numbness seems to be limited just to the left lateral tongue and the jaw region and extends from the angle of the jaw to the lip. he does report he has had about a 20-pound of weight gain over the winter, but notes he has had this in the past just simply from decreased activity. he has had no trauma to the face. he does note a history of headaches. these are occasional and he gets these within the neck area when they do flare up. the headaches are noted to be less than one or two times per month. the patient does note he has a history of anxiety disorder as well. he has tried to eliminate his amount of tobacco and he is actually taking nicorette gum at this time. he denies any fever or chills. he is not having any dental pain with biting down. he has had no jaw popping and no trismus noted. the patient is concerned regarding this numbness and presents today for further workup, evaluation, and treatment.,review of systems: , other than those listed above were otherwise negative.,past surgical history: , pertinent for hernia repair.,family history: , pertinent for hypertension.,current medications:, tylenol. he is on nicorette gum.,allergies: ,he is allergic to codeine, unknown reaction.,social history: ,the patient is single, self-employed carpenter. he chews tobacco or having chewing tobacco for 30 years, about half a can per day, but notes he has been recently off, and he does note occasional moderate alcohol use.,physical examination: , ,vital signs: blood pressure is 138/82, pulse 64 and regular, temperature 98.3, and weight is 191 pounds.,general: the patient is an alert, cooperative, obese, 53-year-old male with a normal-sounding voice and good memory.,head & face: inspected with no scars, lesions or masses noted. sinuses palpated and are normal. salivary glands also palpated and are normal with no masses noted. the patient also has full facial function.,cardiovascular: heart regular rate and rhythm without murmur.,respiratory: lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,eyes: extraocular muscles were tested and within normal limits.,ears: both ears, external ears are normal. the ear canals are clean and dry. the drums are intact and mobile. he does have moderate tympanosclerosis noted, no erythema. weber exam is midline. hearing is grossly intact and normal.,nasal: reveals a deviated nasal septum to the left, moderate, clear drainage, and no erythema.,oral: oral cavity is normal with good moisture. lips, teeth and gums are normal. evaluation of the oropharynx reveals normal mucosa, normal palates, and posterior oropharynx. examination of the larynx with a mirror reveals normal epiglottis, false and true vocal cords with good mobility of the cords. the nasopharynx was briefly examined by mirror with normal appearing mucosa, posterior choanae and eustachian tubes.,neck: the neck was examined with normal appearance. trachea in the midline. the thyroid was normal, nontender, with no palpable masses or adenopathy noted.,neurologic: he does have slightly decreased sensation to the left jaw. he is able to feel pressure on touch. this extends also on to the left lateral tongue and the left intrabuccal mucosa.,dermatologic: evaluation reveals no masses or lesions. skin turgor is normal.,procedure: , a fiberoptic nasopharyngoscopy was also performed. see separate operative report in chart. this does reveal a moderately deviated nasal septum to the left, large inferior turbinates, no mass or neoplasm noted.,impression: ,1. persistent paresthesia of the left manual teeth and tongue, consider possible neoplasm within the mandible.,2. history of tobacco use.,3. hypogeusia with loss of taste.,4. headaches.,5. xerostomia.,recommendations:, i have ordered a ct of the head. this includes sinuses and mandible. this is primarily to evaluate and make sure there is not a neoplasm as the source of this numbness that he has had. on the mucosal surface, i do not see any evidence of malignancy and no visible or palpable masses were noted. i did recommend he increase his fluid intake. he is to remain off the tobacco. i have scheduled a recheck with me in the next two to three weeks to make further recommendations at that time.

preoperative diagnosis: , cataract, right eye.,postoperative diagnosis:, cataract, right eye.,procedure: ,phacoemulsification of cataract with posterior chamber intraocular lens, right eye.,anesthesia: ,topical.,complications: ,none.,procedure in detail: ,the patient was identified. the operative eye was treated with tetracaine 1% topically in the preoperative holding area. the patient was taken to the operating room and prepped and draped in the usual sterile fashion for ophthalmic surgery.,attention was turned to the left/right eye. the lashes were tapped using steri-strips to prevent blinking. a lid speculum was placed to prevent lid closure. anesthesia was verified. then, a 3.5-mm groove was created with a diamond blade temporarily. this was beveled with a crescent blade, and the anterior chamber was entered with a 3.2-mm keratome in the iris plane. a 1% nonpreserved lidocaine was injected intracamerally and followed with viscoat. a paracentesis was made. a round capsulorrhexis was performed. the anterior capsular flap was removed. hydrodelineation and dissection were followed by phacoemulsification of the cataract using a chop technique. the irrigating-aspirating machine was used to clear residual cortex. the provisc was instilled. an sn60ws diopter intraocular lens was inserted into the capsular bag, and the position was verified. the viscoelastic was removed. intraocular lens remained well centered. the incision was hydrated, and the anterior chamber pressure was checked with tactile pressure and found to be normal. the anterior chamber remained deep, and there was no wound leak. the patient tolerated the procedure well. the eye was dressed with maxitrol ointment. a tight patch and fox shield were placed. the patient returned to the recovery room in excellent condition with stable vital signs and no eye pain.

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

preoperative diagnosis: , refractory dyspepsia.,postoperative diagnosis:,1. hiatal hernia.,2. reflux esophagitis.,procedure performed:, esophagogastroduodenoscopy with pseudo and esophageal biopsy.,anesthesia:, conscious sedation with demerol and versed.,specimen: , esophageal biopsy.,complications: , none.,history:, the patient is a 52-year-old female morbidly obese black female who has a long history of reflux and gerd type symptoms including complications such as hoarseness and chronic cough. she has been on multiple medical regimens and continues with dyspeptic symptoms.,procedure: , after proper informed consent was obtained, the patient was brought to the endoscopy suite. she was placed in the left lateral position and was given iv demerol and versed for sedation. when adequate level of sedation achieved, the gastroscope was inserted into the hypopharynx and the esophagus was easily intubated. at the ge junction, a hiatal hernia was present. there were mild inflammatory changes consistent with reflux esophagitis. the scope was then passed into the stomach. it was insufflated and the scope was coursed along the greater curvature to the antrum. the pylorus was patent. there was evidence of bile reflux in the antrum. the duodenal bulb and sweep were examined and were without evidence of mass, ulceration, or inflammation. the scope was then brought back into the antrum.,a retroflexion was attempted multiple times, however, the patient was having difficulty holding the air and adequate retroflexion view was not visualized. the gastroscope was then slowly withdrawn. there were no other abnormalities noted in the fundus or body. once again at the ge junction, esophageal biopsy was taken. the scope was then completely withdrawn. the patient tolerated the procedure and was transferred to the recovery room in stable condition. she will return to the general medical floor. we will continue b.i.d proton-pump inhibitor therapy as well as dietary restrictions. she should also attempt significant weight loss.

preoperative diagnosis (es):, osteoarthritis, right knee.,postoperative diagnosis (es):, osteoarthritis, right knee.,procedure:, right total knee arthroplasty.,description of the operation:, the patient was brought to the operating room and after the successful placement of an epidural, as well as general anesthesia, administration 1 gm of ancef preoperatively, the patient's right thigh, knee and leg were scrubbed, prepped and draped in the usual sterile fashion. the leg was exsanguinated by gravity and pneumatic tourniquet was inflated to 300 mmhg.,a straight anterior incision was carried down through the skin and subcutaneous tissue. unilateral flaps were developed and a median retinacular parapatellar incision was made. the extensor mechanism was partially divided and the patella was everted. some of the femoral bone spurs were resected using an osteotome and a rongeur. ascending drill hole was made in the distal femur and the distal femoral cut, anterior and posterior and chamfer cuts were accomplished for a 67.5 femoral component.,at this point the acl was resected. some of the fat pad and synovium were resected, as well as both medial and lateral menisci. a posterior cruciate retractor was utilized, the tibia brought forward and a centering drill hole made in the tibia. the intramedullary guide was used for cutting the tibia. it was set at 8 mm. an additional 2 mm was resected because of a moderate defect medially.,a trial reduction was done with a 71 tibial baseplate. this was pinned and drilled and then trial reduction done with a 10-mm insert.,this gave good stability and a full range of motion.,the patella was measured with the calibers and 9 mm of bone was resected with an oscillating saw. a 34-mm component was drilled for.,a further trial reduction was done and two liters of pulse lavage were used to clean the bony surfaces. a packet of cement was hand mixed, pressurized with a spatula into the proximal tibia. multiple drill holes were made on the medial side of the tibia where the bone was somewhat sclerotic. the tibia baseplate was secured and the patella was inserted, held with a clamp. the extraneous cement was removed. at this point the tibial baseplate was locked into place and the femoral component also seated solidly.,the knee was extended, held in this position for another 5-6 minutes until the cement was cured. further extraneous cement was removed. the pneumatic tourniquet was released, hemostasis was obtained with electrocoagulation.,retinaculum, quadriceps and extensor were repaired with multiple figure-of-eight #1 vicryl sutures, the subcutaneous tissue with 2-0 and the skin with skin staples. a sterile, bulky compression dressing was placed. the patient was stable on operative release.

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

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

preoperative diagnosis: , secondary capsular membrane, right eye.,postoperative diagnosis: , secondary capsular membrane, right eye.,procedure performed: , yag laser capsulotomy, right eye.,indications: , this patient has undergone cataract surgery, and vision is reduced in the operated eye due to presence of a secondary capsular membrane. the patient is being brought in for yag capsular discission.,procedure: , the patient was seated at the yag laser, the pupil having been dilated with 1% mydriacyl, and iopidine was instilled. the abraham capsulotomy lens was then positioned and applications of laser energy in the pattern indicated on the outpatient note were applied. a total of

doctor's address,dear doctor:,this letter serves as an introduction to my patient, a, who will be seeing you in the near future. he is a pleasant young man who has a diagnosis of bulbar cerebral palsy and hypotonia. he has been treated by dr. x through the pediatric neurology clinic. he saw dr. x recently and she noted that he was having difficulty with mouth breathing, which was contributing to some of his speech problems. she also noted and confirmed that he has significant tonsillar hypertrophy. the concern we have is whether he may benefit from surgery to remove his tonsils and improve his mouth breathing and his swallowing and speech. therefore, i ask for your opinion on this matter.,for his chronic allergic rhinitis symptoms, he is currently on flonase two sprays to each nostril once a day. he also has been taking zyrtec 10 mg a day with only partial relief of the symptoms. he does have an allergy to penicillin.,i appreciate your input on his care. if you have any questions regarding, please feel free to call me through my office. otherwise, i look forward to hearing back from you regarding his evaluation.

admission psychiatric evaluation,identifying information/referral data: ,this is a 16-year-old caucasian adolescent female who is going into ninth grade and lives with her mother, the mother's boyfriend, and a 12, 11, and 10-year-old sister. she also has a stepsister that is 8 years old. the patient was brought in by her mother after being picked up by anchorage police department (apd). she was brought to our institution for an assessment. ,reason for admission/chief complaint: ,the patient ran away in the middle of the night on sunday, 07/19/04, and she has been on the run since then. her friends report to the parents that she is suicidal and that she had a knife. a friend took a knife away from her to keep her from cutting herself. ,history of present illness: ,this is a 16-year-old caucasian adolescent girl who was brought in by apd and her parents. this is her first admission. apd picked her up from a runaway and brought her at her mother's request after some friends told the mother that she was suicidal. the mother found journals in her room talking about suicide, and that she has been raped. there were no details and the client denies that she was raped. she is sexually active with one boyfriend, also 16 years old, that she met while going to school in ketchican in the last school year. she has been with the mother only the last two months and the same ketchican boyfriend, michael, followed her to anchorage. she reports symptoms of depression, no energy, initial and middle insomnia, eating more. she is very irritable and has verbal altercations wither sister who is 14. she admits to being sad and also having poor concentration. she had marked drop in school functioning in the last year, and will need to repeat the ninth grade. the mother is very concerned with the patent's safety and feels she is not able to control her. she lived with her stepfather when she was 8 to 9 years old, but she was too problematic and not successful living there in ketchican. she went to live with her dad up to age 16. now she is living with her mother and her mother's boyfriend for the last two months. in december, her grandmother passed away and she was with her grandmother and her mother during all this process, which is when she started feeling depressed.,legal history: ,no legal history.,treatment/psychiatric history: ,the patient was evaluated once at xyz when she was 14 due to depression, also when she was 3 years old when a new sibling came into the family. ,family psychiatric history: ,the patient has three siblings with adhd (attention deficit hyperactivity disorder) and two of her siblings are in an rtc (residential treatment center) program, one with the diagnosis of bipolar disorder, and the other with adhd and bipolar condition.,pertinent medical history: ,she was born with some eczema. at age 4 she was involved in an accident where she cut one of her legs and needed sutures. there is no history of seizure or head injury. she reports loss of consciousness. this will be investigated; there are no details about it. she admits to being sexually active, protecting herself using condoms. her last menstruation period was 07/20/04. ,allergies: ,no allergies.,development age factors: , the mother reports she was born with some jaundice and eczema. early milestones walk and talk. the patient appears to function at the expected age level. ,pertinent psychosocial data: ,complete pertinent psychosocial will be obtained by our clinician. the patient admits witnessing seeing some domestic violence when she was small, around five years old. there is an allegation of a rape that the mother found in her journal, but this is going to be investigated. ,school history:

history of present illness: , a 71-year-old female who i am seeing for the first time. she has a history of rheumatoid arthritis for the last 6 years. she was followed by another rheumatologist. she says she has been off and on, on prednisone and arava. the rheumatologist, as per the patient, would not want her to be on a long-term medicine, so he would give her prednisone and then switch to arava and then switch her back to prednisone. she says she had been on prednisone for the last 6 to 9 months. she is on 5 mg a day. she recently had a left bka and there was a question of infection, so it had to be debrided. i was consulted to see if her prednisone is to be continued. the patient denies any joint pains at the present time. she says when this started she had significant joint pains and was unable to walk. she had pain in the hands and feet. currently, she has no pain in any of her joints.,review of systems: , denies photosensitivity, oral or nasal ulcer, seizure, psychosis, and skin rashes.,past medical history: , significant for hypertension, peripheral vascular disease, and left bka.,family history: ,noncontributory.,social history: , denies tobacco, alcohol or illicit drugs.,physical examination:,vital signs: bp 130/70, heart rate 80, and respiratory rate 14.,heent: eomi. perrla.,neck: supple. no jvd. no lymphadenopathy.,chest: clear to auscultation.,heart: s1 and s2. no s3, no murmurs.,abdomen: soft and nontender. no organomegaly.,extremities: no edema.,neurologic: deferred.,articular: she has swelling of bilateral wrists, but no significant tenderness.,laboratory data:, labs in chart was reviewed.,assessment and plan:, a 71-year-old female with a history of rheumatoid arthritis, on longstanding prednisone. she is not on dmard, but as she recently had a surgery followed by a probable infection, i will hold off on that. as she has no pain, i have decreased the prednisone to 2.5 mg a day starting tomorrow if she is to go back to her nursing home tomorrow. if in a couple of weeks her symptoms stay the same, then i would discontinue the prednisone. i would defer that to dr. x. if she flares up at that point, prednisone may have to be restarted with a dmard, so that eventually she could stay off the prednisone. i discussed this at length with the patient and she is in full agreement with the plan. i explained to her that if she is to be discharged, if she wishes, she could follow up with me in clinic or if she goes back to victoria, then see her rheumatologist over there.

discharge disposition:, the patient was discharged by court as a voluntary drop by prosecution. this was ama against hospital advice.,discharge diagnoses:,axis i: schizoaffective disorder, bipolar type.,axis ii: deferred.,axis iii: hepatitis c.,axis iv: severe.,axis v: 19.,condition of patient on discharge: , the patient remained disorganized. the patient was suffering from prolactinemia secondary to medications.,discharge followup: ,to be arranged per the patient as the patient was discharged by court.,discharge medications: , a 2-week supply of the following was phoned into the patient's pharmacy: seroquel 25 mg p.o. nightly. zyprexa 5 mg p.o. b.i.d.,mental status at the time of discharge:, attitude was cooperative. appearance showed fair hygiene and grooming. psychomotor behavior showed restlessness. no eps or td was noted. affect was restricted. mood remained anxious and speech was pressured. thoughts remained tangential, and the patient endorsed paranoid delusions. the patient denied auditory hallucinations. the patient denied suicidal or homicidal ideation, was oriented to person and place. overall, insight into her illness remained impaired.,history and hospital course: , the patient is a 22-year-old female with a history of bipolar affective disorder, was initially admitted for evaluation of increasing mood lability, disorganization, and inappropriate behaviors. the patient reportedly was asking her father to have sex with her and tried to pull down her mother's pants. the patient took her clothing off, was noted to be very disorganized sexually, and religiously preoccupied, and endorsed auditory hallucinations of voices telling her to calm herself and others. the patient has a history of depression versus bipolar disorder, last hospitalized in pierce county in 2008, but without recent treatment. the patient on admission interview was noted to be labile and disorganized. the patient was initiated on risperdal m-tab 2 mg p.o. b.i.d. for psychosis and mood lability, and also medically evaluated by rebecca richardson, md. the patient remained labile and suspicious during her hospital stay. the patient continued to be sexually preoccupied and had poor insight into her need for treatment. the patient denied further auditory hallucinations. the patient was treated with seroquel for persistent mood lability and psychosis. the patient was noted to develop prolactinemia with risperdal and this was changed to zyprexa prior to discharge. the patient remained disorganized, but was given a voluntary drop by prosecution against medical advice when she went to court on 01/11/2010. the patient was discharged to return home to her parents and was referred to community mental health agencies. the patient was thus discharged in symptomatic condition.

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

preoperative diagnoses,1. nasal septal deviation with bilateral inferior turbinate hypertrophy.,2. tonsillitis with hypertrophy.,3. edema to the uvula and soft palate.,postoperative diagnoses,1. nasal septal deviation with bilateral inferior turbinate hypertrophy.,2. tonsillitis with hypertrophy.,3. edema to the uvula and soft palate.,operation performed,1. nasal septoplasty.,2. bilateral submucous resection of the inferior turbinates.,3. tonsillectomy and resection of soft palate.,anesthesia: , general endotracheal.,indications: , chris is a very nice 38-year-old male with nasal septal deviation and bilateral inferior turbinate hypertrophy causing nasal obstruction. he also has persistent tonsillitis with hypertrophy and tonsillolith and halitosis. he also has developed tremendous edema to his posterior palate and uvula, which is causing choking. correction of these mechanical abnormalities is indicated.,description of operation: ,the patient was placed on the operating room table in the supine position. after adequate general endotracheal anesthesia was administered, the right and left nasal septal mucosa and right and left inferior turbinates were anesthetized with 1% lidocaine with 1:100,000 epinephrine using approximately 10 ml. afrin-soaked pledgets were placed in the nasal cavity bilaterally. the face was prepped with phisohex and draped in a sterile fashion. a hemitransfixion incision was performed on the left with a #15 blade and submucoperichondrial and mucoperiosteal flap was raised with the cottle elevator. anterior to the septal deflection, the septal cartilage was incised and an opposite-sided submucoperichondrial and mucoperiosteal flap was raised with the cottle elevator. the deviated portion of the nasal septal cartilage and bone was removed with a takahashi forceps, and a large inferior septal spur was removed with a v-chisel. once the septum was reduced in the midline, the hemitransfixion incision was closed with a 4-0 vicryl in an interrupted fashion. the right and left inferior turbinates were trimmed in a submucous fashion using straight and curved turbinate scissors under direct visualization with a 4 mm 0 degree storz endoscope. hemostasis was acquired by using suction electrocautery. the turbinates were then covered with bacitracin ointment after cauterizing them and bacitracin ointment soaked doyle splints were placed in the right and left nares and secured anteriorly to the columella with a 3-0 nylon suture. the table was then turned. a shoulder roll placed under the shoulders and the face was draped in a clean fashion. a mcivor mouth gag was applied. the tongue was retracted and the mcivor was gently suspended from the mayo stand. the left tonsil was grasped with a curved allis forceps, retracted medially, and the anterior tonsillar pillar was incised with bovie electrocautery. the tonsil was removed from the superior pole to inferior pole using a bovie electrocautery in its entirety in a subcapsular fashion. the right tonsil was grasped in a similar fashion, retracted medially, and the anterior tonsillar pillar was incised with bovie electrocautery. the tonsil was removed from the superior pole to inferior pole using bovie electrocautery in its entirety in a subcapsular fashion. the inferior, middle, and superior pole vessels were further cauterized with suction electrocautery. the extremely edematous portion of soft palate was resected using a right angle clamp and right angle scissor and was closed with 3-0 vicryl in a figure-of-eight interrupted fashion. copious saline irrigation of the oral cavity was then performed. there was no further identifiable bleeding at the termination of the procedure. the estimated blood loss was less than 10 ml. the patient was extubated in the operating room, brought to the recovery room in satisfactory condition. there were no intraoperative complications.

title of operation: ,total thyroidectomy for goiter.,indication for surgery: ,this is a 41-year-old woman who notes that compressive thyroid goiter and symptoms related to such who wishes to undergo surgery. risks, benefits, alternatives of the procedures were discussed in great detail with the patient. risks include but were not limited to anesthesia, bleeding, infection, injury to nerve, vocal fold paralysis, hoarseness, low calcium, need for calcium supplementation, tumor recurrence, need for additional treatment, need for thyroid medication, cosmetic deformity, and other. the patient understood all these issues and they wished to proceed.,preop diagnosis: , multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,postop diagnosis: , multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,anesthesia: , general endotracheal.,procedure detail: , after identifying the patient, the patient was placed supine in a operating room table. after establishing general anesthesia via oral endotracheal intubation with a 6 nerve integrity monitoring system endotracheal tube. the eyes were then tacked with tegaderm. the nerve integrity monitoring system, endotracheal tube was confirmed to be working adequately. essentially a 7 cm incision was employed in the lower skin crease of the neck. a 1% lidocaine with 1:100,000 epinephrine were given. shoulder roll was applied. the patient prepped and draped in a sterile fashion. a 15-blade was used to make the incision. subplatysmal flaps were raised to the thyroid notch and sternal respectively. the strap muscles were separated in the midline. as we then turned to the left side where the sternohyoid muscle was separated from the sternothyroid muscle there was a very dense and firm thyroid mass on the left side. the sternothyroid muscle was transected horizontally. similar procedure was performed on the right side.,attention was then turned to identify the trachea in the midline. veins in this area and the pretracheal region were ligated with a harmonic scalpel. subsequently, attention was turned to dissecting the capsule off of the left thyroid lobe. again this was very firm in nature. the superior thyroid pole was dissected in the superior third artery, vein, and the individual vessels were ligated with a harmonic scalpel. the inferior and superior parathyroid glands were protected. recurrent laryngeal nerve was identified in the tracheoesophageal groove. this had arborized early as a course underneath the inferior thyroid artery to a very small tiny anterior motor branch. this was followed superiorly. the level of cricothyroid membrane upon complete visualization of the entire nerve, berry's ligament was transected and the nerve protected and then the thyroid gland was dissected over the trachea. a prominent pyramidal level was also appreciated and dissected as well.,attention was then turned to the right side. there was significant amount of thyroid tissue that was very firm. multiple nodules were appreciated. in a similar fashion, the capsule was dissected. the superior and inferior parathyroid glands protected and preserved. the superior thyroid artery and vein were individually ligated with the harmonic scalpel and the inferior thyroid artery was then ligated close to the thyroid gland capsule. once the recurrent laryngeal nerve was identified again on this side, the nerve had arborized early prior to the coursing underneath the inferior thyroid artery. the anterior motor branch was then very fine, almost filamentous and stimulated at 0.5 milliamps, completely dissected toward the cricothyroid membrane with complete visualization. a small amount of tissue was left at the berry's ligament as the remainder of thyroid level was dissected over the trachea. the entire thyroid specimen was then removed, marked with a stitch upon the superior pole. the wound was copiously irrigated, valsalva maneuver was given, bleeding points controlled. the parathyroid glands appeared to be viable. both the anterior motor branches that were tiny were stimulated at 5 milliamps and confirmed to be working with the nerve integrity monitoring system.,attention was then turned to burying the surgicel on the wound bed on both sides. the strap muscles were reapproximated in the midline using a 3-0 vicryl suture of the sternothyroid horizontal transection and the strap muscles in the midline were then reapproximated. the 1/8th inch hemovac drain was placed and secured with a 3-0 nylon. the incision was then closed with interrupted 3-0 vicryl and indermil for the skin. the patient has a history of keloid formation and approximately 1 cubic centimeter of 40 mg per cubic centimeter kenalog was injected into the incisional line using a tuberculin syringe and 25-gauge needle. the patient tolerated the procedure well, was extubated in the operating room table, and sent to postanesthesia care unit in a good condition. upon completion of the case, fiberoptic laryngoscopy revealed intact bilateral true vocal fold mobility.

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

subjective:, this is a 12-year-old young man who comes in with about 10 days worth of sinus congestion. he does have significant allergies including ragweed. the drainage has been clear. he had a little bit of a headache yesterday. he has had no fever. no one else is ill at home currently.,current medications:, advair and allegra. he has been taking these regularly. he is not sure the allegra is working for him anymore. he does think though better than claritin.,physical exam:,general: alert young man in no distress.,heent: tms clear and mobile. pharynx clear. mouth moist. nasal mucosa pale with clear discharge.,neck: supple without adenopathy.,heart: regular rate and rhythm without murmur.,lungs: lungs clear, no tachypnea, wheezing, rales or retractions.,abdomen: soft, nontender, without masses or splenomegaly.,assessment:, i think this is still his allergic rhinitis rather than a sinus infection.,plan:, change to zyrtec 10 mg samples were given. he is not using nasal spray, but he has some at home. he should restart this. continue to watch his peak flows to make sure his asthma does not come under poor control. call if any further problems.

preoperative diagnoses:,1. hoarseness.,2. bilateral true vocal cord lesions.,3. leukoplakia.,postoperative diagnoses:,1. hoarseness.,2. bilateral true vocal cord lesions.,3. leukoplakia.,procedure performed: ,microscopic suspension direct laryngoscopy with biopsy of left true vocal cord stripping.,anesthesia:, general endotracheal.,estimated blood loss:, minimal.,complications: , none.,indications for procedure: the patient is a 33-year-old caucasian male with a history of chronic hoarseness and bilateral true vocal cord lesions, and leukoplakia discovered on a fiberoptic nasal laryngoscopy in the office. discussed risks, complications, and consequences of a surgical biopsy of the left true vocal cord and consent was obtained.,procedure: , the patient was brought to operative suite by anesthesia, placed on the operating table in supine position. after this, the patient was placed under general endotracheal intubation anesthesia and the operative table was turned 90 degrees by the department of anesthesia. a shoulder roll was then placed followed by the patient being placed in reverse trendelenburg.,after this, a mouthguard was placed in the upper teeth and a dedo laryngoscope was placed in the patient's oral cavity and advanced through the oral cavity in the oropharynx down into the hypopharynx. the patient's larynx was then brought into view with the true vocal cords hidden underneath what appeared to be redundant false vocal cords. the left true vocal cord was then first addressed and appeared to have an extensive area of leukoplakia extending from the posterior one-third up to the anterior third. the false vocal cord also appeared to be very full on the left side along with fullness in the subglottic region. the patient's anterior commissure appeared to be clear. the false cord on the right side also appeared to be very redundant and overshadowing the true vocal cord. once the true vocal cord was retracted laterally, there was revealed a second area of leukoplakia involving the right true vocal cord in the anterior one-third aspect. the patient's subglottic region was very edematous and with redundant mucosal tissue. the areas of leukoplakia appeared to be cobblestoned in appearance, irregularly bordered, and very hard to the touch. the left true vocal cord was then first addressed, was stripped from posteriorly to anteriorly utilizing a #45 laryngeal forceps. after this, the patient had pressure placed upon this area with tropical adrenaline and a rectal swab to maintain hemostasis. the specimen was passed off the field and was sent to pathology for evaluation. hemostasis was maintained on the left side. prior to taking this biopsy, the louie arm was attached to the laryngoscope and then suspended on the mayo stand. the zeiss operating microscope was then brought into view to directly visualize the vocal cords. the biopsies were taken under direct visualization utilizing the zeiss operating microscope. after the specimen was taken and the laryngoscope was desuspended from the mayo stand and louie arm was removed, the scope was then pulled more cephalad and the piriform sinuses, valecula, and base of the tongue were all directly visualized, which appeared normal except for the left base of tongue appeared to be full. this area was biopsied multiple times with a straight laryngeal forceps and passed off the field and sent to pathology as specimen. the scope was then pulled back into the superior aspect of hypopharynx into the oropharynx and the oral cavity demonstrated no signs of any gross lesions. a bimanual examination was then performed, which again demonstrated a fullness on the left base of tongue region with no signs of any other gross lesions. there were no signs of any palpable cervical lymphadenopathy. the tooth guard was removed and the patient was then turned back to anesthesia. the patient did receive intraoperatively 10 mg of decadron. the patient tolerated the procedure well and was extubated in the operating room.,the patient was transferred to recovery room in stable condition and tolerated the procedure well. the patient will be sent home with prescriptions for medrol dosepak, tylenol with codeine, elixir, and amoxicillin 250 mg per 5 cc.

preoperative diagnosis: , herniated nucleus pulposus c5-c6.,postoperative diagnosis: , herniated nucleus pulposus c5-c6.,procedure:, anterior cervical discectomy fusion c5-c6 followed by instrumentation c5-c6 with titanium dynamic plating system, aesculap. operating microscope was used for both illumination and magnification.,first assistant: , nurse practitioner.,procedure in detail: , the patient was placed in supine position. the neck was prepped and draped in the usual fashion for anterior discectomy and fusion. an incision was made midline to the anterior body of the sternocleidomastoid at c5-c6 level. the skin, subcutaneous tissue, and platysma muscle was divided exposing the carotid sheath, which was retracted laterally. trachea and esophagus were retracted medially. after placing the self-retaining retractors with the longus colli muscles having been dissected away from the vertebral bodies at c5 and c6 and confirming our position with intraoperative x-rays, we then proceeded with the discectomy.,we then cleaned out the disc at c5-c6 after incising the annulus fibrosis. we cleaned out the disc with a combination of angled and straight pituitary rongeurs and curettes, and the next step was to clean out the disc space totally. with this having been done, we then turned our attention with the operating microscope to the osteophytes. we drilled off the vertebral osteophytes at c5-c6, as well as the uncovertebral osteophytes. this was removed along with the posterior longitudinal ligament. after we had done this, the dural sac was opposed very nicely and both c6 nerve roots were thoroughly decompressed. the next step after the decompression of the thecal sac and both c6 nerve roots was the fusion. we observed that there was a ____________ in the posterior longitudinal ligament. there was a free fragment disc, which had broken through the posterior longitudinal ligament just to the right of midline.,the next step was to obtain the bone from the back bone, using cortical cancellous graft 10 mm in size after we had estimated the size. that was secured into place with distraction being applied on the vertebral bodies using vertebral body distractor.,after we had tapped in the bone plug, we then removed the distraction and the bone plug was fitting nicely.,we then use the aesculap cervical titanium instrumentation with the 16-mm screws. after securing the c5-c6 disc with four screws and titanium plate, x-rays showed good alignment of the spine, good placement of the bone graft, and after x-rays showed excellent position of the bone graft and instrumentation, we then placed in a jackson-pratt drain in the prevertebral space brought out through a separate incision. the wound was closed with 2-0 vicryl for subcutaneous tissues and skin was closed with steri-strips. blood loss during the operation was less than 10 ml. no complications of the surgery. needle count, sponge count, and cottonoid count were correct.,

procedure:, esophagogastroduodenoscopy with biopsy and snare polypectomy.,indication for the procedure:, iron-deficiency anemia.,medications:, mac.,the risks of the procedure were made aware to the patient and consisted of medication reaction, bleeding, perforation, and aspiration.,procedure:, after informed consent and appropriate sedation, the upper endoscope was inserted into the oropharynx down into the stomach and beyond the pylorus and the second portion of the duodenum. the duodenal mucosa was completely normal. the pylorus was normal. in the stomach, there was evidence of diffuse atrophic-appearing nodular gastritis. multiple biopsies were obtained. there also was a 1.5-cm adenomatous appearing polyp along the greater curvature at the junction of the body and antrum. there was mild ulceration on the tip of this polyp. it was decided to remove the polyp via snare polypectomy. retroflexion was performed, and this revealed a small hiatal hernia in the distal esophagus. the z-line was identified and was unremarkable. the esophageal mucosa was normal.,findings:,1. hiatal hernia.,2. diffuse nodular and atrophic appearing gastritis, biopsies taken.,3. a 1.5-cm polyp with ulceration along the greater curvature, removed.,recommendations:,1. follow up biopsies.,2. continue ppi.,3. hold lovenox for 5 days.,4. place scds.

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.

preoperative diagnoses: ,1. cervical spondylosis c5-c6 greater than c6-c7 (721.0).,2. neck pain, progressive (723.1) with right greater than left radiculopathy (723.4).,postoperative diagnoses: ,1. cervical spondylosis c5-c6 greater than c6-c7 (721.0).,2. neck pain, progressive (723.1) with right greater than left radiculopathy (723.4), surgical findings confirmed.,procedures: ,1. anterior cervical discectomy at c5-c6 and c6-c7 for neural decompression (63075, 63076).,2. anterior interbody fusion at c5-c6 and c6-c7 (22554, 22585) utilizing bengal cages x2 (22851).,3. anterior instrumentation by uniplate construction c5, c6, and c7 (22845); with intraoperative x-ray x2.,anesthesia: ,general.,operations: , the patient was brought to the operating room and placed in the supine position where general anesthesia was administered. then the anterior aspect of the neck was prepped and draped in the routine sterile fashion. a linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected in a subplatysmal manner and then with only blunt dissection, the prevertebral space was encountered and localizing intraoperative x-ray was obtained once cauterized the longus colli muscle bilaterally allowed for the placement along its mesial portion of self-retaining retractors for exposure of tissues. prominent anterior osteophytes once identified and compared to preoperative studies were removed at c5-c6 and then at c6-c7 with rongeur, allowing for an annulotomy with an #11 blade through collapsed disc space at c5-6, and even more collapsed at c6-c7. gross instability appeared and though minimally at both interspaces and residual disc were removed then with the straight disc forceps providing a discectomy at both levels, sending to pathology in a routine fashion as disc specimen. this was sent separately and allowed for residual disc removal of power drill where drilling extended in normal cortical and cancellous elements of the c5 and c6 interspaces and at c6-c7 removing large osteophytes and process, residual osteophytes from which were removed finally with 1 and 2 mm micro kerrison rongeurs allowing for excision of other hypertrophied ligament posteriorly as well. this allowed for the bulging into the interspace of the dura, sign of decompressed status, and this was done widely bilaterally to decompress the nerve roots themselves and this was assured by inspection with a double ball dissector as needed. at no time during the case was there evidence of csf leakage and hemostasis was well achieved with pledgets of gelfoam and subsequently removed with copious amounts of antibiotic irrigation as well as surgifoam. once hemostasis well achieved, bengal cage was filled with the patient's own bone elements of appropriate size, and this was countersunk into position and quite tightly applied it at first c5-c6, then secondly at c6-c7. these were checked and found to be well applied and further stability was then added by placement nonetheless of a uniplate of appropriate size. the appropriate size screws and post-placement x-ray showed well-aligned elements and removal of osteophytes, etc. the wound was again irrigated with antibiotic solution, inspected, and finally closed in a multiple layered closure by approximation of platysma with interrupted #3-0 vicryl and the skin with subcuticular stitch of #4-0 vicryl incorporating a penrose drain from vertebral space externally through the skin wound and safety pin, and later incorporated itself into sterile bandage.,once the bandage was placed, the patient was taken, extubated from the operating room to the recovery area, having in stable, but guarded condition. at the conclusion of the case, all instrument, needle, and sponge counts were accurate and correct. there were no intraoperative complications of any type.

preoperative diagnosis: , chronic plantar fasciitis, right foot.,postoperative diagnosis:, chronic plantar fasciitis, right foot.,procedure: , open plantar fasciotomy, right foot.,anesthesia: , local infiltrate with iv sedation.,indications for surgery:, the patient has had a longstanding history of foot problems. the foot problem has been progressive in nature and has not been responsive to conservative care despite multiple attempts at conservative care. the preoperative discussion with the patient including alternative treatment options, the procedure itself was explained, and risk factors such as infection, swelling, scar tissue, numbness, continued pain, recurrence, falling arch, digital contracture, and the postoperative management were discussed. the patient has been advised, although no guarantee for success could be given, most of the patients have improved function and less pain. all questions were thoroughly answered. the patient requested for surgical repair since the problem has reached a point to interfere with normal daily activities. the purpose of the surgery is to alleviate the pain and discomfort.,details of the procedure: ,the patient was given 1 g ancef for antibiotic prophylaxis 30 minutes prior to the procedure. the patient was brought to the operating room and placed in the supine position. following a light iv sedation, a posterior tibial nerve block and local infiltrate of the operative site was performed with 10 ml, and a 1:1 mixture of 1% lidocaine with epinephrine, and 0.25% marcaine was affected. the lower extremity was prepped and draped in the usual sterile manner. balance anesthesia was obtained.,procedure:, plantar fasciotomy, right foot. the plantar medial tubercle of the calcaneus was palpated and a vertical oblique incision, 2 cm in length with the distal aspect overlying the calcaneal tubercle was affected. blunt dissection was carried out to expose the deep fascia overlying the abductor hallucis muscle belly and the medial plantar fascial band. a periosteal elevator did advance laterally across the inferior aspect of the medial and central plantar fascial bands, creating a small and narrow soft tissue tunnel. utilizing a metzenbaum scissor, transection of the medial two-third of the plantar fascia band began at the junction of the deep fascia of the abductor hallucis muscle belly and medial plantar fascial band, extending to the lateral two-thirds of the band. the lateral plantar fascial band was left intact. visualization and finger probe confirmed adequate transection. the surgical site was flushed with normal saline irrigation.,the deep layer was closed with 3-0 vicryl and the skin edges coapted with combination of 1 horizontal mattress and simples. the dressing consisted of adaptic, 4 x 4, conforming bandages, and an ace wrap to provide mild compression. the patient tolerated the procedure and anesthesia well, and left the operating room to recovery room in good postoperative condition with vital signs stable and arterial perfusion intact. a walker boot was dispensed and applied. the patient will be allowed to be full weightbearing to tolerance, in the boot to encourage physiological lengthening of the release of plantar fascial band.,the next office visit will be in 4 days. the patient was given prescriptions for keflex 500 mg 1 p.o. three times a day x10 days and lortab 5 mg #40, 1 to 2 p.o. q.4-6 h. p.r.n. pain, 2 refills, along with written and oral home instructions. after a short recuperative period, the patient was discharged home with vital signs stable and in no acute distress.

procedure in detail: , after written consent was obtained from the patient, the patient was brought back into the operating room and identified. the patient was placed in the operating room table in supine position and given general anesthetic.,ancef 1 g was given for infectious prophylaxis. once the patient was under general anesthesia, the knee was prepped and draped in usual sterile fashion. once the knee was fully prepped and draped, then we made 2 standard portals medial and lateral. through the lateral portal, the camera was placed. through the medial portal, tools were placed. we proceeded to examine scarring of the patellofemoral joint. then we probed the patellofemoral joint. a chondroplasty was performed using a shaver. then we moved down to the lateral gutter. some loose bodies were found using a shaver and dissection. we moved down the medial gutter. no plica was found.,we moved into the medial joint; we found that the medial meniscus was intact. we moved to the lateral joint and found that the lateral meniscus was intact. pictures were taken. we drained the knee and washed out the knee with copious amounts of sterile saline solution. the instruments were removed. the 2 portals were closed using 3-0 nylon suture. xeroform, 4 x 4s, kerlix x2, and ted stocking were placed. the patient was successfully extubated and brought to the recovery room in stable condition. i then spoke with the family going over the case, postoperative instructions, and followup care.

indication: , lung carcinoma.,whole body pet scanning was performed with 11 mci of 18 fdg. axial, coronal and sagittal imaging was performed over the neck, chest abdomen and pelvis.,findings:,there is normal physiologic activity identified in the myocardium, liver, spleen, ureters, kidneys and bladder.,there is abnormal fdg-avid activity identified in the posterior left paraspinal region best seen on axial images 245-257 with an suv of 3.8, no definite bone lesion is identified on the ct scan or the bone scan dated 08/14/2007 (it may be purely lytic).,additionally there is a significant area of activity corresponding to a mass in the region of the left hilum that is visible on the ct scan with an suv of 18.1, the adjacent atelectasis as likely post obstructive in nature.,additionally, although there is no definite lesion identified on ct , there is a tiny satellite nodule in the left upper lobe that is hypermetabolic with an suv of 5.0. the spiculated density seen in the right upper lobe on the ct scan does not demonstrate fdg activity on this pet scan.,there is a hypermetabolic lymph node identified in the aorta pulmonary window with an suv of 3.7 in the mediastinum.,impression:,no prior pet scans for comparison, there is a large lesion identified in the area of the left hilum with an suv of 18.1 likely causing the obstructive atelectasis seen on the ct scan.,there is a tiny satellite area of hypermetabolic fdg in the left upper lobe adjacent to the pleura with an suv of 5.0.,there is a area of hypermetabolic activity in the left paraspinal soft tissues at the level of the lung apices which may represent a focal bone lesion. however no lesion is identified on bone scan or ct scan.,there is a hypermetabolic lymph node identified. the aorta pulmonary window with a corresponding finding on ct scan with an suv of 3.7.

technique: , sequential axial ct images were obtained through the facial bones without contrast. additional high resolution coronal reconstructed images were also obtained for better visualization of the osseous structures.,findings:, the osseous structures within the face are intact with no evidence of fracture or dislocation. the visualized paranasal sinuses and mastoid air cells are clear. the orbits and extra-ocular muscles are within normal limits. the soft tissues are unremarkable. ,impression: , no acute abnormalities.

allowed conditions:, left knee strain, meniscus tear left knee.,contested condition:, osteoarthritis of the left knee.,employer:, abcd.,i examined xxxxx today september 14, 2007, for the above allowed conditions and also the contested condition of osteoarthritis of his left knee. he is a 57-year-old assembly worker who was injured on june 13, 2007, which according to his froi was due to "repairing cars, down on knees to work on concrete floors." in addition, he slipped on an air hose on the floor at work on march 7, 2007, re-injuring his left knee. he developed pain and swelling in his left knee. he denies having any difficulties with his left knee prior to the injury of june 13, 2002.,diagnostic studies: , august 2, 2002, mri of the left knee showed low-grade chondromalacia of the left patellofemoral joint space and a posterior horn tear of the medial meniscus, likely degenerative in nature, and also grade ii to iii chondromalacia of the medial joint space. on june 26, 2007, mri of his left knee was referred to in the injury management report of june 19, 2007, as showing osteoarthritis of the medial compartment has advanced. he brought with him copies of x-rays taken july 16, 2007, of his left knee, which i reviewed and which showed marked narrowing of the medial compartment of his left knee with spurs on the margins of the joint medially and also spurs on the patella. there was subluxation of the tibia on the femur with standing.,after his injury, he received treatment from dr. x for patellofemoral syndrome with knee sleeve. he also received treatment from dr. y also for left knee sprain and patellar pain. he also did exercise, does use a knee sleeve and aleve. on december 5, 2002, he underwent arthroscopy of the left knee by dr. z who did a partial resection of a torn medial meniscus. he also noticed grade iii chondromalacia of the patella as well as the torn medial meniscus. he states that he was asymptomatic until he slipped on an air hose while at work on march 7, 2007, and again developed pain and swelling in his left knee. standing aggravates his pain. he has had one injection of cortisone by dr. z about a month ago, which has helped his pain. he takes one hydrocodone 7.5/750 mg daily.,examination of his left knee revealed there was bilateral varus deformity, healed arthroscopy incisional scars, there was a 1/2 atrophy of the left calf. there was patellar crepitus with knee motion. there was no motor weakness or reflex changes. he walked without a limp and could stand on his heels and toes equally well. there was no instability of the knee and no effusion. range of motion was 0 to 120 degrees.,question: , xxxxx has recently filed to reactivate this claim. please give me your opinion as to whether xxxxx's current clinical presentation is related to the industrial injury stated above.,answer:, yes. his original mri of august 2, 2002, did show low-grade chondromalacia of the patellofemoral joint and also grade ii to iii chondromalacia of the medial joint space, which was the beginning of osteoarthritis. also, it is well known that torn medial meniscus can result in osteoarthritis of the knee; therefore, the osteoarthritis is related to his original injury of june 13, 2007, specifically to the torn medial meniscus.,question: ,do i believe that claim #123 should be reactivated to allow for treatment of the allowed conditions as stated?,answer:, yes, i believe it should be reactivated to allow treatment of the contested condition of osteoarthritis of his left knee.,question:, xxxxx has filed an application for additional allowance of osteoarthritis of the left knee. based on the current objective findings, mechanism of injury, medical records, and diagnostic studies, does the medical evidence support the existence of the requested condition?,answer: ,yes. please see the discussion in the answer to question no one. in addition, x-rays of july 16, 2007, do reveal medial compartment and patellofemoral compartment osteoarthritis of the left knee.,question: , if you find this condition exists, is it a direct and proximate result of the june 13, 2002, injury?,answer:, yes. see discussion in answer to question number one.,question: , do you find that xxxxx's injury or disability was caused by the natural deterioration of tissue, an organ or part of body?,answer: ,no. i believe the osteoarthritis was the result of the torn medial meniscus as discussed under question number one.,question: , in addition, if you find the condition exists, are there non-occupational activities or intervening injuries, which could have contributed to xxxxx's condition?,answer:, no. he does not give any history of any intervening injuries.,if you opine the requested condition should be additionally recognized, please include the condition as an allowed condition in the discussion of the following questions.,question:, based on the objective findings is the request for 10 sessions of physical therapy per c-9 dated july 27, 2007, medically necessary and appropriate for the allowed conditions of the claim of osteoarthritis of left knee?,answer:, yes.,

delivery note: , this is a 30-year-old g7, p5 female at 39-4/7th weeks who presents to labor and delivery for induction for history of large babies and living far away. she was admitted and started on pitocin. her cervix is 3 cm, 50% effaced and -2 station. artificial rupture of membrane was performed for clear fluid. she did receive epidural anesthesia. she progressed to complete and pushing. she pushed to approximately one contraction and delivered a live-born female infant at 1524 hours. apgars were 8 at 1 minute and 9 at 5 minutes. placenta was delivered intact with three-vessel cord. the cervix was visualized. no lacerations were noted. perineum remained intact. estimated blood loss is 300 ml. complications were none. mother and baby remained in the birthing room in good condition.

review of systems,general/constitutional: , the patient denies fever, fatigue, weakness, weight gain or weight loss.,head, eyes, ears, nose and throat:, eyes - the patient denies pain, redness, loss of vision, double or blurred vision, flashing lights or spots, dryness, the feeling that something is in the eye and denies wearing glasses. ears, nose, mouth and throat. the patient denies ringing in the ears, loss of hearing, nosebleeds, loss of sense of smell, dry sinuses, sinusitis, post nasal drip, sore tongue, bleeding gums, sores in the mouth, loss of sense of taste, dry mouth, dentures or removable dental work, frequent sore throats, hoarseness or constant feeling of a need to clear the throat when nothing is there, waking up with acid or bitter fluid in the mouth or throat, food sticking in throat when swallows or painful swallowing.,cardiovascular: , the patient denies chest pain, irregular heartbeats, sudden changes in heartbeat or palpitation, shortness of breath, difficulty breathing at night, swollen legs or feet, heart murmurs, high blood pressure, cramps in his legs with walking, pain in his feet or toes at night or varicose veins.,respiratory: , the patient denies chronic dry cough, coughing up blood, coughing up mucus, waking at night coughing or choking, repeated pneumonias, wheezing or night sweats.,gastrointestinal: , the patient denies decreased appetite, nausea, vomiting, vomiting blood or coffee ground material, heartburn, regurgitation, frequent belching, stomach pain relieved by food, yellow jaundice, diarrhea, constipation, gas, blood in the stools, black tarry stools or hemorrhoids.,genitourinary: ,the patient denies difficult urination, pain or burning with urination, blood in the urine, cloudy or smoky urine, frequent need to urinate, urgency, needing to urinate frequently at night, inability to hold the urine, discharge from the penis, kidney stones, rash or ulcers, sexual difficulties, impotence or prostate trouble, no sexually transmitted diseases.,musculoskeletal: , the patient denies arm, buttock, thigh or calf cramps. no joint or muscle pain. no muscle weakness or tenderness. no joint swelling, neck pain, back pain or major orthopedic injuries.,skin and breasts: ,the patient denies easy bruising, skin redness, skin rash, hives, sensitivity to sun exposure, tightness, nodules or bumps, hair loss, color changes in the hands or feet with cold, breast lump, breast pain or nipple discharge.,neurologic: , the patient denies headache, dizziness, fainting, muscle spasm, loss of consciousness, sensitivity or pain in the hands and feet or memory loss.,psychiatric: ,the patient denies depression with thoughts of suicide, voices in ?? head telling ?? to do things and has not been seen for psychiatric counseling or treatment.,endocrine: , the patient denies intolerance to hot or cold temperature, flushing, fingernail changes, increased thirst, increased salt intake or decreased sexual desire.,hematologic/lymphatic: ,the patient denies anemia, bleeding tendency or clotting tendency.,allergic/immunologic: , the patient denies rhinitis, asthma, skin sensitivity, latex allergies or sensitivity.

preoperative diagnosis: , left acoustic neuroma.,postoperative diagnosis: , left acoustic neuroma.,procedure performed: , left retrosigmoid craniotomy and excision of acoustic neuroma.,anesthesia:, general.,operative findings: , this patient had a 3-cm acoustic neuroma. the tumor was incompletely excised leaving a remnant of the tumor along the cerebellopontine angle portion of the facial nerve. the facial nerve was stimulated at the brainstem at 0.05 milliamperes at the conclusion of the dissections.,procedure in detail: ,following induction of adequate general anesthetic, the patient was positioned for surgery. she was placed in a lateral position and her head was maintained with mayfield pins. the left periauricular area was shaved, prepped, and draped in the sterile fashion. transdermal electrodes for continuous facial nerve emg monitoring were placed, and no response was verified. the proposed incision was injected with 1% xylocaine with epinephrine. next, t-shaped incision was made approximately 5 cm behind the postauricular crease. the incision was undermined at the level of temporalis fascia, and the portion of the fascia was harvested for further use.,incision was made along the inferior aspect of the temporalis muscle and then extended inferiorly over the mastoid tip. periosteal elevator was used to elevate periosteum in order to expose the mastoid and anterior aspect of the occipital bone. emissary veins posterior to the sigmoid sinus were controlled with electrocautery and bone wax. bergen retractors were used to maintain exposure. using a cutting bur with continuous suction and irrigation of craniotomy was performed. the sigmoid sinus was identified anteriorly and the transverse sites were identified superiorly. from these structures approximately 4 x 4 cm, a window of bone was removed. bone shavings were collected during the dissection and placed in siloxane suspension for later use. the bone flap was also left at the site for further use. dissection was extended along the inferior aspect of the sigmoid sinus to provide additional exposure of the skull base. bone wax was used to occlude air cells lateral to the sigmoid sinus. there was extensively aerated temporal bone. at this point, dr. trask entered the case in order to open the dura and expose the tumor. the cerebellum was retracted away from the tumor, and the retractor was placed to help maintain exposure. once initial exposure was completed, attention was directed to the posterior aspect of the temporal bone. the dura was excised from around the porous acusticus extending posteriorly along the bone. then, using diamond burs, the internal auditory canal was dissected out. the bone was removed laterally for distance of approximately 8 mm. there was considerable aeration around the internal auditory canal as well. the dura was then incised over the internal auditory canal exposing the intracanalicular portion of the tumor. the tumor extended all the way to the fundus such that initial exposure of the facial nerve around the tumor was difficult. therefore, dr. trask returned in order to further release the tumor from the brainstem and to debulk the central portions of the tumor. with dissection, he released the tumor from the trigeminal nerve superiorly and elevated the tumor away from the dorsal brainstem. the eighth nerve was identified and transected. tumor debulking allowed for retraction of the tumor capsule away from the brainstem. the facial nerve was difficult to identify at the brainstem as well. it was identified by using an electrical stimulator but dissection attempted at this time was the plane between the nerve and the tumor proximally but this was difficult to achieve. attention was then redirected to the internal auditory canal where this portion of the tumor was removed. the superior and inferior vestibular nerves were evulsed laterally and dissection proceeded along the facial nerve to the porous acusticus. at this point, plane of dissection was again indistinct. the tumor had been released from the porous and could be rotated. the tumor was further debulked and thinned, but could not crucially visualize the nerve on the anterior face of the tumor. the nerve could be stimulated, but was quite splayed over the anterior face. further debulking of the tumor proceeded and additional attempts were made to establish point of dissection along the nerve, both proximally and distally. however, the cerebellopontine angle portion of the nerve was not usually delineated. however, the tumor was then thinned using cusa down to fine sheath measuring only about 1 to 2 mm in thickness. it was released from the brainstem ventrally. the tumor was then cauterized with bipolar electrocautery. the facial nerve was stimulated at the brainstem and stimulated easily at 0.05 milliamperes. overall, the remaining tumor volume would be of small percentage of the original volume. at this point, dr. trask re-inspected the posterior fossa to ensure complete hemostasis. the air cells around the internal auditory canal were packed off with muscle and bone wax. a piece of fascia was then laid over the bone defect. next, the dura was closed with duragen and duraseal. the bone flap and bone ***** were then placed in the bone defect. postauricular musculature was then reapproximated using interrupted 3-0 vicryl sutures. the skin was also closed using interrupted subdermal 3-0 vicryl sutures. running 4-0 nylon suture was placed at the skin levels. sterile mastoid dressing was then placed. the patient tolerated the procedure well and was transported to the pacu in a stable condition. all counts were correct at the conclusion of the procedure.,estimated blood loss: ,100 ml.

procedure performed:,1. left heart catheterization, left ventriculogram, aortogram, coronary angiogram.,2. pci of the lad and left main coronary artery with impella assist device.,indications for procedure: , unstable angina and congestive heart failure with impaired lv function.,technique of procedure: , after obtaining informed consent, the patient was brought to the cardiac catheterization suite in postabsorptive and nonsedated state. the right groin was prepped and draped in the usual sterile manner. lidocaine 2% was used for infiltration anesthesia. using modified seldinger technique, a 7-french sheath was introduced into the right common femoral artery and a 6-french sheath was introduced into the right common femoral vein. through the arterial sheath, angiography of the right common femoral artery was obtained. thereafter, 6-french pigtail catheter was advanced to the level of the distal aorta where angiography of the distal aorta and the bifurcation of the right and left common iliac arteries was obtained. thereafter, a 4-french sheath was introduced into the left common femoral artery using modified seldinger technique. thereafter, the pigtail catheter was advanced over an 0.035-inch j-wire into the left ventricle and lv-gram was performed in rao view and after pullback, an aortogram was performed in the lao view. therefore, a 6-french jl4 and jr4 guiding catheters were used to engage the left and right coronary arteries respectively and multiple orthogonal views of the coronary arteries were obtained.,angiographic findings: ,1. lv-gram: lvedp was 15 mmhg. lv ejection fraction 10% to 15% with global hypokinesis. only anterior wall is contracting. there was no mitral regurgitation. there was no gradient across the aortic valve upon pullback, and on aortography, there was no evidence of aortic dissection or aortic regurgitation.,2. the right coronary artery is a dominant vessels with a mid 50% to 70% stenosis which was not treated. the left main coronary artery calcified vessel with disease.,2. the left anterior descending artery had an 80% to 90% mid-stenosis. first diagonal branch had a more than 90% stenosis.,3. the circumflex coronary artery had a patent stent.,intervention: , after reviewing the angiographic images, we elected to proceed with intervention of the left anterior descending artery. the 4-french sheath in the left common femoral artery was upsized to a 12-french impella sheath through which an amplatz wire and a 6-french multipurpose catheter were advanced into the left ventricle. the amplatz wire was exchanged for an impella 0.018-inch stiff wire. the multipurpose catheter was removed, and the impella was advanced into the left ventricle and a performance level of 8 was achieved with a cardiac output of 2 to 2.5 l/min. thereafter, a 7-french jl4 guiding catheter was used to engage the left coronary artery and an asahi soft 0.014-inch wire was advanced into the left anterior descending artery and a second 0.014-inch asahi soft wire was advanced into the diagonal branch. the diagonal branch was predilated with a 2.5 x 30-mm sprinter balloon at nominal atmospheres and thereafter a 2.5 x 24 endeavor stent was successfully deployed in the mid-lad and a 3.0 x 15-mm endeavor stent was deployed in the proximal lad. the stent delivery balloon was used to post-dilate the overlapping segment. the lad, the diagonal was rewires with an 0.014-inch asahi soft wire and a 3.0 x 20-mm maverick balloon was advanced into the lad for post-dilatation and a 2.0 x 30-mm sprinter balloon was advanced into the diagonal for kissing inflations which were performed at nominal atmospheres. at this point, it was noted that the left main had a retrograde dissection. a 3.5 x 18-mm endeavor stent was successfully deployed in the left main coronary artery. the asahi soft wire in the diagonal was removed and placed into the circumflex coronary artery. kissing inflations of the lad and the circumflex coronary artery were performed using 3.0 x 20 maverick balloons x2 balloons, inflated at high atmospheres of 14.,results: , lesion reduction in the lad from 90% to 0% and timi 3 flow obtained. lesion reduction in the diagonal from 90% to less than 60% and timi 3 flow obtained. lesion reduction in the left maintained coronary artery from 50% to 0% and timi 3 flow obtained.,the patient tolerated the procedure well and the inflations well with no evidence of any hemodynamic instability. the impella device was gradually decreased from performance level of 8 to performance level of 1 at which point it was removed into the aorta and it was turned off and the impella was removed from the body and the 2 perclose sutures were tightened. from the right common femoral artery, a 6-french ima catheter was advanced and an 0.035-inch wire down into the left common femoral and superficial femoral artery, over which an 8 x 40 balloon was advanced and tamponade of the arteriotomy site of the left common femoral artery was performed from within the artery at 3 atmospheres for a total of 20 minutes. the right common femoral artery and vein sheaths were both sutured in place for further observation. of note, the patient received angiomax during the procedure and an act above 300 was maintained.,impression:,1. left ventricular dysfunction with ejection fraction of 10% to 15%.,2. high complex percutaneous coronary intervention of the left main coronary artery, left anterior descending artery, and diagonal with impella circulatory support.,complications: , none.,the patient tolerated the procedure well with no complications. the estimated blood loss was 200 ml. estimated dye used was 200 ml of visipaque. the patient remained hemodynamically stable with no hypotension and no hematomas in the groins.,plan: ,1. aspirin, plavix, statins, beta blockers, ace inhibitors as tolerated.,2. hydration.,3. the patient will be observed over night for any hemodynamic instability or ischemia. if she remains stable, the right common femoral artery and vein sheaths will be removed and manual pressure will be applied for hemostasis.

preoperative diagnosis: , internal derangement, left knee.,postoperative diagnosis: , internal derangement, left knee.,procedure performed:, arthroscopy of the left knee with medial meniscoplasty.,anesthesia: ,lma.,gross findings: , displaced bucket-handle tear of medial meniscus, left knee.,procedure: , after informed consent was obtained, the patient was taken to abcd general hospital operating room #1 where anesthesia was administered by the department of anesthesiology. the patient was then transferred to the operating room table in supine position with johnson knee holder well-padded. tourniquet was placed around the left upper thigh. the limb was then prepped and draped in usual sterile fashion. standard anteromedial and anterolateral arthroscopy portals were obtained and a systematic examination of the knee was then performed. patellofemoral joint showed frequent chondromalacia. examination of the medial compartment showed a displaced bucket-handle tear of the medial meniscus involving the entire posterior, parietal, and portion of his anterior portion of the medial meniscus. the medial femoral condyle and medial tibial plateau were unaffected. intercondylar notch examination revealed an intact acl and pcl stable to drawer testing and probing and the lateral compartment showed an intact lateral meniscus. the femoral condyle and tibial plateau were all stable to probing. attention was then directed back to the medial compartment where the detached portion of the meniscus was excised using arthroscopy scissors. a shaver was then used to smooth all the edges until the margins were stable to probing.,the knee was then flushed with normal saline and suctioned dry. 20 cc of 0.25% marcaine was injected into the knee and into the arthroscopy portals. a dressing consisting of adaptic, 4x4s, abds, and webril were applied followed by a ted hose. the patient was then transferred to the recovery room in stable condition.

chief complaint: ,followup diabetes mellitus, type 1., ,subjective:, patient is a 34-year-old male with significant diabetic neuropathy. he has been off on insurance for over a year. has been using nph and regular insulin to maintain his blood sugars. states that he is deathly afraid of having a low blood sugar due to motor vehicle accident he was in several years ago. reports that his blood sugar dropped too low which caused the accident. since this point in time, he has been unwilling to let his blood sugars fall within a normal range, for fear of hypoglycemia. also reports that he regulates his blood sugars with how he feels, rarely checking his blood sugar with a glucometer., ,reports that he has been worked up extensively at hospital and was seeing an endocrinologist at one time. reports that he had some indications of kidney damage when first diagnosed. his urine microalbumin today is 100. his last hemoglobin a1c drawn at the end of december is 11.9. reports that at one point, he was on lantus which worked well and he did not worry about his blood sugars dropping too low. while using lantus, he was able to get his hemoglobin a1c down to 7. his last cmp shows an elevated alkaline phosphatase level of 168. he denies alcohol or drug use and is a non smoker. reports he quit drinking 3 years ago. i have discussed with patient that it would be appropriate to do an sggt and hepatic panel today. patient also has a history of gastroparesis and impotence. patient requests nexium and viagra, neither of which are covered under the health plan. , ,patient reports that he was in a scooter accident one week ago, fell off his scooter, hit his head. was not wearing a helmet. reports that he did not go to the emergency room and had a headache for several days after this incident. reports that an ambulance arrived at the scene and he was told he had a scalp laceration and to go into the emergency room. patient did not comply. reports that the headache has resolved. denies any dizziness, nausea, vomiting, or other neurological abnormalities., ,physical examination: , wd, wn. slender, 34-year-old white male. vital signs: blood sugar 145, blood pressure 120/88, heart rate 104, respirations 16. microalbumin 100. skin: there appears to be 2 skin lacerations on the left parietal region of the scalp, each approximately 1 inch long. no signs of infection. wound is closed with new granulation tissue. appears to be healing well. heent: normocephalic. perrla. eomi. tms pearly gray with landmarks present. nares patent. throat with no redness or swelling. nontender sinuses. neck: supple. full rom. no lad. cardiac:

external examination - summary,the body is presented in a black body bag. at the time of examination, the body is clothed in a long-sleeved red cotton thermal shirt, khaki twill cargo pants, and one black shoe.,the body is that of a normally developed, well nourished caucasian female measuring 63 inches in length, weighing 114 pounds, and appearing generally consistent with the stated age of thirty-five years. the body is cold and unembalmed with declining rigor. pronounced unblanching lividity is present on the posterior of the body in the regions of the feet; the upper thighs, particularly on the right side; the lower back, particularly on the right side; the right arm; and the neck.,the scalp is covered by long (16 inches) brown hair. the body hair is female and average. the skull is symmetric and evidences extensive trauma in the occipital region. the eyes are open and the irises are blue. pupils are asymmetrically dilated. the teeth are natural and well maintained. the anterior chest is of normal contour and is intact. the breasts are female and contain no palpable masses. the abdomen is flat and the pelvis is intact. the external genitalia are female and unremarkable. the back is symmetrical and intact. the upper and lower extremities are symmetric, normally developed and intact. the hands and nails are clean and evidence no injury.,there are no residual scars, markings or tattoos.,internal examination - summary,central nervous system: ,the brain weighs 1,303 grams and is within normal limits. ,skeletal system:, subdural hematoma and comminuted fractures of the occipital bone are observed. numerous bone fragments from the fractures penetrated the brain tissue. ,respiratory system--throat structures: ,the oral cavity shows no lesions. the mucosa is intact and there are no injuries to the lips, teeth or gums. there is no obstruction of the airway. the mucosa of the epiglottis, glottis, piriform sinuses, trachea and major bronchi are anatomic. no injuries are seen and there are no mucosal lesions. the lungs weigh: right, 355 grams; left 362 grams. the lungs are unremarkable. ,cardiovascular system:, the heart weighs 253 grams, and has a normal size and configuration. no evidence of atherosclerosis is present. ,gastrointestinal system: ,the mucosa and wall of the esophagus are intact and gray-pink, without lesions or injuries. the gastric mucosa is intact and pink without injury. approximately 125 ml of partially digested semisolid food is found in the stomach. the mucosa of the duodenum, jejunum, ileum, colon and rectum are intact. ,urinary system:, the kidneys weigh: left, 115 grams; right, 113 grams. the kidneys are anatomic in size, shape and location and are without lesions. ,female genital system: ,the structures are within normal limits. examination of the pelvic area indicates the victim had not given birth and was not pregnant at the time of death. vaginal fluid samples are removed for analysis. ,description of injuries - summary,blunt force traumatic injury with multiple cranial fractures resulting in craniocerebral injury. wound measures approximately 4 inches high x 5 1/2 inches wide. subdural hematoma and comminuted fractures of the occipital bone are observed. numerous bone fragments from the fractures penetrated the brain tissue. depths of penetration range from 1/2-inch to 3 inches. injury appears to have resulted from a single blow administered to the posterior of the head, delivered at an approximate 90º angle to the occipital bone.,laboratory data,cerebrospinal fluid culture and sensitivity:,gram stain: unremarkable,culture: no growth after 72 hours,cerebrospinal fluid bacterial antigens:,hemophilus influenza b: negative,streptococcus pneumoniae: negative,n. meningitidis: negative,neiserria meningitidis b/e. coli k1: negative ,preliminary toxicological results:,blood - ethanol - neg ,blood - cannabinoids-ets - inc,blood - cocaine-ets - inc,blood - opiates-ets - inc,blood - amphetamine-ets - inc,blood - barbiturate -ets - inc,blood - benzodiazepine-ets - inc,blood - methadone-ets - inc,blood - pcp-ets - inc,blood - carbon monoxide - neg,urine drugs: initial test results inconclusive. further tests pending. ,evidence collected,1. samples of blood (type o+), urine, bile, and tissue (heart, lung, brain, kidney, liver, spleen). ,2. thirteen autopsy photographs. ,3. two postmortem x-rays. ,clothing transferred to abc lab for further analysis.

final diagnoses:,1. herniated nucleuses pulposus, c5-6 greater than c6-7, left greater than c4-5 right with left radiculopathy.,2. moderate stenosis c5-6.,operation: , on 06/25/07, anterior cervical discectomy and fusions c4-5, c5-6, c6-7 using bengal cages and slimlock plate c4 to c7; intraoperative x-ray.,this is a 60-year-old white male who was in the office on 05/01/07 because of neck pain with left radiculopathy and "tension headaches." in the last year or so, he has had more and more difficulty and more recently has developed tingling and numbness into the fingers of the left hand greater than right. he has some neck pain at times and has seen dr. x for an epidural steroid injection, which was very helpful. more recently he saw dr. y and went through some physical therapy without much relief.,cervical mri scan was obtained and revealed a large right-sided disc herniation at c4-5 with significant midline herniations at c5-6 and a large left hnp at c6-7. in view of the multiple levels of pathology, i was not confident that anything short of surgical intervention would give him significant relief. the procedure and its risk were fully discussed and he decided to proceed with the operation.,hospital course: , following admission, the procedure was carried out without difficulty. blood loss was about 125 cc. postop x-ray showed good alignment and positioning of the cages, plate, and screws. after surgery, he was able to slowly increase his activity level with assistance from physical therapy. he had some muscle spasm and soreness between the shoulder blades and into the back part of his neck. he also had some nausea with the pca. he had a low-grade fever to 100.2 and was started on incentive spirometry. over the next 12 hours, his fever resolved and he was able to start getting up and around much more easily.,by 06/27/07, he was ready to go home. he has been counseled regarding wound care and has received a neck sheet for instruction. he will be seen in two weeks for wound check and for a followup evaluation/x-rays in about six weeks. he has prescriptions for lortab 7.5 mg and robaxin 750 mg. he is to call if there are any problems.

subjective:,

preoperative diagnosis: , wrist ganglion.,postoperative diagnosis: , wrist ganglion.,title of procedure: , excision of dorsal wrist ganglion.,procedure: , after administering appropriate antibiotics and general anesthesia, the upper extremity was prepped and draped in the usual standard fashion. the arm was exsanguinated with an esmarch and tourniquet inflated to 250 mmhg. i made a transverse incision directly over the ganglion. dissection was carried down through the extensor retinaculum, identifying the 3rd and the 4th compartments and retracting them. i then excised the ganglion and its stalk. in addition, approximately a square centimeter of the dorsal capsule was removed at the origin of stalk, leaving enough of a defect to prevent formation of a one-way valve. we then identified the scapholunate ligament, which was uninjured. i irrigated and closed in layers and injected marcaine with epinephrine. i dressed and splinted the wound. the patient was sent to the recovery room in good condition, having tolerated the procedure well.

subjective:, the patient is a 44-year-old white female who is here today with multiple problems. the biggest concern she has today is her that left leg has been swollen. it is swollen for three years to some extent, but worse for the past two to three months. it gets better in the morning when she is up, but then through the day it begins to swell again. lately it is staying bigger and she somewhat uncomfortable with it being so large. the right leg also swells, but not nearly like the left leg. the other problem she had was she has had pain in her shoulder and back. these occurred about a year ago, but the pain in her left shoulder is of most concern to her. she feels like the low back pain is just a result of a poor mattress. she does not remember hurting her shoulder, but she said gradually she has lost some mobility. it is hard time to get her hands behind her back or behind her head. she has lost strength in the left shoulder. as far as the blood count goes, she had an elevated white count. in april of 2005, dr. xyz had asked dr. xyz to see her because of the persistent leukocytosis; however, dr. xyz felt that this was not a problem for the patient and asked her to just return here for follow up. she also complains of a lot of frequency with urination and nocturia times two to three. she has gained weight; she thinks about 12 pounds since march. she now weighs 284. fortunately, her blood pressure is staying stable. she takes atenolol 12.5 mg per day and takes lasix on a p.r.n. basis, but does not like to take it because it causes her to urinate so much. she denies chest pain, but she does feel like she is becoming gradually more short of breath. she works for the city of wichita as bus dispatcher, so she does sit a lot, and just really does not move around much. towards the end of the day her leg was really swollen. i reviewed her lab work. other than the blood count her lab work has been pretty normal, but she does need to have a cholesterol check.,objective:,general: the patient is a very pleasant 44-year-old white female quite obese.,vital signs: blood pressure: 122/70. temperature: 98.6.,heent: head: normocephalic. ears: tms intact. eyes: pupils round, and equal. nose: mucosa normal. throat: mucosa normal.,lungs: clear.,heart: regular rate and rhythm.,abdomen: soft and obese.,extremities: a lot of fluid in both legs, but especially the left leg is really swollen. at least 2+ pedal edema. the right leg just has a trace of edema. she has pain in her low back with range of motion. she has a lot of pain in her left shoulder with range of motion. it is hard for her to get her hand behind her back. she cannot get it up behind her head. she has pain in the anterior left shoulder in that area.,assessment:,1. multiple problems including left leg swelling.,2. history of leukocytosis.,3. joint pain involving the left shoulder, probably impingement syndrome.,4. low back pain, chronic with obesity.,5. obesity.,6. frequency with urination.,7. tobacco abuse.,plan:,1. i will schedule for a venous doppler of the left leg and will have her come back in the morning for a cbc and a metabolic panel. we will start her on detrol 0.4 mg one daily and also started on mobic 15 mg per day.,2. elevate her leg as much as possible and wear support hose if possible. keep her foot up during the day. we will see her back in two weeks. we will have the results of the doppler, the lab work and see how she is doing with the detrol and the joint pain. if her shoulder pain is not any better, we probably should refer her on over to orthopedist. we did do x-rays of her shoulder today that did not show anything remarkable. see her in two weeks or p.r.n.

prostate brachytherapy - prostate i-125 implantation,this patient will be treated to the prostate with ultrasound-guided i-125 seed implantation. the original consultation and treatment planning will be separately performed. at the time of the implantation, special coordination will be required. stepping ultrasound will be performed and utilized in the pre-planning process. some discrepancies are frequently identified, based on the positioning, edema, and/or change in the tumor since the pre-planning process. re-assessment is required at the time of surgery, evaluating the pre-plan and comparing to the stepping ultrasound. modifications will be made in real time to add or subtract needles and seeds as required. this may be integrated with the loading of the seeds performed by the brachytherapist, as well as coordinated with the urologist, dosimetrist or physicist.,the brachytherapy must be customized to fit the individual's tumor and prostate. attention is given both preoperatively and intraoperatively to avoid overdosage of rectum and bladder.

preoperative diagnosis: ,degenerative arthritis of the left knee.,postoperative diagnosis:, degenerative arthritis of the left knee.,procedure performed: , total left knee replacement on 08/19/03. the patient also underwent a bilateral right total knee replacement in the same sitting and that will be dictated by dr. x.,tourniquet time: , 76 minutes.,blood loss: , 150 cc.,anesthesia: ,general.,implant used for procedure:, nexgen size f femur on the left with #8 size peg tibial tray, a #12 mm polyethylene insert and this a cruciate retaining component. the patella on the left was not resurfaced.,gross intraoperative findings: , degenerative ware of three compartments of the trochlea, the medial, as well as the lateral femoral condyles as well was the plateau. the surface of the patella was with a minimal ware and minimal osteophytes and we decided not to resurface the patellar component.,history: ,this is a 69-year-old male with complaints of bilateral knee pain for several years and increased intensity in the past several months where it has affected his activities of daily living. he attempted conservative treatment, which includes anti-inflammatory medications as well as cortisone and synvisc. this has only provided him with temporary relief. it is for that reason, he is elected to undergo the above-named procedure.,all risks as well as complications were discussed with the patient, which include, but are not limited to infection, deep vein thrombosis, pulmonary embolism, need for further surgery, and further pain. he has agreed to undergo this procedure and a consent was obtained preoperatively.,procedure: , the patient was wheeled back to operating room #2 at abcd general hospital on 08/19/03 and was placed supine on the operating room table. at this time, a nonsterile tourniquet was placed on the left upper thigh, but not inflated. an esmarch was then used to exsanguinate the extremity and the left extremity was then prepped and draped in the usual sterile fashion for this procedure. the tourniquet was then inflated to 325 mmhg. at this time, a standard midline incision was made towards the total knee. we did discuss preoperatively for a possible unicompartmental knee replacement for this patient, but he did have radiographic evidence of chondrocalcinosis of the lateral meniscus. we did start off with a small midline skin incision in case we were going to do a unicompartmental. once we exposed the medial parapatellar mini-arthrotomy and visualized the lateral femoral condyle, we decided that this patient would not be an optimal candidate for unicompartmental knee replacement. it is for this reason that we extended the incision and underwent with the total knee replacement. once the full medial parapatellar arthrotomy was performed with the subperiosteal dissection of the proximal tibia in order to evert the patella. once the patella was everted, we then used a drill to cannulate the distal femoral canal in order to place the intramedullary guide. a charnley awl was then used to remove all the intramedullary contents and they were removed from the knee. at this time, a femoral sizer was then placed with reference to the posterior condyles and we measured a size f. once this was performed, three degrees of external rotation was then drilled into the condyle in alignment with the epicondyles of the femur. at this time, the intramedullary guide was then inserted and placed in three degrees of external rotation. our anterior cutting guide was then placed and an anterior cut was performed with careful protection of the soft tissues. next, this was removed and the distal femoral cutting guide was then placed in five degrees of valgus. this was pinned to the distal femur and with careful protection of the collateral ligaments, a distal femoral cut was performed. at this time, the intramedullary guide was removed and a final cutting block was placed. this was placed in the center on the distal femur with 1 mm to 2 mm laterally translated for better patellar tracking. at this time, the block was pinned and screwed in place with spring pins with careful protection of the soft tissues. an oscillating saw was then used to resect the posterior and anterior cutting blocks with anterior and posterior chamfer as well as the notch cut. peg holes were then drilled.,the block was then removed and an osteotome was then used to remove all the bony cut pieces. at this time with a better exposure of the proximal tibia, we placed external tibial guide. this was placed with longitudinal axis of the tibia and carefully positioned in order to obtain an optimal cut for the proximal tibia. at this time with careful soft tissue retraction and protection, an oscillating saw was used to make a proximal tibial osteotomy. prior to the osteotomy, the cut was checked with a depth gauge in order to assure appropriate bony resection. at this time, a _blunt kocher and bovie cautery were used to remove the proximal tibial cut, which had soft tissue attachments. once this was removed, we then implanted our trial components of size f to the femur and a size 8 mm tibial tray with 12 mm plastic articulating surface. the knee was taken through range of motion and revealed excellent femorotibial articulation. the patella did tend to sublux somewhat laterally with extremes of flexion and it was for this reason, we performed a minimal small incision lateral retinacular release. distal lateral patella was tracked more uniformly within the patellar groove of the prosthesis. at this time, an intraoperative x-ray was performed, which revealed excellent alignment with no varus angulation especially of the whole femur and tibial alignment and tibial cut. at this time, the prosthesis was removed. a mcgill retractor was then reinserted and replaced peg tibial tray in order to peg the proximal tibia. once the drill holes were performed, we then copiously irrigated the wound and then suctioned it dry to get ready and prepped for cementation of the drilled components. at this time, polymethyl methacrylate cement was then mixed. the cement was placed on the tibial surface as well as the underneath surface of the component. the component was then placed and impacted with excess cement removed. in a similar fashion, the femoral component was also placed. a 12 mm plastic tray was then placed and the leg held in full extension and compression in order to obtain adequate bony cement content. once the cement was fully hardened, the knee was flexed and a small osteotome was used to remove any extruding cement from around the prosthesis of the bone. once this was performed, copious irrigation was used to irrigate the wound and the wound was then suctioned dry. the knee was again taken through range of motion with a 12 mm plastic as well as #14. the #14 appeared to be a bit too tight especially in extremes of flexion. we decided to go with a #12 mm polyethylene tray. at this time, this was placed to the tibial articulation and then left in place. this was rechecked with careful attention to detail with checking no soft tissue interpositioned between the polyethylene tray and the metal tray of the tibia. the knee was again taken through range of motion and revealed excellent tracking of the patella with good femur and tibial contact. a drain was placed and cut to length.,at this time, the knee was irrigated and copiously suction dried. #1-0 ethibond suture was then used to approximate the medial parapatellar arthrotomy in figure-of-eight fashion. a tight capsular closure was performed. this was reinforced with a #1-0 running vicryl suture. at this time, the knee was again taken through range of motion to assure tight capsular closure. at this time, copious irrigation was used to irrigate the superficial wound. #2-0 vicryl was used to approximate the wound with figure-of-eight inverted suture. the skin was then approximated with staples. the leg was then cleansed. sterile dressing consisting of adaptic, 4x4, abds, and kerlix roll were then applied. at this time, the patient was extubated and transferred to recovery in stable condition. prognosis is good for this patient.

procedures performed,1. insertion of subclavian dual-port port-a-cath.,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 general endotracheal anesthesia was administered. next, the chest was prepped and draped in a standard surgical fashion. a #18-gauge spinal needle was used to aspirate blood from the subclavian vein. after aspiration of venous blood, seldinger technique was used to thread a j wire. the distal tip of the j wire was confirmed to be in adequate position with surgeon-interpreted fluoroscopy. next a #15-blade scalpel was used to make an incision in the skin. dissection was carried down to the level of the pectoralis muscle. a pocket was created. a dual-port port-a-cath was lowered into the pocket and secured with #2-0 prolene. both ports were flushed. the distal tip was pulled through to the wire exit site with a kelly clamp. it was cut to the appropriate length. next a dilator and sheath were threaded over the j wire. the j wire and dilator were removed, and the distal tip of the dual-port port-a-cath was threaded over the sheath, which was simultaneously withdrawn. both ports of the dual-port port-a-cath were flushed and aspirated without difficulty. the distal tip was confirmed to be in adequate position with surgeon-interpreted fluoroscopy. the wire access site was closed with a 4-0 monocryl. the port pocket was closed in 2 layers with 2-0 vicryl followed by 4-0 monocryl in a running subcuticular fashion. sterile dressing was applied. the patient tolerated the procedure well and was transferred to the pacu in good condition

chief complaint:, a 74-year-old female patient admitted here with altered mental status.,history of present illness:, the patient started the last 3-4 days to do poorly. she was more confused, had garbled speech, significantly worse from her baseline. she has also had decreased level of consciousness since yesterday. she has had aphasia which is baseline but her aphasia has gotten significantly worse. she eventually became unresponsive and paramedics were called. her blood sugar was found to be 40 because of poor p.o. intake. she was given some d50 but that did not improve her mental status, and she was brought to the emergency department. by the time she came to the emergency department, she started having some garbled speech. she was able to express her husband's name and also recognize some family members, but she continued to be more somnolent when she was in the emergency department. when seen on the floor, she is more awake, alert.,past medical history: , significant for recurrent utis as she was recently to the hospital about 3 weeks ago for urinary tract infection. she has chronic incontinence and bladder atony, for which eventually it was decided for the care of the patient to put a foley catheter and leave it in place. she has had right-sided cva. she has had atrial fibrillation status post pacemaker. she is a type 2 diabetic with significant neuropathy. she has also had significant pain on the right side from her stroke. she has a history of hypothyroidism. past surgical history is significant for cholecystectomy, colon cancer surgery in 1998. she has had a pacemaker placement. ,review of systems:,general: no recent fever, chills. no recent weight loss.,pulmonary: no cough, chest congestion.,cardiac: no chest pain, shortness of breath.,gi: no abdominal pain, nausea, vomiting. no constipation. no bleeding per rectum or melena.,genitourinary: she has had frequent urinary tract infection but does not have any symptoms with it. endocrine: unable to assess because of patient's bed-bound status.,medications: ,percocet 2 tablets 4 times a day, neurontin 1 tablet b.i.d. 600 mg, cipro recently started 500 b.i.d., humulin n 30 units twice a day. the patient had recently reduced that to 24 units. miralax 1 scoop nightly, avandia 4 mg b.i.d., flexeril 1 tablet t.i.d., synthroid 125 mcg daily, coumadin 5 mg. on the medical records, it shows she is also on ibuprofen, lasix 40 mg b.i.d., lipitor 20 mg nightly, reglan t.i.d. 5 mg, nystatin powder. she is on oxygen chronically.,social/family history: , she is married, lives with her husband, has 2 children that passed away and 4 surviving children. no history of tobacco use. no history of alcohol use. family history is noncontributory.,physical examination:,general: she is awake, alert, appears to be comfortable.,vital signs: blood pressure 111/43, pulse 60 per minute, temperature 37.2. weight is 98 kg. urine output is so far 1000 ml. her intake has been fairly similar. blood sugars are 99 fasting this morning. ,heent: moist mucous membranes. no pallor,neck: supple. she has a rash on her neck. ,heart: regular rhythm, pacemaker could be palpated.,chest: clear to auscultation.,abdomen: soft, obese, nontender.,extremities: bilateral lower extremities edema present. she is able to move the left side more efficiently than the right. the power is about 5 x 5 on the left and about 3-4 x 5 on the right. she has some mild aphasia.,diagnostic studies: , bun 48, creatinine 2.8. lfts normal. she is anemic with a hemoglobin of 9.6, hematocrit 29. inr 1.1, pro time 14. urine done in the emergency department showed 20 white cells. it was initially cloudy but on the floor it has cleared up. cultures from the one done today are pending. the last culture done on august 20 showed guaiac negative status and prior to that she has had mixed cultures. there is a question of her being allergic to septra that was used for her last uti.,impression/plan:,1. cerebrovascular accident as evidenced by change in mental status and speech. she seems to have recovered at this point. we will continue coumadin. the patient's family is reluctant in discontinuing coumadin but they do express the patient since has overall poor quality of life and had progressively declined over the last 6 years, the family has expressed the need for her to be on hospice and just continue comfort care at home.,2. recurrent urinary tract infection. will await culture at this time, continue cipro.,3. diabetes with episode of hypoglycemia. monitor blood sugar closely, decrease the dose of humulin n to 15 units twice a day since intake is poor. at this point, there is no clear evidence of any benefit from avandia but will continue that for now.,4. neuropathy, continue neurontin 600 mg b.i.d., for pain continue the percocet that she has been on.,5. hypothyroidism, continue synthroid.,6. hyperlipidemia, continue lipitor.,7. the patient is not to be resuscitated. further management based on the hospital course.

preoperative diagnoses:,1. ventilator-dependent respiratory failure.,2. laryngeal edema.,postoperative diagnoses:,1. ventilator-dependent respiratory failure.,2. laryngeal edema.,procedure performed: , tracheostomy change. a #6 shiley with proximal extension was changed to a #6 shiley with proximal extension.,indications: , the patient is a 60-year-old caucasian female who presented to abcd general hospital with exacerbation of copd and chf. the patient had subsequently been taken to the operating room by department of otolaryngology and a direct laryngoscope was performed. the patient was noted at that time to have transglottic edema. biopsies were taken. at the time of surgery, it was decided that the patient required a tracheostomy for maintenance of continued ventilation and airway protection. the patient is currently postop day #6 and appears to be unable to be weaned from ventilator at this time and may require prolonged ventricular support. a decision was made to perform tracheostomy change.,description of procedure: , the patient was seen in the intensive care unit. the patient was placed in a supine position. the neck was then extended. the sutures that were previously in place in the #6 shiley with proximal extension were removed. the patient was preoxygenated to 100%. after several minutes, the patient was noted to have a pulse oximetry of 100%. the iv tubing that was supporting the patient's trache was then cut. the tracheostomy tube was then suctioned.,the inner cannula was then removed from the tracheostomy and a nasogastric tube was placed down the lumen of the tracheostomy tube as a guidewire. the tracheostomy tube was then removed over the nasogastric tube and the operative field was suctioned. with the guidewire in place and with adequate visualization, a new #6 shiley with proximal extension was then passed over the nasogastric tube guidewire and carefully inserted into the trachea. the guidewire was then removed and the inner cannula was then placed into the tracheostomy. the patient was then reconnected to the ventilator and was noted to have normal tidal volumes. the patient had a tidal volume of 500 and was returning 500 cc to 510 cc. the patient continued to saturate well with saturations 99%. the patient appeared comfortable and her vital signs were stable. a soft trache collar was then connected to the trachesotomy. a drain sponge was then inserted underneath the new trache site. the patient was observed for several minutes and was found to be in no distress and continued to maintain adequate saturations and continued to return normal tidal volumes.,complications: , none.,disposition: , the patient tolerated the procedure well. 0.25% acetic acid soaks were ordered to the drain sponge every shift.

reason for return visit: , followup of left hand discomfort and systemic lupus erythematosus.,history of present illness: , the patient is a 56-year-old female with a history of systemic lupus erythematosus, who was last seen in rheumatology clinic approximately 4 months ago for bilateral hand discomfort, left greater than right. the patient was seen on 10/30/07. she had the same complaint. she was given a trial of elavil at bedtime because the thought was to see that represented ulnar or radial neuropathy. she was also given a prescription for zostrix cream but was unable to get it filled because of insurance coverage. the patient reports some worsening of the symptoms especially involving at the dorsum of the left hand, and she points to the area that actually involves the dorsal aspect of the second, third, and fourth digits. the patient recently has developed what sounds like an upper respiratory problem with a nonproductive cough for 3 days, although she reports that she has had subjective fevers for the past 3 or 4 days, but has not actually taken the temperature. she has not had any night sweats or chills. she has had no recent problems with chest pain, chest discomfort, shortness of breath or problems with gu or gi complaints. she is returning today for routine followup evaluation.,current medications:,1. plaquenil 200 mg twice a day.,2. fosamax 170 mg once a week.,3. calcium and vitamin d complex twice daily.,4. folic acid 1 mg per day.,5. trilisate 1000 mg a day.,6. k-dur 20 meq twice a day.,7. hydrochlorothiazide 15 mg once a day.,8. lopressor 50 mg one-half tablet twice a day.,9. trazodone 100 mg at bedtime.,10. prempro 0.625 mg per day.,11. aspirin 325 mg once a day.,12. lipitor 10 mg per day.,13. pepcid 20 mg twice a day.,14. reglan 10 mg before meals and at bedtime.,15. celexa 20 mg per day.,review of systems: , noncontributory except for what was noted in the hpi and the remainder or complete review of systems is unremarkable.,physical examination:,vital signs: blood pressure 155/84, pulse 87, weight 223 pounds, and temperature 99.2. general: she is a well-developed, well-nourished female appearing her staged age. she is alert, oriented, and cooperative. heent: normocephalic and atraumatic. there is no facial rash. no oral lesions. lungs: clear to auscultation. cardiovascular: regular rate and rhythm without murmurs, rubs or gallops. extremities: no cyanosis or clubbing. sensory examination of the upper extremity decreased to light touch on the distal tips of the left second and third digits compared to the fifth digit. positive tinel sign. full range of motion of the wrist with no evidence of motor atrophy or muscle loss.,laboratory data: ,wbc 5100, hemoglobin 11.1, hematocrit 32.8, and platelets 200,000. westergren sedimentation rate of 47. urinalysis is negative for protein and blood. lupus serology is pending.,assessment:,1. systemic lupus erythematosus that is chronically stable at this point.,2. carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.,3. upper respiratory infection with cough, cold, and congestion.,recommendations:,1. the patient will have a trial of a resting wrist splint at night for the next 4 to 6 weeks. if there is no improvement, the patient will return for corticosteroid injection of her carpal tunnel.,2. azithromycin 5-day dose pack.,3. robitussin cough and cold flu to be taken twice a day.,4. atarax 25 mg at bedtime for sleep.,5. the patient will return to the rheumatology clinic for a routine followup evaluation in 4 months.

past medical hx: , significant for asthma, pneumonia, and depression.,past surgical hx: , none.,medications:, prozac 20 mg q.d. she desires to be on the nuvaring.,allergies:, lactose intolerance.,social hx: , she denies smoking or alcohol or drug use.,pe:, vitals: stable. weight: 114 lb. height: 5 feet 2 inches. general: well-developed, well-nourished female in no apparent distress. heent: within normal limits. neck: supple without thyromegaly. heart: regular rate and rhythm. lungs: clear to auscultation. abdomen: soft and nontender. there is no rebound or guarding. no palpable masses and no peritoneal signs. extremities: within normal limits. skin: warm and dry. gu: external genitalia is without lesion. vaginal is clean without discharge. cervix appears normal; however, a colposcopy was performed using acetic acid, which showed a thick acetowhite ring around the cervical os and extending into the canal. bimanual: reveals significant cervical motion tenderness and fundal tenderness. she had no tenderness in her adnexa. there are no palpable masses.,a:, although unlikely based on the patient's exam and pain, i have to consider subclinical pelvic inflammatory disease. gc and chlamydia was sent and i treated her prophylactically with rocephin 250 mg and azithromycin 1000 mg. repeat biopsies were not performed based on her colposcopy as well as her previous pap and colposcopy by dr. a. a leep is a reasonable approach even in this 16-year-old.,p:, we will schedule leep in the near future. even though she has already been exposed hpv gardasil would still be beneficial in this patient to help prevent recurrence of low-grade lesions as well as high-grade lesions. now, we have her given her first shot.

preoperative diagnosis: , symptomatic pericardial effusion.,postoperative diagnosis: , symptomatic pericardial effusion.,procedure performed:, subxiphoid pericardiotomy.,anesthesia:, general via et tube.,estimated blood loss: , 50 cc.,findings:, this is a 70-year-old black female who underwent a transhiatal esophagectomy in november of 2003. she subsequently had repeat chest x-rays and ct scans and was found to have a moderate pericardial effusion. she had the appropriate inflammatory workup for pericardial effusion, however, it was nondiagnostic. also, during that time, she had become significantly more short of breath. a dobutamine stress echocardiogram was performed, which was negative with the exception of the pericardial effusions. she had no tamponade physiology.,indication for the procedure: , for therapeutic and diagnostic management of this symptomatic pericardial effusion. risks, benefits, and alternative measures were discussed with the patient. consent was obtained for the above procedure.,procedure: , the patient was prepped and draped in the usual sterile fashion. a 4 cm incision was created in the midline above the xiphoid. dissection was carried down through the fascia and the xiphoid was resected. the sternum was retracted superiorly the pericardium was identified and pericardial fat was cleared off the pericardium. an #0 silk suture was then placed into the pericardium with care taken not to enter the underlying heart.,this suture was used to retract the pericardium and the pericardium was nicked with #15 blade under direct visualization. serous fluid exited through the pericardium and was sent for culture, cytology, and cell count etc. a section of pericardium was taken approximately 2 cm x 2 cm x 2 cm and was removed. the heart was visualized and appeared to be contracting well with no evidence of injury to the heart. the pericardium was then palpated. there was no evidence of studding. a right angle chest tube was then placed in the pericardium along the diaphragmatic of the pericardium and then brought out though a small skin incision in the epigastrium. it was sewn into place with #0 silk suture. there was some air leak of the left pleural cavity, so a right angle chest tube was placed in the left pleural cavity and brought out through a skin nick in the epigastrium. it was sewn in the similar way to the other chest tube. once again, the area was inspected and found to be hemostatic and then closed with #0 vicryl suture for fascial stitch, then #3-0 vicryl suture in the subcutaneous fat, and then #4-0 undyed vicryl in a running subcuticular fashion. the patient tolerated the procedure well. chest tubes were placed on 20 cm of water suction. the patient was taken to pacu in stable condition.

exam:, noncontrast ct scan of the lumbar spine,reason for exam: , left lower extremity muscle spasm.,comparisons: , none.,findings: , transaxial thin slice ct images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.,no abnormal paraspinal masses are identified.,there are sclerotic changes with anterior effusion of the sacroiliac joints bilaterally.,there is marked intervertebral disk space narrowing at the l5-s1 level with intervertebral disk vacuum phenomenon and advanced endplate degenerative changes. posterior disk osteophyte complex is present, most marked in the left paracentral to lateral region extending into the lateral recess on the left. this most likely will affect the s1 nerve root on the left. there are posterior hypertrophic changes extending into the neural foramina bilaterally inferiorly. there is mild neural foraminal stenosis present. small amount of extruded disk vacuum phenomenon is present on the left in the region of the exiting nerve root. there is facet sclerosis bilaterally. mild lateral recess stenosis just on the right, there is prominent anterior spondylosis.,at the l4-5 level, mild bilateral facet arthrosis is present. there is broad based posterior annular disk bulging or protrusion, which mildly effaces the anterior aspect of the thecal sac and extends into the inferior aspect of the neural foramina bilaterally. no moderate or high-grade central canal or neural foraminal stenosis is identified.,at the l3-4 level anterior spondylosis is present. there are endplate degenerative changes with mild posterior annular disk bulging, but no evidence of moderate or high-grade central canal or neural foraminal stenosis.,at the l2-3 level, there is mild bilateral ligamentum flavum hypertrophy. mild posterior annular disk bulging is present without evidence of moderate or high-grade central canal or neural foraminal stenosis.,at the t12-l1 and l1-2 levels, there is no evidence of herniated disk protrusion, central canal, or neural foraminal stenosis.,there is arteriosclerotic vascular calcification of the abdominal aorta and iliac arteries without evidence of aneurysm or dilatation. no bony destructive changes or acute fractures are identified.,conclusions:,1. advanced degenerative disk disease at the l5-s1 level.,2. probable chronic asymmetric herniated disk protrusion with peripheral calcification at the l5-s1 level, laterally in the left paracentral region extending into the lateral recess causing lateral recess stenosis.,3. mild bilateral neural foraminal stenosis at the l5-s1 level.,4. posterior disk bulging at the l2-3, l3-4, and l4-5 levels without evidence of moderate or high-grade central canal stenosis.,5. facet arthrosis to the lower lumbar spine.,6. arteriosclerotic vascular disease.

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

preprocedure diagnosis: , complete heart block.,postprocedure diagnosis: ,complete heart block.,procedures planned and performed,1. implantation of a dual-chamber pacemaker.,2. fluoroscopic guidance for implantation of a dual-chamber pacemaker.,fluoroscopy time: , 2.6 minutes.,medications at the time of study,1. versed 2.5 mg.,2. fentanyl 150 mcg.,3. benadryl 50 mg.,clinical history: , the patient is a pleasant 80-year-old female who presented to the hospital with complete heart block. she has been referred for a pacemaker implantation.,risks and benefits: , risks, benefits, and alternatives to implantation of a dual-chamber pacemaker were discussed with the patient. the patient agreed both verbally and via written consent.,description of procedure: , the patient was transported to the cardiac catheterization laboratory in the fasting state. the region of the left deltopectoral groove was prepped and draped in the usual sterile manner. lidocaine 1% (20 ml) was administered to the area. after achieving appropriate anesthesia, percutaneous access of the left axillary vein was then performed under fluoroscopy. a guide wire was advanced into the vein. following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath. hemostasis was achieved with electrocautery. lidocaine 1% (10 ml) was then administered to the medial aspect of the incision. a pocket was then fashioned in the medial direction. using the previously placed wire, a 7-french side-arm sheath was advanced over the wire into the left axillary vein. the dilator was then removed over the wire. a second wire was then advanced into the sheath into the left axillary vein. the sheath was then removed over the top of the two wires. one wire was then pinned to the drape. using the remaining wire, a 7 french side-arm sheath was advanced back into the left axillary vein. the dilator and wire were removed. a passive pacing lead was then advanced down into the right atrium. the peel-away sheath was removed. the lead was then passed across the tricuspid valve and positioned in the apical location. adequate pacing and sensing functions were established. suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. with the remaining wire, a 7-french side-arm sheath was advanced over the wire into the axillary vein. the wire and dilating sheaths were removed. an active pacing lead was then advanced down into the right atrium. the peel-away sheath was removed. preformed j stylet was then advanced into the lead. the lead was positioned in the appendage location. lead body was then turned, and the active fix screw was fixed to the tissue. adequate pacing and sensing function were established. suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. the pocket was then washed with antibiotic-impregnated saline. pulse generator was obtained and connected securely to the leads. the leads were then carefully wrapped behind the pulse generator, and the entire system was placed in the pocket. the pocket was then closed with 2-0, 3-0, and 4-0 vicryl using a running mattress stitch. sponge and needle counts were correct at the end of the procedure. no acute complications were noted.,device data,1. pulse generator, manufacturer boston scientific, model # 12345, serial #1234.,2. right atrial lead, manufacturer guidant, model #12345, serial #1234.,3. right ventricular lead, manufacturer guidant, model #12345, serial #1234.,measured intraoperative data,1. right atrial lead impedance 534 ohms. p waves measured at 1.2 millivolts. pacing threshold 1.0 volt at 0.5 milliseconds.,2. right ventricular lead impedance 900 ohms. r-waves measured 6.0 millivolts. pacing threshold 1.0 volt at 0.5 milliseconds.,device settings: , ddd 60 to 130.,conclusions,1. successful implantation of a dual-chamber pacemaker with adequate pacing and sensing function.,2. no acute complications.,plan,1. the patient will be taken back to her room for continued observation. she can be dismissed in 24 hours provided no acute complications at the discretion of the primary service.,2. chest x-ray to rule out pneumothorax and verified lead position.,3. completion of the course of antibiotics.,4. home dismissal instructions provided in written format.,5. device interrogation in the morning.,6. wound check in 7 to 10 days.,7. enrollment in device clinic.

preoperative diagnoses:,1. enlarging dark keratotic lesion of the left temple measuring 1 x 1 cm.,2. enlarging keratotic neoplasm of the left nasolabial fold measuring 0.5 x 0.5 cm.,3. enlarging seborrheic keratotic neoplasm of the right temple measuring 1 x 1 cm.,postoperative diagnoses:,1. enlarging dark keratotic lesion of the left temple measuring 1 x 1 cm.,2. enlarging keratotic neoplasm of the left nasolabial fold measuring 0.5 x 0.5 cm.,3. enlarging seborrheic keratotic neoplasm of the right temple measuring 1 x 1 cm.,title of procedures:,1. excision of the left temple keratotic neoplasm, final defect 1.8 x 1.5 cm with two layer plastic closure.,2. excision of the left nasolabial fold defect 0.5 x 0.5 cm with single layer closure.,3. excision of the right temple keratotic neoplasm, final defect measuring 1.5 x 1.5 cm with two layer plastic closure.,anesthesia: , local using 3 ml of 1% lidocaine with 1:100,000 epinephrine.,estimated blood loss: , less than 30 ml.,complications:, none.,procedure: , the patient was evaluated preoperatively and noted to be in stable condition. informed consent was obtained from the patient. all risks, benefits and alternatives regarding the surgery have been reviewed in detail with the patient. this includes risks of bleeding, infection, scarring, recurrence of lesion, need for further procedures, etc. each of the areas was cleaned with a sterile alcohol swab. planned excision site was marked with a marking pen. local anesthetic was infiltrated. sterile prep and drape were then performed.,we began first with excision of the left temple followed by the left nasolabial and right temple lesions. the left temple lesion is noted to be a dark black what appears to be a keratotic or possible seborrheic keratotic neoplasm. however, it is somewhat deeper than the standard seborrheic keratosis. the incision for removal of this lesion was placed within the relaxed skin tension line of the left temple region. once this was removed, wide undermining was performed and the wound was closed in a two layer fashion using 5-0 myochromic for the deep subcutaneous and 5-0 nylon for the skin.,excision of left cheek was a keratotic nevus. it was excised with a defect 0.5 x 0.5 cm. it was closed in a single layer fashion 5-0 nylon.,the lesion of the right temple also dark black keratotic neoplasm was excised with the incision placed within the relaxed skin tension. once it was excised full-thickness, the defect measure 1.5 x 1.5 cm. wide undermine was performed and it was closed in a two layer fashion using 5-0 myochromic for the deep subcutaneous, 5-0 nylon that was used to close skin. sterile dressing was applied afterwards. the patient was discharged in stable condition. postop care instructions reviewed in detail. she is scheduled with me in one week and we will make further recommendations at that time.

chief complaint:, a 2-month-old female with 1-week history of congestion and fever x2 days.,history of present illness:, the patient is a previously healthy 2-month-old female, who has had a cough and congestion for the past week. the mother has also reported irregular breathing, which she describes as being rapid breathing associated with retractions. the mother states that the cough is at times paroxysmal and associated with posttussive emesis. the patient has had short respiratory pauses following the coughing events. the patient's temperature has ranged between 102 and 104. she has had a decreased oral intake and decreased wet diapers. the brother is also sick with uri symptoms, and the patient has had no diarrhea. the mother reports that she has begun to regurgitate after her feedings. she did not do this previously.,medications: , none.,smoking exposure: , none.,immunizations: , none.,diet: ,similac 4 ounces every 2 to 3 hours.,allergies:, no known drug allergies.,past medical history: ,the patient delivered at term. birth weight was 6 pounds 1 ounce. postnatal complications: neonatal jaundice. the patient remained in the hospital for 3 days. the in utero ultrasounds were reported to be normal.,prior hospitalizations: , none.,family/social history: , family history is positive for asthma and diabetes. there is also positive family history of renal disease on the father's side of the family.,development: , normal. the patient tests normal on the newborn hearing screen.,review of systems: general: , the patient has had fever, there have been no chills. skin: no rashes. heent: mild congestion x1 week. cough, at times paroxysmal, no cyanosis. the patient turns red in the face during coughing episodes, posttussive emesis. cardiovascular: no cyanosis. gi: posttussive emesis, decreased oral intake. gu: decreased urinary output. ortho: no current issues. neurologic: no change in mental status. endocrine: there is no history of weight loss. development: no loss of developmental milestones.,physical examination: ,vital signs: weight is 4.8 kg, temperature 100.4, heart rate is 140, respiratory rate 30, and saturations 100%.,general: this is a well-appearing infant in no acute distress.,heent: shows anterior fontanelle to be open and flat. pupils are equal and reactive to light with red reflex. nares are patent. oral mucosa is moist. posterior pharynx is clear. hard palate is intact. normal gingiva.,heart: regular rate and rhythm without murmur.,lungs: a few faint rales. no retractions. no stridor. no wheezing on examination. mild tachypnea.,extremities: warm, good perfusion. no hip clicks.,neurologic: the patient is alert. normal tone throughout. deep tendon reflexes are 2+/4. no clonus.,skin: normal.,laboratory data:, cbc shows a white count of 12.4, hemoglobin 10.1, platelet count 611,000; 38 segs 3 bands, 42 lymphocytes, and 10 monocytes. electrolytes were within normal limits. c-reactive protein 0.3. chest x-ray shows no acute disease with the exception of a small density located in the retrocardiac area on the posterior view. ua shows 10 to 25 bacteria.,assessment/plan: ,this is a 2-month-old, who presents with fever, paroxysmal cough and episodes of respiratory distress. the patient is currently stable in the emergency room. we will admit the patient to the pediatric floor. we will send out pertussis pcr. we will also follow results of urine culture and that the urine dip shows 10 to 25 bacteria. the patient will be followed up for signs of sepsis, apnea, urinary tract infection, and pneumonia. we will wait for a radiology reading on the chest x-ray to determine if the density seen on the lateral film is a normal variant or represents pathology.