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reason for exam: ,left arm and hand numbness.,technique: , noncontrast axial ct images of the head were obtained with 5 mm slice thickness.,findings: ,there is an approximately 5-mm shift of the midline towards the right side. significant low attenuation is seen throughout the white matter of the right frontal, parietal, and temporal lobes. there is loss of the cortical sulci on the right side. these findings are compatible with edema. within the right parietal lobe, a 1.8 cm, rounded, hyperintense mass is seen.,no hydrocephalus is evident.,the calvarium is intact. the visualized paranasal sinuses are clear.,impression: ,a 5 mm midline shift to the left side secondary to severe edema of the white matter of the right frontal, parietal, and temporal lobes. a 1.8 cm high attenuation mass in the right parietal lobe is concerning for hemorrhage given its high density. a postcontrast mri is required for further characterization of this mass. gradient echo imaging should be obtained.

history: ,this 15-day-old female presents to children's hospital and transferred from hospital emergency department for further evaluation. information is obtained in discussion with the mother and the grandmother in review of previous medical records. this patient had the onset on the day of presentation of a jelly-like red-brown stool started on tuesday morning. then, the patient was noted to vomit after feeds. the patient was evaluated at hospital with further evaluation with laboratory data showing a white blood cell count elevated at 22.2; hemoglobin 14.1; sodium 138; potassium 7.2, possibly hemolyzed; chloride 107; co2 23; bun 17; creatinine 1.2; and glucose of 50, which was repeated and found to be stable in that range. the patient underwent a barium enema, which was read by the radiologist as negative. the patient was transferred to children's hospital for further evaluation after being given doses of ampicillin, cefotaxime, and rocephin.,past medical history: , further, the patient was born in hospital. birth weight was 6 pounds 4 ounces. there was maternal hypertension. mother denies group b strep or herpes. otherwise, no past medical history.,immunizations: , none today.,medications: , thrush medicine identified as nystatin.,allergies: , denied.,past surgical history: , denied.,social history: ,here with mother and grandmother, lives at home. there is no smoking at home.,family history: , none noted exposures.,review of systems: ,the patient is fed enfamil, bottle-fed. has had decreased feeding, has had vomiting, has had diarrhea, otherwise negative on the 10 plus systems reviewed.,physical examination:,vital signs/general: on physical examination, the initial temperature 97.5, pulse 140, respirations 48 on this 2 kg 15-day-old female who is small, well-developed female, age appropriate.,heent: head is atraumatic and normocephalic with a soft and flat anterior fontanelle. pupils are equal, round, and reactive to light. grossly conjugate. bilateral red reflex appreciated bilaterally. clear tms, nose, and oropharynx. there is a kind of abundant thrush and white patches on the tongue.,neck: supple, full, painless, and nontender range of motion.,chest: clear to auscultation, equal, and stable.,heart: regular without rubs or murmurs, and femoral pulses are appreciated bilaterally.,abdomen: soft and nontender. no hepatosplenomegaly or masses.,genitalia: female genitalia is present on a visual examination.,skin: no significant bruising, lesions, or rash.,extremities: moves all extremities, and nontender. no deformity.,neurologically: eyes open, moves all extremities, grossly age appropriate.,medical decision making: , the differential entertained on this patient includes upper respiratory infection, gastroenteritis, urinary tract infection, dehydration, acidosis, and viral syndrome. the patient is evaluated in the emergency department laboratory data, which shows a white blood cell count of 13.1, hemoglobin 14.0, platelets 267,000, 7 stabs, 68 segs, 15 lymphs, and 9 monos. serum electrolytes not normal. sodium 138, potassium 5.0, chloride 107, co2 acidotic at 18, glucose normal at 88, and bun markedly elevated at 22 as is the creatinine of 1.4. ast and alt were elevated as well at 412 and 180 respectively. a cath urinalysis showing no signs of infection. spinal fluid evaluation, please see procedure note below. white count 0, red count 2060. gram stain negative.,procedure note: , after discussion of the risks, benefits, and indications, and obtaining informed consent with the family and their agreement to proceed, this patient was placed in the left lateral position and using aseptic betadine preparation, sterile draping, and sterile technique pursued throughout, this patient's l4- l5 interspace was anesthetized with the 1% lidocaine solution following the above sterile preparation, entered with a 22-gauge styletted spinal needle of approximately 0.5 ml clear csf, they were very slow to obtain. the fluid was obtained, the needle was removed, and sterile bandage was placed. the fluid was sent to laboratory for further evaluation (aunt and grandmother) were present throughout the period of time during this procedure and the procedure was tolerated well. an i-stat initially obtained showed somewhat of an acidosis with a base excess of -12. a repeat i-stat after a bolus of normal saline and a second bolus of normal saline, her maintenance rate of d5 half showed a base excess of -11, which is slowly improving, but not very fast. based on the above having this patient consulted to the hospitalist service at 2326 hours of request, this patient was consulted to picu with the plan that the patient need to have continued iv fluids. showing signs of dehydration, a third bolus of normal saline was provided, twice maintenance d5 half was continued. the patient was admitted to the hospitalist service for continued iv fluids. the patient maintains to have clear lungs, has been feeding well here in the department, took virtually a whole small bottle of the appropriate formula. she has not had any vomiting, is burping. the patient is admitted for continued close observation and rehydration due to the working diagnoses of gastroenteritis, metabolic acidosis, and dehydration. critical care time on this patient is less than 30 minutes, exclusive, otherwise time has been spent evaluating this patient according to this patient's care and admission to the hospitalist service.

the right eardrum is intact showing a successful tympanoplasty. i cleaned a little wax from the external meatus. the right eardrum might be very slightly red but not obviously infected. the left eardrum (not the surgical ear) has a definite infection with a reddened bulging drum but no perforation or granulation tissue. also some wax at the external meatus i cleaned with a q-tip with peroxide. the patient has no medical allergies. since he recently had a course of omnicef we chose to put him on augmentin (i checked and we did not have samples), so i phoned in a two-week course of augmentin 400 mg chewable twice daily with food at walgreens. i looked at this throat which looks clear. the nose only has a little clear mucinous secretions. if there is any ear drainage, please use the floxin drops. i asked mom to have the family doctor (or dad, or me) check the ears again in about two weeks from now to be sure there is no residual infection. i plan to see the patient again later this spring.

history of present illness:, patient is a 76-year-old white male who presents with his wife stating that he was stung by a bee on his right hand, left hand, and right knee at approximately noon today. he did not note any immediate reaction. since that time, he has noted some increasing redness and swelling to his left hand, but he denies any generalized symptoms such as itching, hives, or shortness of breath. he denies any sensation of tongue swelling or difficulty swallowing.,the patient states he was stung approximately one month ago without any serious reaction. he did windup taking benadryl at that time. he has not taken anything today for his symptoms, but he is on hydrochlorothiazide and metoprolol for hypertension as well as a baby aspirin each day.,allergies: , he does have medication intolerances to sulfa drugs (headache), morphine (nausea and vomiting), and toradol (ulcer).,social history: , patient is married and is a nonsmoker and lives with his wife, who is here with him.,nursing notes were reviewed with which i agree.,physical examination,vital signs: temp and vital signs are all within normal limits.,general: in general, the patient is an elderly white male who is sitting on the stretcher in no acute distress.,heent: head is normocephalic and atraumatic. the face shows no edema. the tongue is not swollen and the airway is widely patent.,neck: no stridor.,heart: regular rate and rhythm without murmurs, rubs, or gallops.,lungs: clear without rales, rhonchi, or wheezes.,extremities: upper extremities, there is some edema and erythema to the dorsum of the left hand in the region of the distal third to fifth metacarpals. there was some slight edema of the fourth digit, on which he still is wearing his wedding band. the right hand shows no reaction. the right knee is not swollen either.,the left fourth digit was wrapped in a rubber tourniquet to express the edema and using some surgilube, i was able to remove his wedding band without any difficulty. patient was given claritin 10 mg orally for what appears to be a simple local reaction to an insect sting. i did explain to him that his swelling and redness may progress over the next few days.,assessment: , local reaction secondary to insect sting.,plan: , the patient was reassured that this is not a serious reaction to an insect sting and he should not progress to such a reaction. i did urge him to use claritin 10 mg once daily until the redness and swelling has gone. i did explain that the swelling may worsen over the next two to three days, it may produce a large local reaction, but that anti-histamines were still the mainstay of therapy for such a reaction. if he is not improved in the next four days, follow up with his pcp for a re-exam.

chief complaint:, weak and shaky.,history of present illness:, the patient is a 75-year-old, caucasian female who comes in today with complaint of feeling weak and shaky. when questioned further, she described shortness of breath primarily with ambulation. she denies chest pain. she denies cough, hemoptysis, dyspnea, and wheeze. she denies syncope, presyncope, or palpitations. her symptoms are fairly longstanding but have been worsening as of late.,past medical history:, she has had a fairly extensive past medical history but is a somewhat poor historian and is unable to provide details about her history. she states that she has underlying history of heart disease but is not able to elaborate to any significant extent. she also has a history of hypertension and type ii diabetes but is not currently taking any medication. she has also had a history of pulmonary embolism approximately four years ago, hyperlipidemia, peptic ulcer disease, and recurrent urinary tract infections. surgeries include an appendectomy, cesarean section, cataracts, and hernia repair.,current medications:, she is on two different medications, neither of which she can remember the name and why she is taking it.,allergies: , she has no known medical allergies.,family history:, remarkable for coronary artery disease, stroke, and congestive heart failure.,social history:, she is a widow, lives alone. denies any tobacco or alcohol use.,review of systems:, dyspnea on exertion. no chest pain or tightness, fever, chills, sweats, cough, hemoptysis, or wheeze, or lower extremity swelling.,physical examination:,general: she is alert but seems somewhat confused and is not able to provide specific details about her past history.,vital signs: blood pressure: 146/80. pulse: 68. weight: 147 pounds.,heent: unremarkable.,neck: supple without jvd, adenopathy, or bruit.,chest: clear to auscultation.,cardiovascular: regular rate and rhythm.,abdomen: soft.,extremities: no edema.,laboratory:, o2 sat 100% at rest and with exertion. electrocardiogram was normal sinus rhythm. nonspecific s-t segment changes. chest x-ray pending.,assessment/plan:,1. dyspnea on exertion, uncertain etiology. mother would be concerned about the possibility of coronary artery disease given the patient’s underlying risk factors. we will have the patient sign a release of records so that we can review her previous history. consider setting up for a stress test.,2. hypertension, blood pressure is acceptable today. i am not certain as to what, if the patient’s is on any antihypertensive agents. we will need to have her call us what the names of her medications, so we can see exactly what she is taking.,3. history of diabetes. again, not certain as to whether the patient is taking anything for this particular problem when she last had a hemoglobin a1c. i have to obtain some further history and review records before proceeding with treatment recommendations.

nuclear medicine hepatobiliary scan,reason for exam: , right upper quadrant pain.,comparisons: ,ct of the abdomen dated 02/13/09 and ultrasound of the abdomen dated 02/13/09.,radiopharmaceutical 6.9 mci of technetium-99m choletec.,findings:, imaging obtained up to 30 minutes after the injection of radiopharmaceutical shows a normal hepatobiliary transfer time. there is normal accumulation within the gallbladder.,after the injection of 2.1 mcg of intravenous cholecystic _______, the gallbladder ejection fraction at 30 minutes was calculated to be 32% (normal is greater than 35%). the patient experienced 2/10 pain at 5 minutes after the injection of the radiopharmaceutical and the patient also complained of nausea.,impression:,1. negative for acute cholecystitis or cystic duct obstruction.,2. gallbladder ejection fraction just under the lower limits of normal at 32% that can be seen with very mild chronic cholecystitis.

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

medical problem list:,1. status post multiple cerebrovascular accidents and significant left-sided upper extremity paresis in 2006.,2. dementia and depression.,3. hypertension.,4. history of atrial fibrillation. the patient has been in sinus rhythm as of late. the patient is not anticoagulated due to fall risk.,5. glaucoma.,6. degenerative arthritis of her spine.,7. gerd.,8. hypothyroidism.,9. chronic rhinitis (the patient declines nasal steroids).,10. urinary urge incontinence.,11. chronic constipation.,12. diabetes type ii, 2006.,13. painful bunions on feet bilaterally.,current medicines: , aspirin 81 mg p.o. daily, cymbalta 60 mg p.o. daily, diovan 80 mg p.o. daily, felodipine 5 mg p.o. daily, omeprazole 20 mg daily, toprol-xl 100 mg daily, levoxyl 50 mcg daily, lantus insulin 12 units subcutaneously h.s., simvastatin 10 mg p.o. daily, ayrgel to both nostrils twice daily, senna s 2 tablets twice daily, timoptic 1 drop both eyes twice daily, tylenol 1000 mg 3 times daily, xalatan 0.005% drops 1 drop both eyes at bedtime, and tucks to rectum post bms.,allergies: , no known drug allergies. ace inhibitor may have caused a cough.,code status:, do not resuscitate, healthcare proxy, palliative care orders in place.,diet:, no added salt, no concentrated sweets, thin liquids.,restraints:, none. the patient has declined use of chair check and bed check.,interval history: , overall, the patient has been doing reasonably well. she is being treated for some hemorrhoids, which are not painful for her. there has been a note that she is constipated.,her blood glucoses have been running reasonably well in the morning, perhaps a bit on the high side with the highest of 188. i see a couple in the 150s. however, i also see one that is in the one teens and a couple in the 120s range.,she is not bothered by cough or rib pain. these are complaints, which i often hear about.,today, i reviewed dr. hudyncia's note from psychiatry. depression responded very well to cymbalta, and the plan is to continue it probably for a minimum of 1 year.,she is not having problems with breathing. no neurologic complaints or troubles. pain is generally well managed just with tylenol.,physical examination: , vitals: as in chart. the patient is pleasant and cooperative. she is in no apparent distress. her lungs are clear to auscultation and percussion. heart sounds regular to me. abdomen: soft. extremities without any edema. at the rectum, she has a couple of large hemorrhoids, which are not thrombosed and are not tender.,assessment and plan:,1. hypertension, good control, continue current.,2. depression, well treated on cymbalta. continue.,3. other issues seem to be doing pretty well. these include blood pressure, which is well controlled. we will continue the medicines. she is clinically euthyroid. we check that occasionally. continue tylenol.,4. for the bowels, i will increase the intensity of regimen there. i have a feeling she would not tolerate either the fibercon tablets or metamucil powder in a drink. i will try her on annulose and see how she does with that.

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

indication: ,

reason for visit: , i have been asked to see this 63-year-old man with a dilated cardiomyopathy by dr. x at abcd hospital. he presents with a chief complaint of heart failure.,history of present illness: , in retrospect, he has had symptoms for the past year of heart failure. he feels in general "ok," but is stressed and fatigued. he works hard running 3 companies. he has noted shortness of breath with exertion and occasional shortness of breath at rest. there has been some pnd, but he sleeps on 1 pillow. he has no edema now, but has had some mild leg swelling in the past. there has never been any angina and he denies any palpitations, syncope or near syncope. when he takes his pulse, he notes some irregularity. he follows no special diet. he gets no regular exercise, although he has recently started walking for half an hour a day. over the course of the past year, these symptoms have been slowly getting worse. he gained about 20 pounds over the past year.,there is no prior history of either heart failure or other heart problems.,his past medical history is remarkable for a right inguinal hernia repair done in 1982. he had trauma to his right thumb. there is no history of high blood pressure, diabetes mellitus or heart murmur.,on social history, he lives in san salvador with his wife. he has a lot of stress in his life. he does not smoke, but does drink. he has high school education.,on family history, mother is alive at age 89. father died at 72 of heart attack. he has 2 brothers and 1 sister all of whom are healthy, although the oldest suffered a myocardial infarction. he has 3 healthy girls and 9 healthy grandchildren.,a complete review of systems was performed and is negative aside from what is mentioned in the history of present illness.,medications: , aspirin 81 mg daily and chlordiazepoxide and clidinium - combination pill at 5 mg/2.5 mg 1 tablet daily for stress.,allergies: , denied.,major findings:, on my comprehensive cardiovascular examination, he is 5 feet 8 inches and weighs 231 pounds. his blood pressure is 120/70 in each arm seated. his pulse is 80 beats per minute and regular. he is breathing 1two times per minute and that is unlabored. eyelids are normal. pupils are round and reactive to light. conjunctivae are clear and sclerae are anicteric. there is no oral thrush or central cyanosis. neck is supple and symmetrical without adenopathy or thyromegaly. jugular venous pressure is normal. carotids are brisk without bruits. lungs are clear to auscultation and percussion. the precordium is quiet. the rhythm is regular. the first and second heart sounds are normal. he does have a fourth heart sound and a soft systolic murmur. the precordial impulse is enlarged. abdomen is soft without hepatosplenomegaly or masses. he has no clubbing, cyanosis or peripheral edema. distal pulses are normal throughout both arms and both legs. on neurologic examination, his mentation is normal. his mood and affect are normal. he is oriented to person, place, and time.,data: , his ekg shows sinus rhythm with left ventricular hypertrophy.,a metabolic stress test shows that he was able to exercise for 5 minutes and 20 seconds to 90% of his maximum predicted heart rate. his peak oxygen consumption was 19.7 ml/kg/min, which is consistent with mild cardiopulmonary disease.,laboratory data shows his tsh to be 1.33. his glucose is 97 and creatinine 0.9. potassium is 4.3. he is not anemic. urinalysis was normal.,i reviewed his echocardiogram personally. this shows a dilated cardiomyopathy with ef of 15%. the left ventricular diastolic dimension is 6.8 cm. there are no significant valvular abnormalities.,he had a stress thallium. his heart rate response to stress was appropriate. the thallium images showed no scintigraphic evidence of stress-induced myocardial ischemia at 91% of his maximum age predicted heart rate. there is a fixed small sized mild-to-moderate intensity perfusion defect in the distal inferior wall and apex, which may be an old infarct, but certainly does not account for the degree of cardiomyopathy. we got his post-stress ef to be 33% and the left ventricular cavity appeared to be enlarged. the total calcium score will put him in the 56 percentile for subjects of the same age, gender, and race/ethnicity.,assessments: , this appears to be a newly diagnosed dilated cardiomyopathy, the etiology of which is uncertain.,problems diagnoses: ,1. dilated cardiomyopathy.,2. dyslipidemia.,procedures and immunizations: , none today.,plans: , i started him on an ace inhibitor, lisinopril 2.5 mg daily, and a beta-blocker, carvedilol 3.125 mg twice daily. the dose of these drugs should be up-titrated every 2 weeks to a target dose of lisinopril of 20 mg daily and carvedilol 25 mg twice daily. in addition, he could benefit from a loop diuretic such as furosemide. i did not start this as he is planning to go back home to san salvador tomorrow. i will leave that up to his local physicians to up-titrate the medications and get him started on some furosemide.,in terms of the dilated cardiomyopathy, there is not much further that needs to be done, except for family screening. all of his siblings and his children should have an ekg and an echocardiogram to make sure they have not developed the same thing. there is a strong genetic component of this.,i will see him again in 3 to 6 months, whenever he can make it back here. he does not need a defibrillator right now and my plan would be to get him on the right doses of the right medications and then recheck an echocardiogram 3 months later. if his lv function has not improved, he does have new york heart association class ii symptoms and so he would benefit from a prophylactic icd.,thank you for asking me to participate in his care.,medication changes:, see the above.

interpretation: , mri of the cervical spine without contrast showed normal vertebral body height and alignment with normal cervical cord signal. at c4-c5, there were minimal uncovertebral osteophytes with mild associated right foraminal compromise. at c5-c6, there were minimal diffuse disc bulge and uncovertebral osteophytes with indentation of the anterior thecal sac, but no cord deformity or foraminal compromise. at c6-c7, there was a central disc herniation resulting in mild deformity of the anterior aspect of the cord with patent neuroforamina. mri of the thoracic spine showed normal vertebral body height and alignment. there was evidence of disc generation, especially anteriorly at the t5-t6 level. there was no significant central canal or foraminal compromise. thoracic cord normal in signal morphology. mri of the lumbar spine showed normal vertebral body height and alignment. there is disc desiccation at l4-l5 and l5-s1 with no significant central canal or foraminal stenosis at l1-l2, l2-l3, and l3-l4. there was a right paracentral disc protrusion at l4-l5 narrowing of the right lateral recess. the transversing nerve root on the right was impinged at that level. the right foramen was mildly compromised. there was also a central disc protrusion seen at the l5-s1 level resulting in indentation of the anterior thecal sac and minimal bilateral foraminal compromise.,impression: , overall impression was mild degenerative changes present in the cervical, thoracic, and lumbar spine without high-grade central canal or foraminal narrowing. there was narrowing of the right lateral recess at l4-l5 level and associated impingement of the transversing nerve root at that level by a disc protrusion. this was also seen on a prior study.,

preoperative diagnoses:,1. senile nuclear cataract, left eye.,2. senile cortical cataract, left eye., ,postoperative diagnoses:,1. senile nuclear cataract, left eye.,2. senile cortical cataract, left eye., ,procedures: , phacoemulsification of cataract, extraocular lens implant in left eye., ,lens implant used:, alcon, model sn60wf, power of 22.5 diopters., ,phacoemulsification time:, 1 minute 41 seconds at 44.4% power., ,indications for procedure: , this patient has a visually significant cataract in the affected eye with the best corrected visual acuity under moderate glare conditions worse than 20/40. the patient complains of difficulties with glare in performing activities of daily living.,informed consent:, the risks, benefits and alternatives of the procedure were discussed with the patient in the office prior to scheduling surgery. all questions from the patient were answered after the surgical procedure was explained in detail. the risks of the procedure as explained to the patient include, but are not limited to, pain, infection, bleeding, loss of vision, retinal detachment, need for further surgery, loss of lens nucleus, double vision, etc. alternative of the procedure is to do nothing or seek a second opinion. informed consent for this procedure was obtained from the patient.,operative technique: , the patient was brought to the holding area. previously, an intravenous infusion was begun at a keep vein open rate. after adequate sedation by the anesthesia department (under monitored anesthesia care conditions), a peribulbar and retrobulbar block was given around the operative eye. a total of 10 ml mixture with a 70/30 mixture of 2% xylocaine without epinephrine and 0.75% bupivacaine without epinephrine. an adequate amount of anesthetic was infused around the eye without giving excessive tension to the eye or excessive chemosis to the periorbital area. manual pressure and a honan balloon were placed over the eye for approximately 2 minutes after injection and adequate akinesia and anesthesia was noted. vital sign monitors were detached from the patient. the patient was moved to the operative suite and the same monitors were reattached. the periocular area was cleansed, dried, prepped and draped in the usual sterile manner for ocular surgery. the speculum was set into place and the operative microscope was brought over the eye. the eye was examined. adequate mydriasis was observed and a visually significant cataract was noted on the visual axis.,a temporal clear corneal incision was begun using a crescent blade with an initial groove incision made partial thickness through the temporal clear cornea. then a pocket incision was created without entering the anterior chamber of the eye. two peripheral paracentesis ports were created on each side of the initial incision site. viscoelastic was used to deepen the anterior chamber of the eye. a 2.65 mm keratome was then used to complete the corneal valve incision. a cystitome was bent and created using a tuberculin syringe needle. it was placed in the anterior chamber of the eye. a continuous curvilinear capsulorrhexis was begun. it was completed using o'gawa utrata forceps. a balanced salt solution on the irrigating cannula was placed through the paracentesis port of the eye to affect hydrodissection and hydrodelineation of the lens nucleus. the lens nucleus was noted to be freely mobile in the bag.,the phacoemulsification tip was placed into the anterior chamber of the eye. the lens nucleus was phacoemulsified and aspirated in a divide-and-conquer technique. all remaining cortical elements were removed from the eye using irrigation and aspiration using a bimanual technique through the paracentesis ports. the posterior capsule remained intact throughout the entire procedure. provisc was used to deepen the anterior chamber of the eye. a crescent blade was used to expand the internal aspect of the wound. the lens was taken from its container and inspected. no defects were found. the lens power selected was compared with the surgery worksheet from dr. x's office. the lens was placed in an inserter under provisc. it was placed through the wound, into the capsular bag and extruded gently from the inserter. it was noted to be adequately centered in the capsular bag using a sinskey hook. the remaining viscoelastic was removed from the eye with irrigation an aspiration through the paracentesis side ports using a bimanual technique. the eye was noted to be inflated without overinflation. the wounds were tested for leaks, none were found. five drops dilute betadine solution was placed over the eye. the eye was irrigated. the speculum was removed. the drapes were removed. the periocular area was cleaned and dried. maxitrol ophthalmic ointment was placed into the interpalpebral space. a semi-pressure patch and shield was placed over the eye. the patient was taken to the floor in stable and satisfactory condition, was given detailed written instructions and asked to follow up with dr. x tomorrow morning in the office.

reason for evaluation:,

chief complaint:,1. metastatic breast cancer.,2. enrolled is clinical trial c40502.,3. sinus pain.,history of present illness: , she is a very pleasant 59-year-old nurse with a history of breast cancer. she was initially diagnosed in june 1994. her previous treatments included zometa, faslodex, and aromasin. she was found to have disease progression first noted by rising tumor markers. pet/ct scan revealed metastatic disease and she was enrolled in clinical trial of ctsu/c40502. she was randomized to the ixabepilone plus avastin. she experienced dose-limiting toxicity with the fourth cycle. the ixempra was skipped on day 1 and day 8. she then had a dose reduction and has been tolerating treatment well with the exception of progressive neuropathy. early in the month she had concerned about possible perforated septum. she was seen by ent urgently. she was found to have nasal septum intact. she comes into clinic today for day eight ixempra.,current medications: ,zometa monthly, calcium with vitamin d q.d., multivitamin q.d., ambien 5 mg q.h.s., pepcid ac 20 mg q.d., effexor 112 mg q.d., lyrica 100 mg at bedtime, tylenol p.r.n., ultram p.r.n., mucinex one to two tablets b.i.d., neosporin applied to the nasal mucosa b.i.d. nasal rinse daily.,allergies: ,compazine.,review of systems: , the patient is comfort in knowing that she does not have a septal perforation. she has progressive neuropathy and decreased sensation in her fingertips. she makes many errors when keyboarding. i would rate her neuropathy as grade 2. she continues to have headaches respond to ultram which she takes as needed. she occasionally reports pain in her right upper quadrant as well as right sternum. he denies any fevers, chills, or night sweats. her diarrhea has finally resolved and her bowels are back to normal. the rest of her review of systems is negative.,physical exam:,vitals:

history of present illness: , this 40-year-old white single man was hospitalized at xyz hospital in the mental health ward, issues were filled up by his sister and his mother. the issues involved include the fact that for the last 10 years he has been on disability for psychiatric reasons and has been not working, and in the last several weeks to month he began to call his family talking about the fact that he had been sexually abused by brother. he has been in outpatient therapy with jeffrey silverberg for the past 10 years and mr. silverberg became concerned about his behavior, called the family and told them to have him put in the hospital, and at one point called the police because the patient was throwing cellphones and having tantrums in his office.,the history includes the fact that the patient is the 3rd of 4 children. a brother who is approximately 8 years older, sexually abused brother who is 4 years older. the brother who is 8 years older lives in california and will contact the family, has had minimal contact for many years.,that brother in california is gay. the brother who is 4 years older, sexually abused, the patient from age 8 to 12 on a regular basis. he said, he told his mother several years ago, but she did nothing about it.,the patient finished high school and with some struggle completed college at the university of houston. he has a sister who is approximately a year and half younger than he is, who was sexually abused by the brothers will, but only on one occasion. she has been concerned about patient's behavior and was instrumental in having him committed.,reportedly, the patient ran away from home at the age of 12 or 13 because of the abuse, but was not able to tell his family what happened.,he had no or minimal psychiatric treatment growing up and after completing college worked in retail part time.,he states he injured his back about 10 yeas ago. he told he had disk problems but never had surgery. he subsequently was put on psychiatric disability for depression, states he has been unable to get out of bed at times and isolates and keeps to himself.,he has been on a variety of different medications including celexa 40 mg and add medication different times, and reportedly has used amphetamines in the past, although he denies it at this time. he minimizes any alcohol use which appears not to be a problem, but what does appear to be a problem is he isolates, stays at home, has been in situations where he brings in people he does not know well and he runs the risk of getting himself physically harmed.,he has never been psychiatrically hospitalized before.,mental status examination:, revealed a somewhat disheveled 40-year-old man who was clearly quite depressed and somewhat shocked at his family's commitment. he says he has not seen them on a regular basis because every time he sees them he feels hurt and acknowledged that he called up the brother who abused him and told the brother's wife what had happened. the brother has a child and wife became very upset with him.,normocephalic. pleasant, cooperative, disheveled man with about 37 to 40, thoughts were somewhat guarded. his affect was anxious and depressed and he denied being suicidal, although the family said that he has talked about it at times.,recent past memory were intact.,diagnoses:,axis i: major depression rule out substance abuse.,axis ii: deferred at this time.,axis iii: noncontributory.,axis iv: family financial and social pressures.,axis v: global assessment of functioning 40.,recommendation:, the patient will be hospitalized to assess.,along the issues, the fact that he is been living in disability in the fact that his family has had to support him for all this time despite the fact that he has had a college degree. he says he has had several part time jobs, but never been able to sustain employment, although he would like to.

procedure: , radiofrequency thermocoagulation of bilateral lumbar sympathetic chain.,anesthesia: , local sedation.,vital signs: , see nurse's notes.,complications: , none.,details of procedure: ,int was placed. the patient was in the operating room in the prone position with the back prepped and draped in a sterile fashion. the patient was given sedation and monitored. lidocaine 1.5% for skin wheal was made 10 cm from the midline to the bilateral l2 distal vertebral body. a 20-gauge, 15 cm smk needle was then directed using ap and fluoroscopic guidance so that the tip of the needle was noted to be along the distal one-third and anterior border on the lateral view and on the ap view the tip of the needle was inside the lateral third of the border of the vertebral body. at this time a negative motor stimulation was obtained. injection of 10 cc of 0.5% marcaine plus 10 mg of depo-medrol was performed. coagulation was then carried out for 90oc for 90 seconds. at the conclusion of this, the needle under fluoroscopic guidance was withdrawn approximately 5 mm where again a negative motor stimulation was obtained and the sequence of injection and coagulation was repeated. this was repeated one more time with a 5 mm withdrawal and coagulation.,at that time, attention was directed to the l3 body where the needle was placed to the upper one-third/distal two-thirds junction and the sequence of injection, coagulation, and negative motor stimulation with needle withdrawal one time of a 5 mm distance was repeated. there were no compilations from this. the patient was discharged to operating room recovery in stable condition.

preoperative diagnosis:, cataract, right eye.,postoperative diagnosis:, cataract, right eye.,operation performed: , phacoemulsification with iol, right eye.,anesthesia:, topical with mac.,complications,: none.,estimated blood loss: , none.,procedure in detail: after appropriate consent was obtained, the patient was brought to the operating room and then prepared and draped in the usual sterile fashion per ophthalmology. a lid speculum was placed in the right eye after which a supersharp was used to make a stab incision at the 4 o'clock position through which 2% preservative-free xylocaine was injected followed by viscoat. a 2.75-mm keratome then made a stab incision at the 2 o'clock position through which an anterior capsulorrhexis was performed using cystotome and utrata. bss on blunt cannula, hydrodissector, and spun the nucleus after which phacoemulsification divided the nucleus in 3 quadrants each was subsequently cracked and removed through phacoemulsification i&a. healon was injected into the posterior capsule and a xxx lens was then placed with a shooter into the posterior capsule and rotated into position with i&a, which then removed all remaining cortex as well as viscoelastic material. bss on blunt cannula hydrated all wounds, which were noted to be free of leak and lid speculum was removed. under microscope, the anterior chamber being soft and well formed. pred forte, vigamox, and iopidine were placed in the eye. a shield was placed over the eye. the patient was followed to recovery where he was noted to be in good condition.

operative procedures: , colonoscopy and biopsies, epinephrine sclerotherapy, hot biopsy cautery, and snare polypectomy.,preoperative diagnoses:,1. colon cancer screening.,2. family history of colon polyps.,postoperative diagnoses:,1. multiple colon polyps (5).,2. diverticulosis, sigmoid colon.,3. internal hemorrhoids.,endoscope used: , ec3870lk.,biopsies: ,biopsies taken from all polyps. hot biopsy got applied to one. epinephrine sclerotherapy and snare polypectomy applied to four polyps.,anesthesia: , fentanyl 75 mcg, versed 6 mg, and glucagon 1.5 units iv push in divided doses. also given epinephrine 1:20,000 total of 3 ml.,the patient tolerated the procedure well.,procedure: ,the patient was placed in left lateral decubitus after appropriate sedation. digital rectal examination was done, which was normal. endoscope was introduced and passed through a rather spastic tortuous sigmoid colon with multiple diverticula seen all the way through transverse colon where about 1 cm x 1 cm sessile polyp was seen. it was biopsied and then in piecemeal fashion removed using snare polypectomy after base was infiltrated with epinephrine. pedunculated polyp next to it was hard to see and there was a lot of peristalsis. the scope then was advanced through rest of the transverse colon to ascending colon and cecum. terminal ileum was briefly reviewed, appeared normal and so did cecum after copious amount of fecal material was irrigated out. ascending colon was unremarkable. at hepatic flexure may be proximal transverse colon, there was a sessile polyp about 1.2 cm x 1 cm that was removed in the same manner with a biopsy taken, base infiltrated with epinephrine and at least two passes of snare polypectomy and subsequent hot biopsy cautery removed to hold polypoid tissue, which could be seen. in transverse colon on withdrawal and relaxation with epinephrine, an additional 1 mm to 2 mm sessile polyp was removed by hot biopsy. then in the transverse colon, additional larger polyp about 1.3 cm x 1.2 cm was removed in piecemeal fashion again with epinephrine, sclerotherapy, and snare polypectomy. subsequently pedunculated polyp in distal transverse colon near splenic flexure was removed with snare polypectomy. the rest of the splenic flexure and descending colon were unremarkable. diverticulosis was again seen with almost constant spasm despite of glucagon. sigmoid colon did somewhat hinder the inspection of that area. rectum, retroflexion posterior anal canal showed internal hemorrhoids moderate to large. excess of air insufflated was removed. the endoscope was withdrawn.,plan: , await biopsy report. pending biopsy report, recommendation will be made when the next colonoscopy should be done at least three years perhaps sooner besides and due to multitude of the patient's polyps.

preoperative diagnosis: , left tibial tubercle avulsion fracture.,postoperative diagnosis:, comminuted left tibial tubercle avulsion fracture with intraarticular extension.,procedure:, open reduction and internal fixation of left tibia.,anesthesia: , general. the patient received 10 ml of 0.5% marcaine local anesthetic.,tourniquet time: , 80 minutes.,estimated blood loss:, minimal.,drains: , one jp drain was placed.,complications: , no intraoperative complications or specimens. hardware consisted of two 4-5 k-wires, one 6.5, 60 mm partially threaded cancellous screw and one 45, 60 mm partially threaded cortical screw and 2 washers.,history and physical:, the patient is a 14-year-old male who reported having knee pain for 1 month. apparently while he was playing basketball on 12/22/2007 when he had gone up for a jump, he felt a pop in his knee. the patient was seen at an outside facility where he was splinted and subsequently referred to children's for definitive care. radiographs confirmed comminuted tibial tubercle avulsion fracture with patella alta. surgery is recommended to the grandmother and subsequently to the father by phone. surgery would consist of open reduction and internal fixation with subsequent need for later hardware removal. risks of surgery include the risks of anesthesia, infection, bleeding, changes on sensation in most of the extremity, hardware failure, need for later hardware removal, failure to restore extensor mechanism tension, and need for postoperative rehab. all questions were answered, and father and grandmother agreed to the above plan.,procedure: , the patient was taken to the operating and placed supine on the operating table. general anesthesia was then administered. the patient was given ancef preoperatively. a nonsterile tourniquet was placed on the upper aspect of the patient's left thigh. the patient's extremity was then prepped and draped in the standard surgical fashion. midline incision was marked on the skin extending from the tibial tubercle proximally and extremities wrapped in esmarch. finally, the patient had tourniquet that turned in 75 mmhg. esmarch was then removed. the incision was then made. the patient had significant tearing of the posterior retinaculum medially with proximal migration of the tibial tubercle which was located in the joint there was a significant comminution and intraarticular involvement. we were able to see the underside of the anterior horn of both medial and lateral meniscus. the intraarticular cartilage was restored using two 45 k-wires. final position was checked via fluoroscopy and the corners were buried in the cartilage. there was a large free floating metaphyseal piece that included parts of proximal tibial physis. this was placed back in an anatomic location and fixed using a 45 cortical screw with a washer. the avulsed fragment with the patellar tendon was then fixed distally to this area using a 6.5, 60 mm cancellous screw with a washer. the cortical screw did not provide good compression and fixation at this distal fragment. retinaculum was repaired using 0 vicryl suture as best as possible. the hematoma was evacuated at the beginning of the case as well as the end. the knee was copiously irrigated with normal saline. the subcutaneous tissue was re-approximated using 2-0 vicryl and the skin with 4-0 monocryl. the wound was cleaned, dried, and dressed with steri-strips, xeroform, and 4 x4s. tourniquet was released at 80 minutes. jp drain was placed on the medium gutter. the extremity was then wrapped in ace wrap from the proximal thigh down to the toes. the patient was then placed in a knee mobilizer. the patient tolerated the procedure well. subsequently extubated and taken to the recovery in stable condition.,postop plan: ,the patient hospitalized overnight to decrease swelling and as well as manage his pain. he may weightbear as tolerated using knee mobilizer. postoperative findings relayed to the grandmother. the patient will need subsequent hardware removal. the patient also was given local anesthetic at the end of the case.

history:, the patient presents today for medical management. the patient presents to the office today with complaints of extreme fatigue, discomfort in the chest and the back that is not related to any specific activity. stomach gets upset with pain. she has been off her supplements for four weeks with some improvement. she has loose bowel movements. she complains of no bladder control. she has pain in her hips. the peripheral neuropathy is in both legs, her swelling has increased and headaches in the back of her head.,diagnoses:,1. type ii diabetes mellitus.,2. generalized fatigue and weakness.,3. hypertension.,4. peripheral neuropathy with atypical symptoms.,5. hypothyroidism.,6. depression.,7. long-term use of high-risk medications.,8. postmenopausal age-related symptoms.,9. abdominal pain with nonspecific irritable bowel type symptoms, intermittent diarrhea.,current medications: , her list of medicines is as noted on 04/22/03. there is a morning and evening lift.,past surgical history:, as listed on 04/22/04 along with allergies 04/22/04.,family history: , basically unchanged. her father died of an mi at 65, mother died of a stroke at 70. she has a brother, healthy.,social history: ,she has two sons and an adopted daughter. she is married long term, retired from avon. she is a nonsmoker, nondrinker.,review of systems:,general: certainly at the present time on general exam no fever, sweats or chills and no significant weight change. she is 189 pounds currently and she was 188 pounds in january.,heent: heent, there is no marked decrease in visual or auditory function. ent, there is no change in hearing or epistaxis, sore throat or hoarseness.,respiratory: chest, there is no history of palpitations, pnd or orthopnea. the chest pains are nonspecific, tenderness to palpation has been reported. there is no wheezing or cough reported.,cardiovascular: no pnd or orthopnea. thromboembolic disease history.,gastrointestinal: intermittent symptoms of stomach pain, they are nonspecific. no nausea or vomiting noted. diarrhea is episodic and more related to nerves.,genitourinary: she reports there is generally poor bladder control, no marked dysuria, hematuria or history of stones.,musculoskeletal: peripheral neuropathy and generalized muscle pain, joint pain that are sporadic.,neurological: no marked paralysis, paresis or paresthesias.,skin: no rashes, itching or changes in the nails.,breasts: no report of any lumps or masses.,hematology and immune: no bruising or bleeding-type symptoms.,physical examination:,weight: 189 pounds. bp: 140/80. pulse: 76. respirations: 20. general appearance: well developed, well nourished. no acute distress.,heent: head is normocephalic. ears, nose, and throat, normal conjunctivae. pupils are reactive. ear canals are patent. tms are normal. nose, nares patent. septum midline. oral mucosa is normal in appearance. no tonsillar lesions, exudate or asymmetry. neck, adequate range of motion. no thyromegaly or adenopathy.,chest: symmetric with clear lungs clear to auscultation and percussion.,heart: rate and rhythm is regular. s1 and s2 audible. no appreciable murmur or gallop.,abdomen: soft. no masses, guarding, rigidity, tenderness or flank pain.,gu: no examined.,extremities: no cyanosis, clubbing or edema currently.,skin and integuments: intact. no lesions or rashes.,neurologic: nonfocal to cranial nerve testing ii through xii, motor, sensory, gait and random motion.,additional information, the patient has been off metformin for few months and this is not part of her medication list.,impression:,

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.

preoperative diagnoses,1. a 40 weeks 6 days intrauterine pregnancy.,2. history of positive serology for hsv with no evidence of active lesions.,3. non-reassuring fetal heart tones.,post operative diagnoses,1. a 40 weeks 6 days intrauterine pregnancy.,2. history of positive serology for hsv with no evidence of active lesions.,3. non-reassuring fetal heart tones.,procedures,1. vacuum-assisted vaginal delivery of a third-degree midline laceration and right vaginal side wall laceration.,2. repair of the third-degree midline laceration lasting for 25 minutes.,anesthesia: , local.,estimated blood loss: , 300 ml.,complications: ,none.,findings,1. live male infant with apgars of 9 and 9.,2. placenta delivered spontaneously intact with a three-vessel cord.,disposition: ,the patient and baby remain in the ldr in stable condition.,summary: , this is a 36-year-old g1 woman who was pregnant since 40 weeks 6 days when she was admitted for induction of labor for post dates with favorable cervix. when she was admitted, her cervix was 2.5 cm dilated with 80% effacement. the baby had a -2 station. she had no regular contractions. fetal heart tones were 120s and reactive. she was started on pitocin for labor induction and labored quite rapidly. she had spontaneous rupture of membranes with a clear fluid. she had planned on an epidural; however, she had sudden rapid cervical change and was unable to get the epidural. with the rapid cervical change and descent of fetal head, there were some variable decelerations. the baby was at a +1 station when the patient began pushing. i had her push to get the baby to a +2 station. during pushing, the fetal heart tones were in the 80s and did not recover in between contractions. because of this, i recommended a vacuum delivery for the baby. the patient agreed.,the baby's head was confirmed to be in the right occiput anterior presentation. the perineum was injected with 1% lidocaine. the bladder was drained. the vacuum was placed and the correct placement in front of the posterior fontanelle was confirmed digitally. with the patient's next contraction, the vacuum was inflated and a gentle downward pressure was used to assist with brining the baby's head to a +3 station. the contraction ended. the vacuum was released and the fetal heart tones remained in the, at this time, 90s to 100s. with the patient's next contraction, the vacuum was reapplied and the baby's head was delivered to a +4 station. a modified ritgen maneuver was used to stabilize the fetal head. the vacuum was deflated and removed. the baby's head then delivered atraumatically. there was no nuchal cord. the baby's anterior shoulder delivered after a less than 30 second delay. no additional maneuvers were required to deliver the anterior shoulder. the posterior shoulder and remainder of the body delivered easily. the baby's mouth and nose were bulb suctioned. the cord was clamped x2 and cut. the infant was handed to the respiratory therapist.,pitocin was added to the patient's iv fluids. the placenta delivered spontaneously, was intact and had a three-vessel cord. a vaginal inspection revealed a third-degree midline laceration as well as a right vaginal side wall laceration. the right side wall laceration was repaired with #3-0 vicryl suture in a running fashion with local anesthesia. the third-degree laceration was also repaired with #3-0 vicryl sutures. local anesthesia was used. the capsule was visible, but did not appear to be injured at all. it was reinforced with three separate interrupted sutures and then the remainder of the incision was closed with #3-0 vicryl in the typical fashion.,the patient tolerated the procedure very well. she remains in the ldr with the baby. the baby is vigorous, crying and moving all extremities. he will go to the new born nursery when ready. the total time for repair of the laceration was 25 minutes.

chief complaint: , left flank pain and unable to urinate.,history: , the patient is a 46-year-old female who presented to the emergency room with left flank pain and difficulty urinating. details are in the history and physical. she does have a vague history of a bruised left kidney in a motor vehicle accident. she feels much better today. i was consulted by dr. x.,medications:, ritalin 50 a day.,allergies: , to penicillin.,past medical history: , adhd.,social history:, no smoking, alcohol, or drug abuse.,physical examination: , she is awake, alert, and quite comfortable. abdomen is benign. she points to her left flank, where she was feeling the pain.,diagnostic data: , her cat scan showed a focal ileus in left upper quadrant, but no thickening, no obstruction, no free air, normal appendix, and no kidney stones.,laboratory work: , showed white count 6200, hematocrit 44.7. liver function tests and amylase were normal. urinalysis 3+ bacteria.,impression:,1. left flank pain, question etiology.,2. no evidence of surgical pathology.,3. rule out urinary tract infection.,plan:,1. no further intervention from my point of view.,2. agree with discharge and followup as an outpatient. further intervention will depend on how she does clinically. she fully understood and agreed.

cc:, left sided weakness.,hx:, 74 y/o rhf awoke from a nap at 11:00 am on 11/22/92 and felt weak on her left side. she required support on that side to ambulate. in addition, she felt spoke as though she "was drunk." nevertheless, she was able to comprehend what was being spoken around her. her difficulty with speech completely resolved by 12:00 noon. she was brought to uihc etc at 8:30am on 11/23/92 for evaluation.,meds:, none. ,allergies:, asa/ pcn both cause rash.,pmh:, 1)?htn. 2)copd. 3)h/o hepatitis (unknown type). 4)macular degeneration.,shx:, widowed; lives alone. denied etoh/tobacco/illicit drug use.,fhx:, unremarkable.,exam: , bp191/89 hr68 rr16 37.2c,ms: a & o to person, place and time. speech fluent; without dysarthria. intact naming, comprehension, and repetition.,cn: central scotoma, os (old). mild upper lid ptosis, od (old per picture). lower left facial weakness.,motor: mild left hemiparesis (4+ to 5- strength throughout affected side). no mention of muscle tone in chart.,sensory: unremarkable.,coord: impaired fnf and hks movement secondary to weakness.,station: left pronator drift. no romberg sign seen.,gait: left hemiparetic gait with decreased lue swing.,reflexes: 3/3+ biceps and triceps. 3/3+ patellae. 2/3+ ankles with 3-4beats of non-sustained ankle clonus on left. plantars: left babinski sign; and flexor on right.,general exam: 2/6 sem at left sternal border.,course:, gs, cbc, pt, ptt, ck, esr were within normal limits. abc 7.4/46/63 on room air. ekg showed a sinus rhythm with right bundle branch block. mri brain, 11/23/95, revealed a right pontine pyramidal tract infarction. she was treated with ticlopidine 250mg bid. on 11/26/92, her left hemiparesis worsened. a hct, 11/27/92, was unremarkable. the patient was treated with iv heparin. this was discontinued the following day when her strength returned to that noted on 11/23/95. on 11/27/92, she developed angina and was ruled out for mi by serial ekg and cardiac enzyme studies. carotid duplex showed 0-15% bilateral ica stenosis and antegrade vertebral artery flow bilaterally. transthoracic echocardiogram revealed aortic insufficiency only. transesophageal echocardiogram revealed trivial mitral and tricuspid regurgitation, aortic valvular fibrosis. there was calcification and possible thrombus seen in the descending aorta. cardiology did not feel the later was an indication for anticoagulation. she was discharged home on isordil 20 tid, metoprolol 25mg q12hours, and ticlid 250mg bid.

current medications:, lortab.,previous medical history: , cardiac stent in 2000.,patient's goal: , to eat again by mouth.,study: ,a trial of passy-muir valve was completed to allow the patient to achieve hands-free voicing and also to improve his secretion management. a clinical swallow evaluation was not completed due to the severity of the patient's mucus and lack of saliva control.,the patient's laryngeal area was palpated during a dry swallow and he does have significantly reduced laryngeal elevation and radiation fibrosis. the further evaluate of his swallowing function is safety; a modified barium swallow study needs to be concluded to objectively evaluate his swallow safety, and to rule out aspiration. a trial of neuromuscular electrical stimulation therapy was completed to determine if this therapy protocol will be beneficial and improving the patient's swallowing function and safety.,for his neuromuscular electrical stimulation therapy, the type was bmr with a single mode cycle time is 4 seconds and 12 seconds off with frequency was 60 __________ with a ramp of 2 seconds, phase duration was 220 with an output of 99 milliamps. electrodes were placed on the suprahyoid/submandibular triangle with an upright body position, trial length was 10 minutes. on a pain scale, the patient reported no pain with the electrical stimulation therapy.,findings: ,the patient was able to tolerate a 5-minute placement of the passy-muir valve. he reported no discomfort on the inhalation; however, he felt some resistance on exhalation. instructions were given on care placement and cleaning of the passy-muir valve. the patient was instructed to buildup tolerance over the next several days of his passy-muir valve and to remove the valve at anytime or he is going to be sleeping or napping throughout the day. the patient's voicing did improve with the passy-muir valve due to decreased leakage from his trach secondary to finger occlusion. mucus production also seemed to decrease when the passy-muir was placed.,on the dry swallow during this evaluation, the patient's laryngeal area is reduced and tissues around his larynx and showed radiation fibrosis. the patient's neck range of motion appears to be adequate and within normal limits.,a trial of neuromuscular electrical stimulation therapy:,the patient tolerating the neuromuscular electrical stimulation, we did achieve poor passive response, but these muscles were contracting and the larynx was moving upon stimulation. the patient was able to actively swallow with stimulation approximately 30% of presentation.,diagnostic impression: , the patient with a history of head and neck cancer status post radiation and chemotherapy with radiation fibrosis, which is impeding his swallowing abilities. the patient would benefit from outpatient skilled speech therapy for neuromuscular electrical stimulation for muscle reeducation to improve his swallowing function and safety and he would benefit from a placement of a passy-muir valve to have hands-free communication.,plan of care: , outpatient skilled speech therapy two times a week to include neuromuscular electrical stimulation therapy, passy-muir placement and a completion of the modified barium swallow study.,short-term goals (6 weeks):,1. completion of modified barium swallow study.,2. the patient will coordinate volitional swallow with greater than 75% of the neuromuscular electrical stimulations.,3. the patient will increase laryngeal elevation by 50% for airway protection.,4. the patient will tolerate placement of passy-muir valve for greater than 2 hours during awaking hours.,5. the patient will tolerate therapeutic feedings with the speech and language pathologist without signs and symptoms of aspiration.,6. the patient will decrease mild facial restrictions to the anterior neck by 50% to increase laryngeal movement.,long-term goals (8 weeks):,1. the patient will improve secretion management to tolerable levels.,2. the patient will increase amount and oral consistency of p.o. intake tolerated without signs and symptoms of aspirations.,3. the patient will be able to communicate without using finger occlusion with the assistance of a passy-muir valve.

subjective: , i am following the patient today for immune thrombocytopenia. her platelets fell to 10 on 01/09/07 and shortly after learning of that result, i increased her prednisone to 60 mg a day. repeat on 01/16/07 revealed platelets up at 43. no bleeding problems have been noted. i have spoken with her hematologist who recommends at this point we decrease her prednisone to 40 mg for 3 days and then go down to 20 mg a day. the patient had been on 20 mg every other day at least for a while, and her platelets hovered at least above 20 or so.,physical examination: , vitals: as in chart. the patient is alert, pleasant, and cooperative. she is in no apparent distress. the petechial areas on her legs have resolved.,assessment and plan: , patient with improvement of her platelet count on burst of prednisone. we will decrease her prednisone to 40 mg for 3 days, then go down to 20 mg a day. basically thereafter, over time, i may try to sneak it back a little bit further. she is on medicines for osteoporosis including bisphosphonate and calcium with vitamin d. we will arrange to have a cbc drawn weekly.,

cc: ,rle weakness.,hx: ,this 42y/o rhm was found 2/27/95 slumped over the steering wheel of the fed ex truck he was driving. he was cyanotic and pulseless according to witnesses. emt evaluation revealed him to be in ventricular fibrillation and he was given epinephrine, lidocaine, bretylium and electrically defibrillated and intubated in the field. upon arrival at a local er his cardiac rhythm deteriorated and he required more than 9 counter shocks (defibrillation) at 360 joules per shock, epinephrine and lidocaine. this had no effect. he was then given intracardiac epinephrine and a subsequent electrical defibrillation placed him in atrial fibrillation. he was then taken emergently to cardiac catherization and was found to have normal coronary arteries. he was then admitted to an intensive care unit and required intraortic balloon pump pressure support via the right gorin. his blood pressure gradually improved and his balloon pump was discontinued on 5/5/95. recovery was complicated by acute renal failure and liver failure. initail ck=13,780, the ckmb fraction was normal at 0.8.,on 3/10/95, the patient experienced cp and underwent cardiac catherization. this time he was found to have a single occlusion in the distal lad with association inferior hypokinesis. subsequent ck=1381 and ckmb=5.4 (elevated). the patient was amnestic to the event and for 10 days following the event. he was transferred to uihc for cardiac electrophysiology study.,meds: ,nifedipine, asa, amiodarone, capoten, isordil, tylenol, darvocet prn, reglan prn, coumadin, kcl, slntg prn, caco3, valium prn, nubain prn.,pmh:, hypercholesterolemia.,fhx:, father alive age 69 with h/o tias. mother died age 62 and had chf, a-fib, cad. maternal grandfather died of an mi and had h/o svt. maternal grandmother had h/o svt.,shx: ,married, 7 children, driver for fed ex. denied tobacco/etoh/illicit drug use.,exam: ,bp112/74 hr64 rr16 afebrile.,ms: a&o to person, place and time. euthymic with appropriate affect.,cn: unremarkable.,motor: hip flexion 3/5, hip extension 5/5, knee flexion5/5, knee extension 2/5, plantar flexion, extension, inversion and eversion 5/5. there was full strength thoughout bue.,sensory: decreased pp/vib/lt/temp about anterior aspect of thigh and leg in a femoral nerve distribution.,coord: poor and slowed hks on right due to weakness.,station: no drift or romberg sign.,gait: difficulty bearing weight on rle.,reflexes: 1+/1+ throughout bue. 0/2 patellae. 2/2 archilles. plantar responses were flexor, bilaterally.,course:, mri pelvis, 3/28/95, revealed increased t1 weighted signal within the right iliopsoas suggestive of hematoma. an intra-osseous lipoma was incidentally notice in the right sacrum. neuropsychologic assessment showed moderately compromised anterograde verbal memory, and temporal orientation and retrograde recall were below expectations. these findings were consistent with mesial temporal dysfunction secondary to anoxic injury and were mild in lieu of his history. he underwent implantation of a medtronic internal cardiac difibrillator. his cardiac electrophysiology study found no inducible ventricular tachycardia or fibrillation. he suffered mild to moderate permanent rle weakness, especially involving the quadriceps. his femoral nerve compression had been present to long to warrant decompression. emg/ncv studies revealed severe axonal degeneration.

history:, the patient is a 46-year-old right-handed gentleman with a past medical history of a left l5-s1 lumbar microdiskectomy in 1998 with complete resolution of left leg symptoms, who now presents with a four-month history of gradual onset of right-sided low back pain with pain radiating down into his buttock and posterior aspect of his right leg into the ankle. symptoms are worsened by any activity and relieved by rest. he also feels that when the pain is very severe, he has some subtle right leg weakness. no left leg symptoms. no bowel or bladder changes.,on brief examination, full strength in both lower extremities. no sensory abnormalities. deep tendon reflexes are 2+ and symmetric at the patellas and absent at both ankles. positive straight leg raising on the right.,mri of the lumbosacral spine was personally reviewed and reveals a right paracentral disc at l5-s1 encroaching upon the right exiting s1 nerve root.,nerve conduction studies:, motor and sensory distal latencies, evoked response amplitudes, and conduction velocities are normal in the lower extremities. the right common peroneal f-wave is minimally prolonged. the right tibial h reflex is absent.,needle emg:, needle emg was performed on the right leg, left gastrocnemius medialis muscle, and right lumbosacral paraspinal muscles using a disposable concentric needle. it revealed spontaneous activity in the right gastrocnemius medialis, gluteus maximus, and lower lumbosacral paraspinal muscles. there was evidence of chronic denervation in right gastrocnemius medialis and gluteus maximus muscles.,impression: , this electrical study is abnormal. it reveals an acute right s1 radiculopathy. there is no evidence for peripheral neuropathy or left or right l5 radiculopathy.,results were discussed with the patient and he is scheduled to follow up with dr. x in the near future.

general evaluation: ,twin b,fetal cardiac activity: normal at 166 bpm,fetal lie: longitudinal, to the maternal right.,fetal presentation: cephalic.,placenta: fused, posterior placenta, grade i to ii.,uterus: normal,cervix: closed.,adnexa: not seen,amniotic fluid: afi 5.5cm in a single ap pocket.,biometry:,bpd: 7.9cm consistent with 31weeks, 5 days gestation,hc: 31.1cm consistent with 33 weeks, 3 days gestation,ac: 30.0cm consistent with 34 weeks, 0 days gestation,fl:

procedure:, a 21-channel digital electroencephalogram was performed on a patient in the awake state. per the technician's notes, the patient is taking depakene.,the recording consists of symmetric 9 hz alpha activity. throughout the recording, repetitive episodes of bursts of 3 per second spike and wave activity are noted. the episodes last from approximately1 to 7 seconds. the episodes are exacerbated by hyperventilation.,impression:, abnormal electroencephalogram with repetitive bursts of 3 per second spike and wave activity exacerbated by hyperventilation. this activity could represent true petit mal epilepsy. clinical correlation is suggested.

preoperative diagnoses:,1. radiation cystitis.,2. refractory voiding dysfunction.,3. status post radical retropubic prostatectomy and subsequent salvage radiation therapy.,postoperative diagnoses:,1. radiation cystitis.,2. refractory voiding dysfunction.,3. status post radical retropubic prostatectomy and subsequent salvage radiation therapy.,title of operation: , salvage cystectomy (very difficult due to postradical prostatectomy and postradiation therapy to the pelvis), indiana pouch continent cutaneous diversion, and omental pedicle flap to the pelvis.,anesthesia: , general endotracheal with epidural.,indications: ,this patient is a 65-year-old white male who in 1998 had a radical prostatectomy. he was initially dry without pads and then underwent salvage radiation therapy for rising psa. after that he began with episodes of incontinence as well as urinary retention requiring catheterization. one year ago, he was unable to catheterize and was taken to the operative room and had cystoscopy. he had retained staple removed and a diverticulum identified. there were also bladder stones that were lasered and removed, and he had been incontinent ever since that time. he wears 8 to 10 pads per day, and this has affected his quality of life significantly. i took him to the operating room on january 16, 2008, and found diffuse radiation changes with a small capacity bladder and wide-open bladder neck. we both felt that his lower urinary tract was not rehabilitatable and that a continent cutaneous diversion would solve the number of problems facing him. i felt like if we could remove the bladder safely, then this would also provide a benefit.,findings: , at exploration, there were no gross lesions of the smaller or large bowel. the bladder was predictably sucked into the pelvic sidewall both inferiorly and laterally. the opened bladder, which we were able to remove completely, had a wide-open capacious diverticulum in its very distal segment. because of the previous radiation therapy and a dissection down to the pelvis, i elected to place an omental pedicle flap to provide additional blood supply for healing as well in the pelvis and also under the pubic bone which was exposed inferiorly due to previous surgery and treatment.,procedure in detail: ,the patient was brought to the operative suite and after adequate general endotracheal and epidural anesthesia obtained, placed in the supine position, flexed over the anterosuperior iliac spine, and his abdomen and genitalia were sterilely prepped and draped in the usual fashion. a nasogastric tube was placed as well as radial arterial line. he was given intravenous antibiotics for prophylaxis. a generous midline skin incision was made from the midepigastrium down to the symphysis pubis, deep into the rectus fascia, the rectus muscle separated in the midline, and exploration carried out with the findings described. moist wound towels and a bookwalter retractor were placed for exposure. we began by retracting the bowels by mobilizing the cecum and ascending colon and hepatic flexure and elevating the terminal ileum up to the second and third portion of the duodenum. the ureter was identified as a crisis over the iliac vessels and dissected deep into pelvis and subsequently divided between clips. an identical procedure was performed in the left side with similar findings and the bowels were packed cephalad.,we began then dissecting the bladder away from the pelvic side walls staying medial to both epigastric arteries. this was quite challenging because of the previous radiation therapy and radical prostatectomy. we essentially carved the bladder off of the pelvic sidewall inferiorly as best we could and then we were able to have enough freedom to identify the lateral pedicles, and these were taken between double clips approximately and clipped distally. we then approached things posteriorly and carefully dissected between the __________ and posterior bladder. there was some remnant seminal vesicle on the right as well as both remnant ejaculatory duct and we used this to dissect the longus safe plane anterior to the rectum. we then entered the bladder anteriorly as distal as we could and remove the bladder and what we thought was a bladder neck and this appeared to end in a diverticulum. we then peeled it off the remaining rectum and passed the specimen off the operative field. bladder was irrigated with warm sterile water and a meticulous inspection was made for hemostasis.,we then completely mobilized the omentum off of the proximal transverse colon. this allowed a generous flap to be able to be laid into the pelvis without tension.,we then turned our attention to forming the indiana pouch. i completed the dissection of the right hepatic flexure and the proximal transverse colon and mobilized the omentum off of this portion of the colon. the colon was divided proximal to the middle colic using a gia-80 stapler. i then divided the avascular plane of treves along the terminal ileum and selected a point approximately 15 cm proximal to the ileocecal valve to divide the ileum. the mesentery was then sealed with a ligasure device and divided, and the bowel was divided with a gia-60 stapler. we then performed a side-to-side ileo-transverse colostomy using a gia-80 stapler, closing the open end with a ta 60. the angles were reinforced with silk sutures and the mesenteric closed with interrupted silk sutures.,we then removed the staple line along the terminal ileum, passed a 12-french robinson catheter into the cecal segment, and plicated the ileum with 3 firings of the gia-60 stapler. the ileocecal valve was then reinforced with interrupted 3-0 silk sutures as described by rowland, et al, and following this, passage of an 18-french robinson catheter was associated with the characteristic "pop," indicating that we had adequately plicated the ileocecal valve.,as the patient had had a previous appendectomy, we made an opening in the cecum in the area of the previous appendectomy. we then removed the distal staple line along the transverse colon and aligned the cecal end and the distal middle colic end with two 3-0 vicryl sutures. the bowel segment was then folded over on itself and the reservoir formed with 3 successive applications of the sgia polysorb-75. between the staple lines, vicryl sutures were placed and the defects closed with 3-0 vicryl suture ligatures.,we then turned our attention to forming the ileocolonic anastomosis. the left ureter was mobilized and brought underneath the sigmoid mesentery and brought through the mesentery of the terminal ileum and an end-to-side anastomosis performed with an open technique using interrupted 4-0 vicryl sutures, and this was stented with a cook 8.4-french ureteral stent, and this was secured to the bowel lumen with a 5-0 chromic suture. the right ureter was brought underneath the pouch and placed in a stented fashion with an identical anastomosis. we then brought the stents out through a separate incision cephalad in the pouch and they were secured with a 2-0 chromic suture. a 24-french malecot catheter was placed through the cecum and secured with a chromic suture. the staple lines were then buried with a running 3-0 vicryl two-layer suture and the open end of the pouch closed with a ta 60 polysorb suture. the pouch was filled to 240 cc and noted to be watertight, and the ureteral anastomoses were intact.,we then made a final inspection for hemostasis. the cecostomy tube was then brought out to the right lower quadrant and secured to the skin with silk sutures. we then matured our stoma through the umbilicus. we removed the plug of skin through the umbilicus and delivered the ileal segment through this. a portion of the ileum was removed and healthy, well-vascularized tissue was matured with interrupted 3-0 chromic sutures. we left an 18-french robinson through the stomag and secured this to the skin with silk sutures. the malecot and stents were also secured in a similar fashion.,we matured the stoma to the umbilicus with interrupted chromic stitches. the stitch was brought out to the right upper quadrant and the malecot to the left lower quadrant. a large jp drain was placed in the pelvis dependent to the omentum pedicle flap as well as the indiana pouch.,the rectus fascia was closed with a buried #2 prolene running stitch, tying a new figure-of-eight proximally and distally and meeting in the middle and tying it underneath the fascia. subcutaneous tissue was irrigated with saline and skin was closed with surgical clips. the estimated blood loss was 450 ml, and the patient received no packed red blood cells. the final sponge and needle count were reported to be correct. the patient was awakened and extubated, and taken on stretcher to the recovery room in satisfactory condition.

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

preoperative diagnosis: , achilles tendon rupture, left lower extremity.,postoperative diagnosis: , achilles tendon rupture, left lower extremity.,procedure performed:, primary repair left achilles tendon.,anesthesia: , general.,complications: , none.,estimated blood loss: , minimal.,total tourniquet time: ,40 minutes at 325 mmhg.,position:, prone.,history of present illness: ,the patient is a 26-year-old african-american male who states that he was stepping off a hilo at work when he felt a sudden pop in the posterior aspect of his left leg. the patient was placed in posterior splint and followed up at abc orthopedics for further care.,procedure:, after all potential complications, risks, as well as anticipated benefits of the above-named procedure were discussed at length with the patient, informed consent was obtained. the operative extremity was then confirmed with the patient, the operative surgeon, department of anesthesia, and nursing staff. while in this hospital, the department of anesthesia administered general anesthetic to the patient. the patient was then transferred to the operative table and placed in the prone position. all bony prominences were well padded at this time.,a nonsterile tourniquet was placed on the left upper thigh of the patient, but not inflated at this time. left lower extremity was sterilely prepped and draped in the usual sterile fashion. once this was done, the left lower extremity was elevated and exsanguinated using an esmarch and the tourniquet was inflated to 325 mmhg and kept up for a total of 40 minutes. after all bony and soft tissue land marks were identified, a 6 cm longitudinal incision was made paramedial to the achilles tendon from its insertion proximal. careful dissection was then taken down to the level of the peritenon. once this was reached, full thickness flaps were performed medially and laterally. next, retractor was placed. all neurovascular structures were protected. a longitudinal incision was then made in the peritenon and opened up exposing the tendon. there was noted to be complete rupture of the tendon approximately 4 cm proximal to the insertion point. the plantar tendon was noted to be intact. the tendon was debrided at this time of hematoma as well as frayed tendon. wound was copiously irrigated and dried. most of the ankle appeared that there was sufficient tendon links in order to do a primary repair. next #0 pds on a taper needle was selected and a krackow stitch was then performed. two sutures were then used and tied individually ________ from the tendon. the tendon came together very well and with a tight connection. next, a #2-0 vicryl suture was then used to close the peritenon over the achilles tendon. the wound was once again copiously irrigated and dried. a #2-0 vicryl sutures were then used to close the skin and subcutaneous fashion followed by #4-0 suture in the subcuticular closure on the skin. steri-strips were then placed over the wound and the sterile dressing was applied consisting of 4x4s, kerlix roll, sterile kerlix and a short length fiberglass cast in a plantar position. at this time, the department of anesthesia reversed the anesthetic. the patient was transferred back to hospital gurney to the postanesthesia care unit. the patient tolerated the procedure well. there were no complications.

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

subsequently, the patient developed a moderately severe depression. she was tried on various medications, which caused sweating, nightmares and perhaps other side effects. she was finally put on effexor 25 mg two tablets h.s. and trazodone 100 mg h.s., and has done fairly well, although she still has significant depression.,her daughter brought her in today to be sure that she does not have dementia. there is no history of memory loss. there is no history of focal neurologic symptoms or significant headaches.,the patient's complaints, according to the daughter, include not wanted to go out in public, shamed regarding her appearance (25-pound weight loss over the past year), eating poorly, not doing things unless asked, hiding food to prevent having to eat it, nervousness, and not taking a shower. she has no focal neurologic deficits. she does complain of constipation. she has severe sleep maintenance insomnia and often sleeps only 2 hours before awakening frequently for the rest of the night.,the patient was apparently visiting her daughter in northern california in december 2003. she was taken to her daughter's primary care physician. she underwent vitamin b12 level, rpr, t4 and tsh, all of which were normal.,on 05/15/04, the patient underwent mri scan of the brain. i reviewed the scan in the office today. this shows moderate cortical and central atrophy and also shows mild-to-moderate deep white matter ischemic changes.,past medical history: , the patient has generally been in reasonably good physical health. she did have a "nervous breakdown" in 1975 after the death of her husband. she was hospitalized for several weeks and was treated with ect. this occurred while she was living in korea.,she does not smoke or drink alcoholic beverages. she has had no prior surgeries. there is a past history of hypertension, but this is no longer present.,family history: , negative for dementia. her mother died of a stroke at the age of 62.,physical examination:,vital signs: blood pressure 128/80, pulse 84, temperature 97.4 f, and weight 105 lbs (dressed).,general: well-developed, well-nourished korean female in no acute distress.,head: normocephalic, without evidence of trauma or bruits.,neck: supple, with full range of motion. no spasm or tenderness. carotid pulsations are of normal volume and contour bilaterally without bruits. no thyromegaly or adenopathy.,extremities: no clubbing, cyanosis, edema, or deformity. range of motion full throughout.,neurological examination:,mental status: the patient is awake, alert and oriented to time, place, and person and generally appropriate. she exhibits mild psychomotor retardation and has a flat or depressed affect. she knows the current president of korea and the current president of the united states. she can recall 3 out of 3 objects after 5 minutes. calculations are performed fairly well with occasional errors. there is no right-left confusion, finger agnosia, dysnomia or aphasia.,cranial nerves:,ii:

subjective: , this patient presents to the office today because of some problems with her right hand. it has been going tingling and getting numb periodically over several weeks. she just recently moved her keyboard down at work. she is hoping that will help. she is worried about carpal tunnel. she does a lot of repetitive type activities. it is worse at night. if she sleeps on it a certain way, she will wake up and it will be tingling then she can usually shake out the tingling, but nonetheless it is very bothersome for her. it involves mostly the middle finger, although, she says it also involves the first and second digits on the right hand. she has some pain in her thumb as well. she thinks that could be arthritis.,objective: , weight 213.2 pounds, blood pressure 142/84, pulse 92, respirations 16. general: the patient is nontoxic and in no acute distress. musculoskeletal: the right hand was examined. it appears to be within normal limits and the appearance is similar to the left hand. she has good and equal grip strength noted bilaterally. she has negative tinel's bilaterally. she has a positive phalen's test. the fingers on the right hand are neurovascularly intact with a normal capillary refill.,assessment: ,numbness and tingling in the right upper extremity, intermittent and related to the positioning of the wrist. i suspect carpal tunnel syndrome.,plan: ,the patient is going to use anaprox double strength one pill every 12 hours with food as well as a cock-up wrist splint. we are going to try this for two weeks and if the condition is still present, then we are going to proceed with emg test at that time. she is going to let me know. while she is here, i am going to also get her the blood test she needs for her diabetes. i am noting that her blood pressure is elevated, but improved from the last visit. i also noticed that she has lost a lot of weight. she is working on diet and exercise and she is doing a great job. right now for the blood pressure we are going to continue to observe as she carries forward additional measures in her diet and exercise to lose more weight and i expect the blood pressure will continue to improve.

admission diagnoses:,1. syncope.,2. end-stage renal disease requiring hemodialysis.,3. congestive heart failure.,4. hypertension.,discharge diagnoses:,1. syncope.,2. end-stage renal disease requiring hemodialysis.,3. congestive heart failure.,4. hypertension.,condition on discharge: , stable.,procedure performed: , none.,hospital course: , the patient is a 44-year-old african-american male who was diagnosed with end-stage renal disease requiring hemodialysis three times per week approximately four to five months ago. he reports that over the past month, he has been feeling lightheaded when standing and has had three syncopal episodes during this time with return of consciousness after several minutes. he reportedly had this even while seated and denied overt dizziness. he reports this lightheadedness is made even worse when standing. he has had these symptoms almost daily over the past month. he does report some confusion when he awakens. he reports that he loses consciousness for two to three minutes. denies any bowel or bladder loss, although he reports very little urine output secondary to his end-stage renal disease. he denied any palpitations, warmth, or diaphoresis, which is indicative of vasovagal syncope. there were no witnesses to his syncopal episodes. he also denied any clonic activity and no history of seizures. in the emergency room, the patient was given fluids and orthostatics were checked. at that time, orthostatics were negative; however, due to the fact that fluid had been given before, it is impossible to rule out orthostatic hypotension. the patient presented to the hospital on coreg 12.5 mg b.i.d. and lisinopril 10 mg daily secondary to his hypertension, congestive heart failure with dilated cardiomyopathy and end-stage renal disease. regarding his syncopal episodes, he was admitted with likely orthostatic hypotension. cardiology was consulted and their recommendations were to reduce the lisinopril to 5 mg daily. at that time, the coreg had been held secondary to hypotension. cardiology also ordered a nuclear medicine myocardial perfusion stress test. regarding the end-stage renal disease, nephrology was consulted as the patient was due for hemodialysis treatment the day following admission. nephrology was able to perform dialysis on the patient and renal concurred that the presyncopal symptoms were likely due to decreased intravascular volume in the postdialytic time frame. renal agreed with decreasing his lisinopril to 5 mg daily and decreasing the coreg to 6.25 mg b.i.d. they reported that the procrit should be continued. as previously indicated regarding the dilated cardiomyopathy, cardiology ordered a nuclear medicine stress test to be performed. also, regarding the patient's hypertension, he actually was noted to have hypotension on admission, and as previously stated, the coreg was originally discontinued and then it was restarted at 6.25 mg b.i.d. and the patient tolerated this well. the patient's hospital course remained uncomplicated until september 17, 2007, the day the nuclear medicine stress test was scheduled. the patient stated that he was reluctant to proceed with the test and he was afraid of needles and the risks associated with the test although the procedure was explained to the patient and the risks of the procedure were quit low, the patient proceeded to discharge himself against medical advice.,discharge instructions/medications:,the patient left ama. no specific discharge instructions and medications were given. at the time of the patient leaving ama, his medications were as follows:,1. aspirin 81 mg p.o. daily.,2. multivitamin, nephrocaps one cap p.o. daily.,3. fosrenol 500 mg chewable t.i.d.,4. lisinopril 2.5 mg daily.,6. coreg 3.125 mg p.o. b.i.d.,7. procrit 10,000 units inject every tuesday, thursday, and saturday.,8. heparin 5000 units q.8h. subcutaneous for dvt prophylaxis.

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.

cc:, progressive lower extremity weakness.,hx: ,this 54 y/o rhf presented on 7/3/93 with a 2 month history of lower extremity weakness. she was admitted to a local hospital on 5/3/93 for a 3 day h/o of progressive ble weakness associated with incontinence and ble numbness. there was little symptom of upper extremity weakness at that time, according to the patient. her evaluation was notable for a bilateral l1 sensory level and 4/4 strength in ble. a t-l-s spine mri revealed a t4-6 lipomatosis with anterior displacement of the cord without cord compression. csf analysis yielded: opening pressure of 14cm h20, protein 88, glucose 78, 3 lymphocytes and 160 rbc, no oligoclonal bands or elevated igg index, and negative cytology. bone marrow biopsy was negative. b12, folate, and ferritin levels were normal. crp 5.2 (elevated). ana was positive at 1:5,120 in speckled pattern. her hospital course was complicated by deep venous thrombosis, which recurred after heparin was stopped to do the bone marrow biopsy. she was subsequently placed on coumadin. emg/ncv testing revealed " lumbosacral polyradiculopathy with axonal degeneration and nerve conduction block." she was diagnosed with atypical guillain-barre vs. polyradiculopathy and received a single course of decadron; and no plasmapheresis or iv igg. she was discharged home o 6/8/93.,she subsequently did not improve and after awaking from a nap on her couch the day of presentation, 7/3/93, she found she was paralyzed from the waist down. there was associated mild upper lumbar back pain without radiation. she had had no bowel movement or urination since that time. she had no recent trauma, fever, chills, changes in vision, dysphagia or upper extremity deficit.,meds:, coumadin 7.5mg qd, zoloft 50mg qd, lithium 300mg bid.,pmh:, 1) bi-polar affective disorder, dx 1979 2) c-section.,fhx:, unremarkable.,shx:, denied tobacco/etoh/illicit drug use.,exam: ,bp118/64, hr103, rr18, afebrile.,ms: ,a&o to person, place, time. speech fluent without dysarthria. lucid thought processes.,cn: ,unremarkable.,motor:, 5/5 strength in bue. plegic in ble. flaccid muscle tone.,sensory:, l1 sensory level (bilaterally) to pp and temp, without sacral sparing. proprioception was lost in both feet.,cord: ,normal in bue.,reflexes were 2+/2+ in bue. they were not elicited in ble. plantar responses were equivocal, bilaterally.,rectal: ,poor rectal tone. stool guaiac negative. she had no perirectal sensation.,course:, crp 8.8 and esr 76. fvc 2.17l. wbc 1.5 (150 bands, 555 neutrophils, 440 lymphocytes and 330 monocytes), hct 33%, hgb 11.0, plt 220k, mcv 88, gs normal except for slightly low total protein (8.0). lft were normal. creatinine 1.0. pt and ptt were normal. abcg 7.46/25/79/96% o2sat. ua notable for 1+ proteinuria. ekg normal.,mri l-spine, 7/3/93, revealed an area of abnormally increased t2 signal extending from t12 through l5. this area causes anterior displacement of the spinal cord and nerve roots. the cauda equina are pushed up against the posterior l1 vertebral body. there bilaterally pulmonary effusions. there is also abnormally increased t2 signal in the center of the spinal cord extending from the mid thoracic level through the conus. in addition, the fila terminale appear thickened. there is increased signal in the t3 vertebral body suggestion a hemangioma. the findings were felt consistent with a large epidural lipoma displacing the spinal cord anteriorly. there also appeared spinal cord swelling and increased signal within the spinal cord which suggests an intramedullary process.,csf analysis revealed: protein 1,342, glucose 43, rbc 4,900, wbc 9. c3 and c$ complement levels were 94 and 18 respectively (normal) anticardiolipin antibodies were negative. serum beta-2 microglobulin was elevated at 2.4 and 3.7 in the csf and serum, respectively. it was felt the patient had either a transverse myelitis associated with sle vs. partial cord infarction related to lupus vasculopathy or hypercoagulable state. she was place on iv decadron. rheumatology felt that a diagnosis of sle was likely. pulmonary effusion analysis was consistent with an exudate. she was treated with plasma exchange and place on cytoxan.,on 7/22/93 she developed fever with associated proptosis and sudden loss of vision, od. mri brain, 7/22/93, revealed a 5mm thick area of intermediate signal adjacent to the posterior aspect of the right globe, possibly representing hematoma. ophthalmology felt she had a central retinal vein occlusion; and it was surgically decompressed.,she was placed on prednisone on 8/11/93 and cytoxan was started on 8/16/93. she developed a headache with meningismus on 8/20/93. csf analysis revealed: protein 1,002, glucose2, wbc 8,925 (majority were neutrophils). sinus ct scan negative. she was placed on iv antibiotics for presumed bacterial meningitis. cultures were subsequently negative. she spontaneously recovered. 8/25/93, cisternal tap csf analysis revealed: protein 126, glucose 35, wbc 144 (neutrophils), rbc 95, cultures negative, cytology negative. mri brain scan revealed diffuse leptomeningeal enhancement in both brain and spinal canal.,dsdna negative. she developed leukopenia in 9/93, and she was switched from cytoxan to imuran. her lft's rose and the imuran was stopped and she was placed back on prednisone.,she went on to have numerous deep venous thrombosis while on coumadin. this required numerous hospital admissions for heparinization. anticardiolipin antibodies and protein c and s testing was negative.

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.

admitting diagnosis: , right c5-c6 herniated nucleus pulposus.,primary operative procedure: , anterior cervical discectomy at c5-6 and placement of artificial disk replacement.,summary:, this is a pleasant, 43-year-old woman, who has been having neck pain and right arm pain for a period of time which has not responded to conservative treatment including esis. she underwent another mri and significant degenerative disease at c5-6 with a central and right-sided herniation was noted. risks and benefits of the surgery were discussed with her and she wished to proceed with surgery. she was interested in participating in the artificial disk replacement study and was entered into that study. she was randomly picked for the artificial disk and underwent the above named procedure on 08/27/2007. she has done well postoperatively with a sensation of right arm pain and numbness in her fingers. she will have x-rays ap and lateral this morning which will be reviewed and she will be discharged home today if she is doing well. she will follow up with dr. x in 2 weeks in the clinic as per the study protocol with cervical ap and lateral x-rays with ring prior to the appointment. she will contact our office prior to her appointment if she has problems. prescriptions were written for flexeril 10 mg 1 p.o. t.i.d. p.r.n. #50 with 1 refill and lortab 7.5/500 mg 1 to 2 q.6 h. p.r.n. #60 with 1 refill.

chief complaint / reason for the visit:, patient has been diagnosed to have breast cancer.,breast cancer history:, patient presented with the following complaints: lump in the upper outer quadrant of the right breast that has been present for the last 4 weeks. the lump is painless and the skin over the lump is normal. patient denies any redness, warmth, edema and nipple discharge. patient had a mammogram recently and was told to have a mass measuring 2 cm in the uoq and of the left breast. patient had an excisional biopsy of the mass and subsequently axillary nodal sampling.,pathology:, infiltrating ductal carcinoma, estrogen receptor 56, progesterone receptor 23, s-phase fraction 2., her 2 neu 0 and all nodes negative.,stage:, stage i.,tnm stage:, t1, n0 and m0.,surgery:, s/p lumpectomy left breast and left axillary node sampling. patient is here for further recommendation.,past medical history:, osteoarthritis for 5 years. ashd for 10 years. kidney stones recurrent for 10 years.,screening test history:, last rectal exam was done on 10/99. last mammogram was done on 12/99. last gynecological exam was done on 10/99. last pap smear was done on 10/99. last chest x-ray was done on 10/99. last f.o.b. was done on 10/99-x3. last sigmoidoscopy was done on 1998. last colonoscopy was done on 1996.,immunization history:, last flu vaccine was given on 1999. last pneumonia vaccine was given on 1996.,family medical history:, father age 85, history of cerebrovascular accident (stroke) and hypertension. mother history of chf and emphysema that died at the age of 78. no brothers and sisters. 1 son healthy at age 54.,past surgical history:, appendectomy. biopsy of the left breast 1996 - benign.

subjective: , the patient is a 20-year-old caucasian male admitted via abcd hospital emergency department for evaluation of hydrocarbon aspiration. the patient ingested "tiki oil" (kerosene, liquid paraffin, citronella oil) approximately two days prior to admission. he subsequently developed progressive symptoms of dyspnea, pleuritic chest pain, hemoptysis with nausea and vomiting. he was seen in the abcd hospital emergency department, toxic appearing with an abnormal chest x-ray demonstrating bilateral lower lobe infiltrates, greater on the right. he had a temperature of 38.3 with tachycardia approximating 130. white count was 59,300 with a marked left shift. arterial blood gases showed ph 7.48, po2 79, and pco2 35. he was admitted for further medical management.,past medical history:, aplastic crisis during childhood requiring splenectomy and a cholecystectomy at age 9.,drug allergies: , none known.,current medications: , none.,family history: ,noncontributory.,social history: ,the patient works at a local christmas tree farm. he smokes cigarettes approximately one pack per day.,review of systems:, ten-system review significant for nausea, vomiting, fever, hemoptysis, and pleuritic chest pain.,physical examination,general: a toxic-appearing 20-year-old caucasian male, in mild respiratory distress.,vital signs: blood pressure 122/74, pulse 130 and regular, respirations 24, temperature 38.3, and oxygen saturation 93%.,skin: no rashes, petechiae or ecchymoses.,heent: within normal limits. pupils are equally round and reactive to light and accommodation. ears clean. throat clean.,neck: supple without thyromegaly. lymph nodes are nonpalpable.,chest: decreased breath sounds bilaterally, greater on the right, at the right base.,cardiac: no murmur or gallop rhythm.,abdomen: mild direct diffuse tenderness without rebound. no detectable masses, pulsations or organomegaly.,extremities: no edema. pulses are equal and full bilaterally.,neurologic: nonfocal.,database: , chest x-ray, bilateral lower lobe pneumonia, greater on the right. ekg, sinus tachycardia, rate of 130, normal intervals, no st changes. arterial blood gases on 2 l of oxygen, ph 7.48, po2 79, and pco2 35.,blood studies: , hematocrit is 43, wbc 59,300 with a left shift, and platelet count 394,000. sodium is 130, potassium 3.8, chloride 97, bicarbonate 24, bun 14, creatinine 0.8, random blood sugar 147, and calcium 9.4.,impression,1. hydrocarbon aspiration.,2. bilateral pneumonia with pneumonitis secondary to aspiration.,3. asplenic patient.,plan,1. icu monitoring.,2. o2 protocol.,3. hydration.,4. antiemetic therapy.,5. parenteral antibiotics.,6. prophylactic proton pump inhibitors.,the patient will need icu monitoring and pulmonary medicine evaluation pending clinical course.,

preoperative diagnosis: , right upper eyelid squamous cell carcinoma.,postoperative diagnosis: , right upper eyelid squamous cell carcinoma.,procedure performed: , excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.,complications: ,none.,blood loss: , minimal.,anesthesia:, local with sedation.,indication:, the patient is a 65-year-old male with a large squamous cell carcinoma on his right upper eyelid, which had previous radiation.,description of procedure: , the patient was taken to the operating room, laid supine, administered intravenous sedation, and prepped and draped in a sterile fashion. he was anesthetized with a combination of 2% lidocaine and 0.5% marcaine with epinephrine on both upper eyelids. the area of obvious scar tissue from the radiation for the squamous cell carcinoma on the right upper eyelid was completely excised down to the eyelid margin including resection of a few of the upper eye lashes. this was extended essentially from the punctum to the lateral commissure and extended up on to the upper eyelid. the resection was carried down through the orbicularis muscle resecting the pretarsal orbicularis muscle and the inferior portion of the preseptal orbicularis muscle leaving the tarsus intact and leaving the orbital septum intact. following complete resection, the patient was easily able to open and close his eyes as the levator muscle insertion was left intact to the tarsal plate. the specimen was sent to pathology, which revealed only fibrotic tissue and no evidence of any residual squamous cell carcinoma. meticulous hemostasis was obtained with bovie cautery and a full-thickness skin graft was taken from the opposite upper eyelid in a fashion similar to a blepharoplasty of the appropriate size for the defect in the right upper eyelid. the left upper eyelid incision was closed with 6-0 fast-absorbing gut interrupted sutures, and the skin graft was sutured in place with 6-0 fast-absorbing gut interrupted sutures. an eye patch was placed on the right side, and the patient tolerated the procedure well and was taken to pacu in good condition.

title of operation:, diagnostic laparoscopy.,indication for surgery: , the patient is a 22-year-old woman with a possible ruptured ectopic pregnancy.,preop diagnosis: , possible ruptured ectopic pregnancy.,postop diagnosis: , no evidence of ectopic pregnancy or ruptured ectopic pregnancy.,anesthesia: , general endotracheal.,specimen: , peritoneal fluid.,ebl: , minimal.,fluids:, 900 cubic centimeters crystalloids.,urine output: , 400 cubic centimeters.,findings: , adhesed left ovary with dilated left fallopian tube, tortuous right fallopian tube with small 1 cm ovarian cyst noted on right ovary, perihepatic lesions consistent with history of pid, approximately 1-200 cubic centimeters of more serous than sanguineous fluid. no evidence of ectopic pregnancy.,complications: , none.,procedure:, after obtaining informed consent, the patient was taken to the operating room where general endotracheal anesthesia was administered. she was examined under anesthesia. an 8-10 cm anteverted uterus was noted. the patient was placed in the dorsal-lithotomy position and prepped and draped in the usual sterile fashion, a sponge on a sponge stick was used in the place of a humi in order to not instrument the uterus in the event that this was a viable intrauterine pregnancy and this may be a desired intrauterine pregnancy. attention was then turned to the patient's abdomen where a 5-mm incision was made in the inferior umbilicus. the abdominal wall was tented and versastep needle was inserted into the peritoneal cavity. access into the intraperitoneal space was confirmed by a decrease in water level when the needle was filled with water. no peritoneum was obtained without difficulty using 4 liters of co2 gas. the 5-mm trocar and sleeve were then advanced in to the intraabdominal cavity and access was confirmed with the laparoscope.,the above-noted findings were visualized. a 5-mm skin incision was made approximately one-third of the way from the asi to the umbilicus at mcburney's point. under direct visualization, the trocar and sleeve were advanced without difficulty. a third incision was made in the left lower quadrant with advancement of the trocar into the abdomen in a similar fashion using the versastep. the peritoneal fluid was aspirated and sent for culture and wash and cytology. the abdomen and pelvis were surveyed with the above-noted findings. no active bleeding was noted. no evidence of ectopic pregnancy was noted. the instruments were removed from the abdomen under good visualization with good hemostasis noted. the sponge on a sponge stick was removed from the vagina. the patient tolerated the procedure well and was taken to the recovery room in stable condition.,the attending, dr. x, was present and scrubbed for the entire procedure.

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

preoperative diagnoses:,1. need for intravenous access.,2. status post fall.,3. status post incision and drainage of left lower extremity.,postoperative diagnoses:,1. need for intravenous access.,2. status post fall.,3. status post incision and drainage of left lower extremity.,procedure performed: , insertion of right subclavian central venous catheter.,second anesthesia: , approximately 10 cc of 1% lidocaine.,estimated blood loss: , minimal.,indications for procedure: ,the patient is a 74-year-old white female who presents to abcd general hospital after falling down flight of eleven stairs and sustained numerous injuries. the patient went to or today for an i&d of left lower extremity degloving injury. orthopedics was planning on taking the patient back for serial debridements and need for reliable iv access is requested.,procedure: , informed consent was obtained by the patient and her daughter. all risks and benefits of the procedure were explained and all questions were answered. the patient was prepped and draped in the normal sterile fashion. after landmarks were identified, approximately 5 cc of 1% lidocaine were injected into the skin and subcuticular tissues and the right neck posterior head of the sternocleidomastoid. locator needle was used to correctly cannulate the right internal jugular vein. multiple attempts were made and the right internal jugular vein was unable to be cannulized.,therefore, we prepared for a right subclavian approach. the angle of the clavicle was found and a #22 gauge needle was used to anesthetize approximately 5 cc of 1% lidocaine in skin and subcuticular tissues along with the periosteum of the clavicle. a cook catheter needle was then placed and ________ the clavicle in the orientation aimed toward the sternal notch. the right subclavian vein was then accessed. a guidewire was placed with a cook needle and then the needle was subsequently removed and a #11 blade scalpel was used to nick the skin. a dilator sheath was placed over the guidewire and subsequently removed. the triple lumen catheter was then placed over the guidewire and advanced to 14 cm. all ports aspirated and flushed. good blood return was noted and all ports were flushed well. the triple lumen catheter was then secured at 14 cm using #0 silk suture. a sterile dressing was then applied. a stat portable chest x-ray was ordered to check line placement. the patient tolerated the procedure well and there were no complications.

chief complaint:, patient af is a 50-year-old hepatitis c positive african-american man presenting with a 2-day history of abdominal pain and distention with nausea and vomiting.,history of present illness: , af's symptoms began 2 days ago, and he has not passed gas or had any bowel movements. he has not eaten anything, and has vomited 8 times. af reports 10/10 pain in the llq.,past medical history:, af's past medical history is significant for an abdominal injury during the vietnam war which required surgery, and multiple episodes of small bowel obstruction and abdominal pain. other elements of his history include alcoholism, cocaine abuse, alcoholic hepatitis, hepatitis c positive, acute pancreatitis, chronic pancreatitis, appendicitis, liver hematoma/contusion, hodgkin's disease, constipation, diarrhea, paralytic ileus, anemia, multiple blood transfusions, chorioretinitis, pneumonia, and "crack chest pain" ,past surgical history: , af has had multiple abdominal surgeries, including bill roth procedure type 1 (partial gastrectomy) during vietnam war, at least 2 exploratory laparotomies and enterolysis procedures (1993; 2000), and appendectomy,medications:, none.,allergies:, iodine, iv contrast (anaphylaxis), and seafood/shellfish.,family history:, noncontributory.,social history:, af was born and raised in san francisco. his father was an alcoholic. he currently lives with his sister, and does not work; he collects a pension.,health-related behaviors:, af reports that he smokes 1 to 2 cigarettes per day, and drinks 40 ounces of beer per day.,review of systems: , noncontributory, except that patient reports a 6 pound weight loss since his symptoms began, and reports multiple transfusions for anemia.,physical exam:,vital signs: t: 37.1

preoperative diagnoses:, tearing, eyelash encrustation with probable tear duct obstruction bilateral.,postoperative diagnoses: ,1. distal nasolacrimal duct stenosis with obstruction, left eye.,2. distal nasolacrimal duct stenosis with obstruction, right eye.,operative procedure: , bilateral nasolacrimal probing.,anesthesia: , monitored anesthesia care along with mask sedation.,indications for surgery: , this young infant is a 19-month-old who has had persistent tearing and mild eyelash encrustation of each eye for many months. conservative measures at home have failed to completely resolve the symptoms. he has been placed on previous antibiotics treatment for presumed conjunctivitis. please refer to clinic note for more details. conservative measures at home have failed to resolve the symptoms. a nasolacrimal probing was offered as an elective procedure. procedure as well as inherent risks, expected outcomes, benefits, and alternatives (including continued observation) were discussed with his mother prior to scheduling surgery. again, a description of procedure as well as diagram instruction was provided to mother and father in the morning of the procedure. the risks as explained included, but were not limited to temporary bleeding, persistent symptoms, recurrence need for further procedure, possible need for future stent placement or repeat probing, and anesthesia risk were all discussed. also a rare possibility of errant passage of the nasolacrimal probe was discussed. preoperative evaluation and explanation include drying of the nasolacrimal system with an explanation expected outcome/result from surgery. no guarantees were offered. informed consent was signed and placed on the chart.,description of procedure: ,the patient was identified and the procedure was verified. procedure as well as inherent risks were again discussed with parents prior to the procedure. after anesthesia was induced in the operating room, tetracaine drops were applied to each eye and the pressure of the eyes were checked with tono-pen. the pressure on the right was 17 mmhg and on the left was 16 mmhg.,a punctal dilator was then used to dilate the left superior puncta. a size 00 bowman probe was used to navigate the superior puncta and canaliculus with traction of the eyelid temporally. the probe was advanced until a firm stop of the lacrimal bone was felt. the probe was rotated in a superior and medial fashion along the brow to allow for navigation through the nasolacrimal sac and duct. a mild resistance was felt at the distal aspect of the nasolacrimal duct consistent with a location of the valve. there was also some mild stenosis distally, but not felt significant. the probe was used to navigate through this mild resistance. a second bowman probe was then placed through the left naris and metal on metal contact was felt confirming patency. both probes were removed. the 00 bowman probe was then used to navigate the inferior puncta canaliculus system. patency was confirmed. the left upper lid was everted and inspected and was found to be normal.,attention was then turned to the right side where the similar procedure through the right superior puncta was performed. a punctal dilator was used to dilate the puncta followed by a size 00 bowman probe. again on this side, a size 0 bowman probe was unable to be placed initially to the superior puncta. the probe was used to navigate the superior puncta, canaliculus, and then the probe was rotated superomedially and the probe was advanced. similar amount of distal stenosis and distal nasolacrimal duct obstruction was felt. the mild resistance was over come at the approximate location of the valve. metal-on-metal feel confirmed patency through the right naris with a second metal probe. at the completion of the procedure all probes were removed. awakened and taken to the postanesthesia recovery unit in good condition having tolerated the procedure well.,postoperative instructions were provided to the parents by me, and the discharging nurse. i did advised nasolacrimal massage for the next 7 to 10 days on each side two to three times daily. technique explained and demonstrated. erythromycin ointment to both eyes twice daily for three days. follow up was arranged and he may call with any further questions or concerns.

reason for visit:, followup status post l4-l5 laminectomy and bilateral foraminotomies, and l4-l5 posterior spinal fusion with instrumentation.,history of present illness:, ms. abc returns today for followup status post l4-l5 laminectomy and bilateral foraminotomies, and posterior spinal fusion on 06/08/07.,preoperatively, her symptoms, those of left lower extremity are radicular pain.,she had not improved immediately postoperatively. she had a medial breech of a right l4 pedicle screw. we took her back to the operating room same night and reinserted the screw. postoperatively, her pain had improved.,i had last seen her on 06/28/07 at which time she was doing well. she had symptoms of what she thought was "restless leg syndrome" at that time. she has been put on requip for this.,she returned. i had spoken to her 2 days ago and she had stated that her right lower extremity pain was markedly improved. i had previously evaluated this for a pain possibly relating to deep venous thrombosis and ultrasound was negative. she states that she had recurrent left lower extremity pain, which was similar to the pain she had preoperatively but in a different distribution, further down the leg. thus, i referred her for a lumbar spine radiograph and lumbar spine mri and she presents today for evaluation.,she states that overall, she is improved compared to preoperatively. she is ambulating better than she was preoperatively. the pain is not as severe as it was preoperatively. the right leg pain is improved. the left lower extremity pain is in a left l4 and l5 distribution radiating to the great toe and first web space on the left side.,she denies any significant low back pain. no right lower extremity symptoms.,no infectious symptoms whatsoever. no fever, chills, chest pain, shortness of breath. no drainage from the wound. no difficulties with the incision.,findings: ,on examination, ms. abc is a pleasant, well-developed, well-nourished female in no apparent distress. alert and oriented x 3. normocephalic, atraumatic. respirations are normal and nonlabored. afebrile to touch.,left tibialis anterior strength is 3 out of 5, extensor hallucis strength is 2 out of 5. gastroc-soleus strength is 3 to 4 out of 5. this has all been changed compared to preoperatively. motor strength is otherwise 4 plus out of 5. light touch sensation decreased along the medial aspect of the left foot. straight leg raise test normal bilaterally.,the incision is well healed. there is no fluctuance or fullness with the incision whatsoever. no drainage.,radiographs obtained today demonstrate pedicle screw placement at l4 and l5 bilaterally without evidence of malposition or change in orientation of the screws.,lumbar spine mri performed on 07/03/07 is also reviewed.,it demonstrates evidence of adequate decompression at l4 and l5. there is a moderate size subcutaneous fluid collection seen, which does not appear compressive and may be compatible with normal postoperative fluid collection, especially given the fact that she had a revision surgery performed.,assessment and plan: ,ms. abc is doing relatively well status post l4 and l5 laminectomy and bilateral foraminotomies, and posterior spinal fusion with instrumentation on 07/08/07. the case is significant for merely misdirected right l4 pedicle screw, which was reoriented with subsequent resolution of symptoms.,i am uncertain with regard to the etiology of the symptoms. however, it does appear that the radiographs demonstrate appropriate positioning of the instrumentation, no hardware shift, and the mri demonstrates only a postoperative suprafascial fluid collection. i do not see any indication for another surgery at this time.,i would also like to hold off on an interventional pain management given the presence of the fluid collection to decrease the risk of infection.,my recommendation at this time is that the patient is to continue with mobilization. i have reassured her that her spine appears stable at this time. she is happy with this.,i would like her to continue ambulating as much as possible. she can go ahead and continue with requip for the restless leg syndrome as her primary care physician has suggested. i have also her referred to mrs. khan at physical medicine and rehabilitation for continued aggressive management.,i will see her back in followup in 3 to 4 weeks to make sure that she continues to improve. she knows that if she has any difficulties, she may follow up with me sooner.

preoperative diagnoses,1. adrenal mass, right sided.,2. umbilical hernia.,postoperative diagnoses,1. adrenal mass, right sided.,2. umbilical hernia.,operation performed: , laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair.,anesthesia: ,general.,clinical note: , this is a 52-year-old inmate with a 5.5 cm diameter nonfunctioning mass in his right adrenal. procedure was explained including risks of infection, bleeding, possibility of transfusion, possibility of further treatments being required. alternative of fully laparoscopic are open surgery or watching the lesion.,description of operation: ,in the right flank-up position, table was flexed. he had a foley catheter in place. incision was made from just above the umbilicus, about 5.5 cm in diameter. the umbilical hernia was taken down. an 11 mm trocar was placed in the midline, superior to the gelport and a 5 mm trocar placed in the midaxillary line below the costal margin. a liver retractor was placed to this.,the colon was reflected medially by incising the white line of toldt. the liver attachments to the adrenal kidney were divided and the liver was reflected superiorly. the vena cava was identified. the main renal vein was identified. coming superior to the main renal vein, staying right on the vena cava, all small vessels were clipped and then divided. coming along the superior pole of the kidney, the tumor was dissected free from top of the kidney with clips and bovie. the harmonic scalpel was utilized superiorly and laterally. posterior attachments were divided between clips and once the whole adrenal was mobilized, the adrenal vein and one large adrenal artery were noted, doubly clipped, and divided. specimen was placed in a collection bag, removed intact.,hemostasis was excellent.,the umbilical hernia had been completely taken down. the edges were freshened up. vicryl #1 was utilized to close the incision and 2-0 vicryl was used to close the fascia of the trocar.,skin closed with clips.,he tolerated the procedure well. all sponge and instrument counts were correct. estimated blood loss less than 100 ml.,the patient was awakened, extubated, and returned to recovery room in satisfactory condition.

reason for exam: ,left arm and hand numbness.,technique: , noncontrast axial ct images of the head were obtained with 5 mm slice thickness.,findings: ,there is an approximately 5-mm shift of the midline towards the right side. significant low attenuation is seen throughout the white matter of the right frontal, parietal, and temporal lobes. there is loss of the cortical sulci on the right side. these findings are compatible with edema. within the right parietal lobe, a 1.8 cm, rounded, hyperintense mass is seen.,no hydrocephalus is evident.,the calvarium is intact. the visualized paranasal sinuses are clear.,impression: ,a 5 mm midline shift to the left side secondary to severe edema of the white matter of the right frontal, parietal, and temporal lobes. a 1.8 cm high attenuation mass in the right parietal lobe is concerning for hemorrhage given its high density. a postcontrast mri is required for further characterization of this mass. gradient echo imaging should be obtained.

subjective: , she is a 79-year-old female who came in with acute cholecystitis and underwent attempted laparoscopic cholecystectomy 8 days ago. the patient has required conversion to an open procedure due to difficult anatomy. her postoperative course has been lengthened due to a prolonged ileus, which resolved with tetracycline and reglan. the patient is starting to improve, gain more strength. she is tolerating her regular diet.,physical examination:,vital signs: today, her temperature is 98.4, heart rate 84, respirations 20, and bp is 140/72.,lungs: clear to auscultation. no wheezes, rales, or rhonchi.,heart: regular rhythm and rate.,abdomen: soft, less tender.,laboratory data:, her white count continues to come down. today, it is 11.6, h&h of 8.8 and 26.4, platelets 359,000. we have ordered type and cross for 2 units of packed red blood cells. if it drops below 25, she will receive a transfusion. her electrolytes today show a glucose of 107, sodium 137, potassium 4.0, chloride 103.2, bicarbonate 29.7. her ast is 43, alt is 223, her alkaline phosphatase is 214, and her bilirubin is less than 0.10.,assessment and plan:, she had a bowel movement today and is continuing to improve.,i anticipate another 3 days in the hospital for strengthening and continued tpn and resolution of elevated white count.

preoperative diagnosis: , brain tumors, multiple.,postoperative diagnoses:, brain tumors multiple - adenocarcinoma and metastasis from breast.,procedure:, occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and cusa.,procedure:, the patient was placed in the prone position after general endotracheal anesthesia was administered. the scalp was prepped and draped in the usual fashion. the cusa was brought in to supplement the use of operating microscope as well as the stealth, which was used to localize the tumor. following this, we then made a transverse linear incision, the scalp galea was reflected and the quadrilateral bone flap was removed after placing burr holes in the midline and over the parietal areas directly over the tumor. the bone flap was elevated. the ultrasound was then used. the ultrasound showed the tumors directly i believe are in the interhemispheric fissure. we noticed that the dura was quite tense despite that the patient had slight hyperventilation. we gave 4 ounce of mannitol, the brain became more pulsatile. we then used the stealth to perform a ventriculostomy. once this was done, the brain began to pulsate nicely. we then entered the interhemispheric space after we incised the dura in an inverted u fashion based on the superior side of the sinus. after having done this we then used operating microscope and slight self-retaining retraction was used. we obtained access to the tumor. we biopsied this and submitted it. this was returned as a malignant brain tumor - metastatic tumor, adenocarcinoma compatible with breast cancer.,following this we then debulked this tumor using cusa and then removed it in total. after gross total removal of this tumor, the irrigation was used to wash the tumor bed and a meticulous hemostasis was then obtained using bipolar cautery. the next step was after removal of this tumor, closure of the wound, a large piece of duragen was placed over the dural defect and the bone flap was reapproximated and held secured with lorenz plates. the tumors self extend into the ventricle and after we had removed the tumor, we could see our ventricular catheter in the occipital horn of the ventricle. this being the case, we left this ventricular catheter in, brought it out through a separate incision and connected to sterile drainage. the next step was to close the wound after reapproximating the bone flap. the galea was closed with 2-0 vicryl and the skin was closed with interrupted 3-0 nylon sutures inverted with mattress sutures. the sterile dressings were applied to the scalp. the patient returned to the recovery room in satisfactory condition. hemodynamically remained stable throughout the operation.,once again, we performed occipital craniotomy, total removal of her large metastatic tumor involving the parietal lobe using a biparietal craniotomy. the tumor was removed using the combination of cusa, ultrasound, stealth guided-ventriculostomy and the patient will have a second operation today, we will perform a selective craniectomy to remove another large tumor in the posterior fossa.

preoperative diagnosis: , blood loss anemia.,postoperative diagnoses:,1. normal colon with no evidence of bleeding.,2. hiatal hernia.,3. fundal gastritis with polyps.,4. antral mass.,anesthesia: , conscious sedation with demerol and versed.,specimen: ,antrum and fundal polyps.,history: , the patient is a 66-year-old african-american female who presented to abcd hospital with mental status changes. she has been anemic as well with no gross evidence of blood loss. she has had a decreased appetite with weight loss greater than 20 lb over the past few months. after discussion with the patient and her daughter, she was scheduled for egd and colonoscopy for evaluation.,procedure: , after 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 was achieved, a digital rectal exam was performed, which demonstrated no masses and no hemorrhoids. the colonoscope was inserted into the rectum and air was insufflated. the scope was coursed through the rectum and sigmoid colon, descending colon, transverse colon, ascending colon to the level of the cecum. there were no polyps, masses, diverticuli, or areas of inflammation. the scope was then slowly withdrawn carefully examining all walls. air was aspirated. once in the rectum, the scope was retroflexed. there was no evidence of perianal disease. no source of the anemia was identified.,attention was then taken for performing an egd. the gastroscope was inserted into the hypopharynx and was entered into the hypopharynx. the esophagus was easily intubated and traversed. there were no abnormalities of the esophagus. the stomach was entered and was insufflated. the scope was coursed along the greater curvature towards the antrum. adjacent to the pylorus, towards the anterior surface, was a mass like lesion with a central _______. it was not clear if this represents a healing ulcer or neoplasm. several biopsies were taken. the mass was soft. the pylorus was then entered. the duodenal bulb and sweep were examined. there was no evidence of mass, ulceration, or bleeding. the scope was then brought back into the antrum and was retroflexed. in the fundus and body, there was evidence of streaking and inflammation. there were also several small sessile polyps, which were removed with biopsy forceps. biopsy was also taken for clo. a hiatal hernia was present as well. air was aspirated. the scope was slowly withdrawn. the ge junction was unremarkable. the scope was fully withdrawn. the patient tolerated the procedure well and was transferred to recovery room in stable condition. she will undergo a cat scan of her abdomen and pelvis to further assess any possible adenopathy or gastric obstructional changes. we will await the biopsy reports and further recommendations will follow.

chief complaint:, "i can’t walk as far as i used to.",history of present illness:, the patient is a 66-year-old african american gentleman with a past medical history of atrial fibrillation and arthritis who presented c/o progressively worsening shortness of breath. the patient stated that he had been in his usual state of health six years ago at which time he had been able to walk more than five blocks without difficulty. approximately five years prior to admission, he began to note a decreased tolerance to exercise. this progressed with a gradual worsening in his functional capacity such that he is presently unable to walk for more than 25 feet. over the two years prior to admission, he has been having a gradually worsening non-productive cough associated with shortness of breath. his shortness of breath is worse when he lies flat, and he periodically wakes at night gasping for air. he sleeps with three pillows. he has also noted swelling of his legs and states that he has had two episodes of syncope at home for which he has not sought medical attention. approximately one month prior to admission he was seen in an outside clinic where he states that he was started on medications for heart failure. he stated that he had had a brother who died of heart failure at age 72.,he did report that he had had an episode of hemoptysis approximately 2 years prior to admission for which he did not seek medical attention. he denied any history of chest pain and did not report any history of myocardial infarction. he denied fever, chills, and night sweats. he denied diarrhea, dysuria, hematuria, urgency and frequency. he denied any history of rash. he had been diagnosed with osteoarthritis of the knees and had undergone arthroscopy years prior to admission.,past medical history :, atrial fibrillation on anticoagulation, osteoarthritis of the knees bilaterally, h/o retinal tear.,past surgical history :, hernia repair, bilateral arthroscopic evaluation, h/o surgical correction of retinal tear.,family history:, the father of the patient died at age 69 with a cva. the mother of the patient died at age 79 when her "heart stopped". there were 12 siblings. four siblings have died, two due to diabetes, one cause unknown, and one brother died at age 72 with heart failure. the patient has four children with no known medical problems.,social history:, the patient retired one year pta due to his disability. he was formerly employed as an electronic technician for the us postal service. the patient lives with his wife and daughter in an apartment. he denied any smoking history. he used to drink alcohol rarely but stopped entirely with the onset of his symptoms. he denied any h/o drug abuse. he denied any recent travel history.,medications:,1. spironolactone 25 mg po qd.,2. digoxin 0.125 mg po qod.,3. coumadin 3 mg monday and tuesday and 4.5 mg saturday and sunday.,4. metolazone 10 mg po qd.,5. captopril 25 mg po tid.,6. torsemide 40 mg po qam and 20 mg po qpm.,7. carvedilol 3.125 mg po bid.,allergies:, no known drug allergies.,review of systems:, no headaches. no visual, hearing, or swallowing difficulties. no changes in bowel or urinary habits.,physical exam:,temperature: 98.4 degrees fahrenheit.,blood pressure: 134/84.,heart rate: 98 beats per minute.,respiratory rate: 18 breaths per minute.,pulse oximetry: 92% on 2l o 2 via nasal canula.,gen: elderly gentleman lying in bed in mild respiratory distress, thin, tired appearing, wife and daughter present at bedside, articulate.,heent: the right eye was opacified. the left pupil was reactive to light. there was mild bitemporal wasting. the tongue was moist. there was no lymphadenopathy. the sclerae were anicteric. the oropharynx was clear. the conjunctivae were pink.,neck: the neck was supple with 15 cm of jugular venous distension.,heart: irregularly irregular. no murmurs, gallops, rubs. no displaced pmi.,lungs: breath sounds were absent over two thirds of the right lower lung field. there were trace crackles at the left base.,abdomen: soft, nontender, nondistended, bowel sounds were present. there was no hepatosplenomegaly. no rebound or guarding.,ext: bilateral pitting edema to the thighs with diminished peripheral pulses bilaterally.,neuro: the patient was alert and oriented x three. cranial nerves were intact. the dtrs were 2+ bilaterally and symmetrically. motor strength and sensation were within normal limits.,lymph: no cervical, axillary, or inguinal lymph nodes were present.,skin: warm, no rashes, no lesions; no tattoos.,musculoskeletal: no synovitis. there were no joint deformities. full range of motion b/l throughout.,studies:,cxr: large right sided pleural effusion. a small pleural effusion with atelectatic changes are seen on the left. the heart size is borderline.,echo: lv size is normal. there is severe concentric lv hypertrophy. global hypokinesis. lv function is severely depressed. estimate ef is 20-24%. there is rv hypertrophy. rv size is mildly enlarged. rv function is severely depressed. rv wall motion is severely hypokinetic. la size is moderately enlarged. ra size is mildly enlarged. trace aortic regurgitation. moderate tricuspid regurgitation. estimated pa systolic pressure is 46-51 mmhg, assuming a mean rap of 15-20mmhg. small anterior and posterior pericardial effusion.,hospital course:, the patient was admitted to the hospital for workup and management. a diagnostic procedure was performed.

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

history of present illness:, the patient is a 74-year-old white woman who has a past medical history of hypertension for 15 years, history of cva with no residual hemiparesis and uterine cancer with pulmonary metastases, who presented for evaluation of recent worsening of the hypertension. according to the patient, she had stable blood pressure for the past 12-15 years on 10 mg of lisinopril. in august of 2007, she was treated with doxorubicin and, as well as procrit and her blood pressure started to go up to over 200s. her lisinopril was increased to 40 mg daily. she was also given metoprolol and hctz two weeks ago, after she visited the emergency room with increased systolic blood pressure. denies any physical complaints at the present time. denies having any renal problems in the past.,past medical history:, as above plus history of anemia treated with procrit. no smoking or alcohol use and lives alone.,family history:, unremarkable.,present medications: , as above.,review of systems: , cardiovascular: no chest pain. no palpitations. pulmonary: no shortness of breath, cough, or wheezing. gastrointestinal: no nausea, vomiting, or diarrhea. gu: no nocturia. denies having gross hematuria. salt intake is minimal. neurological: unremarkable, except for history of old cva.,physical examination: , blood pressure today is 182/78. examination of the head is unremarkable. neck is supple with no jvd. lungs are clear. there is no abdominal bruit. extremities 1+ edema bilaterally.,laboratory data:, urinalysis done in the office shows 1+ proteinuria; same is shown by urinalysis done at hospital. the creatinine is 0.8. renal ultrasound showed possible renal artery stenosis and a 2 cm cyst in the left kidney. mra of the renal arteries was essentially unremarkable with no suspicion for renal artery stenosis.,impression and plan:, accelerated hypertension. no clear-cut etiology for recent worsening since renal artery stenosis was ruled out by negative mra. i could only blame procrit initiation, as well as possible fluid retention as a cause of the patient's accelerated hypertension. she was started on hydrochlorothiazide less than two weeks ago with some improvement in her hypertension. at this point, i would not pursue a diagnosis of renal artery stenosis. since she is maxed out on lisinopril and her pulse is 60, i would not increase beta-blocker or ace inhibitor. i will continue hctz at 24 mg daily. the patient was also given a sample of tekturna, which would hopefully improve her systolic blood pressure. the patient was told to be stick with her salt intake. she will report to me in 10 days with the result of her blood pressure. she will also repeat an sma7 to rule out possible hyperkalemia due to tekturna.

reason for consultation: , clogged av shunt.,history of present illness:, this is a 32-year-old african-american male who came to abcd general hospital with the above chief complaint. the patient complains of fatigue, nausea, vomiting and fever. the patient states that the shunt was placed in february, although according to medical records it was placed in april and it has been periodically clogging since its placement. the patient had dialysis today, which is saturday, for approximately one hour before the shunt no longer worked. the patient had been seen in the emergency room yesterday, 08/29/03, by dr. x for the same problem. at that time, dr. x felt that the patient should use the av fistula during dialysis and after the fistula is able to be used, the permcath on the right subclavian should be removed. as mentioned above, he had dialysis today and they were unable to use av fistula as well as the permcath read "did not work". the patient has had dialysis since january secondary to hypertension-induced renal failure. he takes dialysis monday, wednesday, and friday at the abcd dialysis center. he also was seen at xyz and he had an apparent thrombectomy with reversal done a few days ago. the patient's history at this point is a little sketchy; however, he states that he left ama. all other systems are reviewed and are negative.,past medical history: , significant for heart attack, chronic renal failure with dialysis, chf, hypertension, and permcath.,past surgical history: , av fistula on the left arm and a permcath.,allergies: , penicillin.,medications: , include metoprolol 100 mg two tablets b.i.d., tylenol #3, accupril 20 mg q.d., digoxin, renocaps, aspirin, and combivent.,social history: , half pack of tobacco x3 years. no alcohol, occasional marijuana, and no iv drug use. he lives alone, single and no children.,physical examination: , vital signs: in emergency room, temperature 98.2, pulse 83, respirations 20, blood pressure 146/84 and 99% on room air. general: this is an alert and oriented african-american male x3 and in no acute distress. the patient is extremely lethargic and had to be aroused multiple times to answer questions. mucous membranes are moist. heent: head is normocephalic and atraumatic. there is no scleral icterus noted. pupils are equal, round, and reactive to light. extraocular muscles are intact. cardiovascular: shows a heart rate that is regular with a laterally displaced point of maximum intensity. there is no murmur, gallop, or rub noted. lungs: clear to auscultation bilaterally. no wheeze, rhonchi or rales. abdomen: soft, nontender and nondistended. bowel sounds are present. extremities: show left forearm with an incision that is well healed from a left av fistula. there is a distal thrill palpable and there is some tenderness over the incisional area. there is no erythema or pus noted. other extremities show peripheral pulses present and no edema.,laboratory values: , sodium 139, potassium 3.9, chloride 92, co2 33, bun 36, creatinine 9.2, and glucose 131. digoxin 0.6, white count is 5.8, hemoglobin 11.7, hematocrit 34.9 and platelets are 252.,impression:,1. nonfunctional av fistula.,2. end-stage renal disease.,3. hypertension.,4. status post mi.,5. clogged permcath.,plan:,1. give the patient tpa to the shunt, permcath in both feet.,2. to board for tuesday for shunt repair if needed.,3. to dialyze as soon as possible.,4. to review previous operative report.,5. the patient will be contacted in the morning and told whether to go to dialysis or not.

history of present illness: , this is a 48-year-old black male with stage iv chronic kidney disease, likely secondary to hiv nephropathy who presents to clinic for followup having missed prior clinic appointments. he was last seen in this clinic on 05/29/2007 by dr. x. this is the first time that i have met the patient. the patient's history of renal insufficiency dates back to 06/2006 when he was hospitalized for an hiv-associated complication. he is unclear of the exact reason for his hospitalization at that time, but he was diagnosed with renal insufficiency and was followed in our renal clinic for approximately one year. he had a baseline creatinine during that time of between 3.2 to 3.3. when he was initially diagnosed with renal insufficiency, he had been noncompliant with his haart regimen. since that time, he has been very compliant with treatment for his hiv and is seeing dr. y in our infectious disease clinic. he is currently on three-drug antiretroviral therapy. his last cd4 count in 03/2008 was 350. he has had no hiv complications since he was last seen in our clinic. the patient is also followed by dr. z at the outpatient va clinic, here in abcd, although he has not seen her in approximately one year. the patient has an av fistula that was placed in late 2006. the latest blood work that i have is from 06/11/2008 and shows a serum creatinine of 3.8, which represents a gfr of 22 and a potassium of 5.9. these laboratories were drawn by his infectious disease doctor and the results prompted their recommendation for him to return to our clinic for further evaluation. the only complaint that the patient has at this time is some difficulty sleeping. he was given ambien by his primary care doctor, but this has not helped significantly with his difficulty sleeping. he says that he has trouble getting to sleep. the ambien will allow him to sleep for about two hours, and then he is awake again. he is tired during the day, but is not taking any daytime naps. he has no history of excessive snoring or apneic periods. he has no history of falling asleep at work or while driving. he has never had a formal sleep study. he does continue to work in sales at a local butcher shop.,review of systems: ,he denies any change in his appetite. he has actually gained some weight in recent months. he denies any nausea, vomiting, or abdominal discomfort. he denies any pruritus. he denies any lower extremity edema. all other systems are reviewed and negative.,past medical history:,1. stage iv chronic kidney disease with most recent gfr of 22.,2. hiv diagnosed in 09/2006 with the most recent cd4 count of 350 in 03/2008.,3. hyperlipidemia.,4. hypertension.,5. secondary hyperparathyroidism.,6. status post right upper extremity av fistula in the fall of 2006.,7. history of a right brachial plexus palsy.,8. recent lower back pain, status post lumbar steroid injection.,allergies:, he says that vitamin d has caused headaches.,medications:,1. kaletra daily.,2. epivir one daily.,3. ziagen two daily.,4. lasix 20 mg b.i.d.,5. valsartan 20 mg b.i.d.,6. ambien 10 mg q.h.s.,social history: , he lives here in abcd. he is employed at the sales counter of a local butcher shop. he continues to smoke one pack of cigarettes daily, as he has for the past 28 years. he denies any alcohol or illicit substances.,family history:, his mother is deceased. he said that she had some type of paralysis before she died. his father is deceased at age 64 of a head and neck cancer. he has a 56-year-old brother with type-two diabetes and blindness secondary to diabetic retinopathy. he has a 41-year-old brother who has hypertension. he has a sister who has thyroid disease.,physical examination:,vital signs: weight is 191 pounds. his temperature is 97.1. pulse is 94. blood pressure by automatic cuff 173/97, by manual cuff 180/90.,heent: his oropharynx is clear without thrush or ulceration.,neck: supple without lymphadenopathy or thyromegaly.,heart: regular with normal s1 and s2. there are no murmurs, rubs, or gallops. he has no jvd.,lungs: clear to auscultation bilaterally without wheezes, rhonchi, or crackles.,abdomen: soft, nontender, nondistended, without abdominal bruit or organomegaly.,musculoskeletal: he has difficulty with abduction of his right shoulder.,access: he has a right forearm av fistula with an audible bruit and a palpable thrill. there is no sign of stenosis. the vascular access looks like it is ready to use.,extremities: no peripheral edema.,skin: no bruises, petechiae, or rash.,labs: ,sodium was 140, potassium 5.9, chloride 114, bicarbonate 18. bun is 49, creatinine 4.3. gfr is 19. albumin 3.2. protein 7. ast 17, alt 16, alkaline phosphatase 106. total bilirubin 0.4. calcium 9.1., phosphorus 4.7, pth of 448. the corrected calcium was 9.7. wbc is 8.9, hemoglobin 13.4, platelet 226. total cholesterol 234, triglycerides 140, ldl 159, hdl 47. his ferritin is 258, iron is 55, and percent sat is 24.,impression: ,this is a 48-year-old black male with stage iv chronic kidney disease likely secondary to hiv nephropathy, although there is no history of renal biopsy, who has been noncompliant with the renal clinic and presents today for followup at the recommendation of his infection disease doctors.,recommendations:,1. renal. his serum creatinine is progressively worsening. his creatinine was 3.2 the last time we saw him in 05/2007 and today is 4.3. this represents a gfr of 19. this is stage iv chronic kidney disease. he does have vascular access and this appears to be ready to use. he is having some difficulty sleeping and it is possible that this represents some early signs of uremia. otherwise, he has no signs or symptoms of uremia at this time. i am going to touch base with the dialysis educator and try to get the patient in to the dialysis teaching classes. he has already received some literature for the dialysis teaching, but has not yet enrolled in the classes. i have encouraged him to continue to exercise his right forearm. i am also going to contact the transplant coordinator and see if he can be evaluated for possible transplant. given his progression of his chronic kidney disease, i will anticipate that he will need to start dialysis soon.,2. hypertension. i have added labetolol 100 mg b.i.d. to his antihypertensive regimen. he shows no signs at this point of volume overload, although if he does demonstrate this in the future, his lasix could be increased. goal blood pressure would be less than 130/80.,3. hyperkalemia. i am going to instruct him in a low-potassium diet and decrease his valsartan to 20 mg daily. i will have him return in one week to recheck his potassium. if his potassium continues to remain elevated, he may require initiation of dialysis for this.,4. bone metabolism. his pth is elevated and i am going to add phoslo 800 mg t.i.d. with meals. his corrected calcium is 9.7, and i would like to avoid calcium-containing phosphate bonders in this situation.,5. acid base. his bicarbonate is 18 and i will initiate the sodium bicarbonate 650 mg three tablets t.i.d.,6. anemia. his hemoglobin is at goal for this stage of chronic kidney disease. his iron stores are adequate.

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

preoperative diagnosis: , cholecystitis and cholelithiasis.,postoperative diagnosis: ,cholecystitis and cholelithiasis.,title of procedure,1. laparoscopic cholecystectomy.,2. intraoperative cholangiogram.,anesthesia: ,general.,procedure in detail: ,the patient was taken to the operative suite and placed in the supine position under general endotracheal anesthetic. the patient received 1 gm of iv ancef intravenously piggyback. the abdomen was prepared and draped in routine sterile fashion.,a 1-cm incision was made at the umbilicus and a veress needle was inserted. saline test was performed. satisfactory pneumoperitoneum was achieved by insufflation of co2 to a pressure of 14 mmhg. the veress needle was removed. a 10- to 11-mm cannula was inserted. inspection of the peritoneal cavity revealed a gallbladder that was soft and without adhesions to it. it was largely mobile. the liver had a normal appearance as did the peritoneal cavity. a 5-mm cannula was inserted in the right upper quadrant anterior axillary line. a second 5-mm cannula was inserted in the subcostal space. a 10- to 11-mm cannula was inserted into the upper midline.,the gallbladder was reflected in a cephalad direction. the gallbladder was punctured with the aspirating needle, and under c-arm fluoroscopy was filled with contrast, filling the intra- and extrahepatic biliary trees, which appeared normal. extra contrast was aspirated and the aspirating needle was removed. the ampulla was grasped with a second grasper, opening the triangle of calot. the cystic duct was dissected and exposed at its junction with the ampulla, was controlled with a hemoclip, digitally controlled with two clips and divided. this was done while the common duct was in full visualization. the cystic artery was similarly controlled and divided. the gallbladder was dissected from its bed and separated from the liver, brought to the outside through the upper midline cannula and removed.,the subhepatic and subphrenic spaces were irrigated thoroughly with saline solution. there was oozing and bleeding from the lateral 5-mm cannula site, but this stopped spontaneously with removal of the cannula. the subphrenic and subhepatic spaces were again irrigated thoroughly with saline until clear. hemostasis was excellent. co2 was evacuated and the camera removed. the umbilical fascia was closed with 2-0 vicryl, the subcu with 3-0 vicryl, and the skin was closed with 4-0 nylon. sterile dressings were applied. sponge and needle counts were correct.

bnp, (brain natriuretic peptide or b-type natriuretic peptide) is a substance produced in the heart ventricles when there is excessive strain to the heart muscles. a blood test for this can be used as an effective parameter for detecting an acute event of congestive heart failure, where the heart is unable to pump sufficient amount of blood required by the body's needs. when a person has a heart failure (such as mi), bnp is secreted so immensely that it sits well above the measurable range. values above 100 signal a problematic situation and those above 500 a highly demanding state. note that a person with a remote history of heart problems may not have bnp levels elevated, but it is used as a measure of acute events.,on the other hand, ,bmp, or basic metabolic panel is not a single test but a group of 8 tests (glucose, calcium, sodium, potassium, bicarbonate, chloride, bun, creatinine). any test that has the word panel in it is not a single test, so cannot have a single value.,with this logic in mind, if a doctor uses phrases like "bnp/bmp is elevated/negative/positive/is greater than/less than etc." and then a single value, it may not be bmp. you can also take the hint from the file whether the patient presented to the hospital with an acute coronary event. likewise, if he says multiple values for this test, this must be bmp.,

cc: ,sensory loss.,hx: ,25y/o rhf began experiencing pruritus in the rue, above the elbow and in the right scapular region, on 10/23/92. in addition she had paresthesias in the proximal ble and toes of the right foot. her symptoms resolved the following day. on 10/25/92, she awoke in the morning and her legs felt "asleep" with decreased sensation. the sensory loss gradually progressed rostrally to the mid chest. she felt unsteady on her feet and had difficulty ambulating. in addition she also began to experience pain in the right scapular region. she denied any heat or cold intolerance, fatigue, weight loss.,meds:, none.,pmh:, unremarkable.,fhx: ,gf with cad, otherwise unremarkable.,shx:, married, unemployed. 2 children. patient was born and raised in iowa. denied any h/o tobacco/etoh/illicit drug use.,exam:, bp121/66 hr77 rr14 36.5c,ms: a&o to person, place and time. speech normal with logical lucid thought process.,cn: mild optic disk pallor os. no rapd. eom full and smooth. no ino. the rest of the cn exam was unremarkable.,motor: full strength throughout all extremities except for 5/4+ hip extensors. normal muscle tone and bulk.,sensory: decreased pp/lt below t4-5 on the left side down to the feet. decreased pp/lt/vib in ble (left worse than right). allodynic in rue.,coord: intact fnf, hks and ram, bilaterally.,station: no pronator drift. romberg's test not documented.,gait: unsteady wide-based. able to tt and hw. poor tw.,reflexes: 3/3 bue. hoffman's signs were present bilaterally. 4/4 patellae. 3+/3+ achilles with 3-4 beat nonsustained clonus. plantar responses were extensor on the right and flexor on the left.,gen. exam: unremarkable.,course:, cbc, gs, pt, ptt, esr, ft4, tsh, ana, vit b12, folate, vdrl and urinalysis were normal. mri t-spine, 10/27/92, was unremarkable. mri brain, 10/28/92, revealed multiple areas of abnormally increased signal on t2 weighted images in the white matter regions of the right corpus callosum, periventricular region, brachium pontis and right pons. the appearance of the lesions was felt to be strongly suggestive of multiple sclerosis. 10/28/92, lumbar puncture revealed the following csf results: rbc 1, wbc 9 (8 lymphocytes, 1 histiocyte), glucose 55mg/dl, protein 46mg/dl (normal 15-45), csf igg 7.5mg/dl (normal 0.0-6.2), csf igg index 1.3 (normal 0.0-0.7), agarose gel electrophoresis revealed oligoclonal bands in the gamma region which were not seen on the serum sample. beta-2 microglobulin was unremarkable. an abnormal left tibial somatosensory evoked potential was noted consistent with central conduction slowing. visual and brainstem auditory evoked potentials were normal. htlv-1 titers were negative. csf cultures and cytology were negative. she was not treated with medications as her symptoms were primarily sensory and non-debilitating, and she was discharged home.,she returned on 11/7/92 as her symptoms of rue dysesthesia, lower extremity paresthesia and weakness, all worsened. on 11/6/92, she developed slow slurred speech and had marked difficulty expressing her thoughts. she also began having difficulty emptying her bladder. her 11/7/92 exam was notable for normal vital signs, lying motionless with eyes open and nodding and rhythmically blinking every few minutes. she was oriented to place and time of day, but not to season, day of the week and she did not know who she was. she had a leftward gaze preference and right lower facial weakness. her rle was spastic with sustained ankle clonus. there was dysesthetic sensory perception in the rue. jaw jerk and glabellar sign were present.,mri brain, 11/7/92, revealed multiple enhancing lesions in the peritrigonal region and white matter of the centrum semiovale. the right peritrigonal region is more prominent than on prior study. the left centrum semiovale lesion has less enhancement than previously. multiple other white matter lesions are demonstrated on the right side, in the posterior limb of the internal capsule, the anterior periventricular white matter, optic radiations and cerebellum. the peritrigonal lesions on both sides have increased in size since the 10/92 mri. the findings were felt more consistent with demyelinating disease and less likely glioma. post-viral encephalitis, rapidly progressive demyelinating disease and tumor were in the differential diagnosis. lumbar puncture, 11/8/92, revealed: rbc 2, wbc 12 (12 lymphocytes), glucose 57, protein 51 (elevated), cytology and cultures were negative. hiv 1 titer was negative. urine drug screen, negative. a stereotactic brain biopsy of the right parieto-occipital region was consistent with demyelinating disease. she was treated with decadron 6mg iv qhours and cytoxan 0.75gm/m2 (1.25gm). on 12/3/92, she has a focal motor seizure with rhythmic jerking of the lue, loss of consciousness and rightward eye deviation. eeg revealed diffuse slowing with frequent right-sided sharp discharges. she was placed on dilantin. she became depressed.

reason for consult: , peripheral effusion on the cat scan.,history of present illness: , the patient is a 70-year-old caucasian female with prior history of lung cancer, status post upper lobectomy. she was recently diagnosed with recurrent pneumonia and does have a cancer on the cat scan, lung cancer with metastasis. the patient had a visiting nurse for christmas and started having abdominal pain, nausea and vomiting for which, she was admitted. she had a cat scan of the abdomen done, showed moderate pericardial effusion for which cardiology consult was requested. she had an echo done, which shows moderate pericardial effusion with early tamponade. the patient has underlying shortness of breath because of copd, emphysema and chronic cough. however, denies any dizziness, syncope, presyncope, palpitation. denies any prior history of coronary artery disease.,allergies: , no known drug allergies.,medications: , at this time, she is on hydromorphone p.r.n., erythromycin, ceftriaxone, calcium carbonate, ambien. she is on oxygen and nebulizer.,past medical history: , history of copd, emphysema, pneumonia, and lung cancer.,past surgical history: ,hip surgery and resection of the lung cancer 10 years ago.,social history:, still smokes, but less than before. drinks socially.,family history:, noncontributory.,review of systems: , denies any syncope, presyncope, palpitations, shortness of breath, cough, nausea, vomiting, or diarrhea.,physical examination:,general: the patient is comfortable not in any distress.,vital signs: blood pressure 121/79, pulse rate 94, respiratory rate 19, and temperature 97.6.,heent: atraumatic and normocephalic.,neck: supple. no jvd. no carotid bruit.,chest: breath sounds vesicular. clear on auscultation.,heart: pmi could not be localized. s2 and s2 regular. no s3, no s4. no murmur.,abdomen: soft and nontender. positive bowel sounds.,extremities: no cyanosis, clubbing, or edema. pulse 2+.,cns: alert, awake, and oriented x3.,ekg shows normal sinus rhythm, low voltage.,laboratory data: , white cell count 7.3, hemoglobin 12.9, hematocrit 38.1, and platelet at 322,000. sodium 135, potassium 5, bun 6, creatinine 1.2, glucose 71, alkaline phosphatase 263, total protein 5.3, lipase 414, and amylase 57.,diagnostic studies:, chest x-ray shows left upper lobe airspace disease consistent with pneumonia _______. ct abdomen showed diffuse replacement of the _______ metastasis, hepatomegaly, perihepatic ascites, moderate pericardial effusion, small left _______ sigmoid diverticulosis.,assessment:,1. moderate peripheral effusion with early tamponade, probably secondary to lung cancer.,2. lung cancer with metastasis most likely.,3. pneumonia.,4. copd.,plan: , we will get ct surgery consult for pericardial window. continue present medication.

procedure: , urgent cardiac catheterization with coronary angiogram.,procedure in detail: , the patient was brought urgently to the cardiac cath lab from the emergency room with the patient being intubated with an abnormal ekg and a cardiac arrest. the right groin was prepped and draped in usual manner. under 2% lidocaine anesthesia, the right femoral artery was entered. a 6-french sheath was placed. the patient was already on anticoagulation. selective coronary angiograms were then performed using a left and a 3drc catheter. the catheters were reviewed. the catheters were then removed and an angio-seal was placed. there was some hematoma at the cath site.,results,1. the left main was free of disease.,2. the left anterior descending and its branches were free of disease.,3. the circumflex was free of disease.,4. the right coronary artery was free of disease. there was no gradient across the aortic valve.,impression: , normal coronary angiogram.,

preoperative diagnoses: ,1. posttraumatic nasal deformity.,2. nasal obstruction.,3. nasal valve collapse.,4. request for cosmetic change with excellent appearance of nose.,postoperative diagnoses:,1. posttraumatic nasal deformity.,2. nasal obstruction.,3. nasal valve collapse.,4. request for cosmetic change with excellent appearance of nose.,operative procedures:,1. left ear cartilage graft.,2. repair of nasal vestibular stenosis using an ear cartilage graft.,3. cosmetic rhinoplasty.,4. left inferior turbinectomy.,anesthesia: , general via endotracheal tube.,indications for operation: , the patient is with symptomatic nasal obstruction and fixed nasal valve collapse following a previous nasal fracture and attempted repair. we discussed with the patient the indications, risks, benefits, alternatives, and complications of the proposed surgical procedure, she had her questions asked and answered. preoperative imaging was performed in consultation with regard to aesthetic results and communicated via the computerized imager. the patient had questions asked and answered. informed consent was obtained.,procedure in detail: , the patient was taken to the operating room and placed in supine position. the appropriate level of general endotracheal anesthesia was induced. the patient was converted to the lounge chair position, and the nose was anesthetized and vasoconstricted in the usual fashion. procedure began with an inverted going incision and elevation of the skin of the nose in the submucoperichondrial plane over the medial crural footplates and lower lateral cartilages and up over the dorsum. the septal angle was approached and submucoperichondrial flaps were elevated. severe nasal septal deviation to the right hand side and evidence of an old fracture with a separate alignment of the cartilaginous nose from the bony nose was encountered. the upper laterals were divided and medial and lateral osteotomies were carried out. inadequate septal cartilage was noted to be present for use as spreader graft; therefore, left postauricular incision was made, and the conchal bowl cartilage graft was harvested, and it was closed with 3-0 running locking chromic with a sterile cotton ball pressure dressing applied. ear cartilage graft was then placed to put two spreader grafts on the left and one the right. the two on the left extended all the way up to the caudal tip, the one on the right just primarily the medial wall. it was placed in such a way to correct a caudal dorsal deviation of the nasal tip septum. the upper lateral cartilage was noted to be of the same width and length in size. yet, the left lower cartilage was scarred and adherent to the upper lateral cartilage. the upper lateral cartilages were noted to be excessive of uneven length with the right being much taller than the left and that was shortened to the same length. the scar bands were released in the lower lateral cartilages to the upper lateral cartilages to allow free mobilization of the lower lateral cartilages. a middle crus stitch was used to unite the domes, and then the nose was projected by suturing the medial crural footplates of the caudal septum in deep projected fashion. crushed ear cartilage was then placed in the pockets above the spreader grafts in the area of the deficient dorsal nasal height and the lateral nasal sidewall height. the spreader brought an excellent aesthetic appearance to the nose. we left more than 1 cm of dorsal and caudal support for the nasal tip and dorsum height. mucoperichondrial flaps were closed with 4-0 plain gut suture. the skin was closed with 5-0 chromic and 6-0 fast absorbing gut. doyle splints were placed on each side of nasal septum and secured with 3-0 nylon and a denver splint was applied. the patient was awakened in the operating room and taken to the recovery room in good condition.

preoperative diagnoses:,1. cholelithiasis.,2. acute cholecystitis.,postoperative diagnoses:,1. acute on chronic cholecystitis.,2. cholelithiasis.,procedure performed: , laparoscopic cholecystectomy with cholangiogram.,anesthesia: , general.,indications: , this is a 38-year-old diabetic hispanic female patient, with ongoing recurrent episodes of right upper quadrant pain, associated with nausea. ultrasound revealed cholelithiasis. the patient also had somewhat thickened gallbladder wall. the patient was admitted through emergency room last night with acute onset right upper quadrant pain. clinically, it was felt the patient had acute cholecystitis. laparoscopic cholecystectomy with cholangiogram was advised. procedure, indication, risk, and alternative were discussed with the patient in detail preoperatively and informed consent was obtained.,description of procedure: , the patient was put in supine position on the operating table under satisfactory general anesthesia, and abdomen was prepped and draped. a small transverse incision was made just above the umbilicus under local anesthesia. fascia was opened vertically. stay sutures were placed in the fascia. peritoneal cavity was carefully entered. hasson cannula was inserted and peritoneal cavity was insufflated with co2.,laparoscopic camera was inserted, and the patient was placed in reverse trendelenburg, rotated to the left. a 11-mm trocar was placed in the subxiphoid space and two 5-mm in the right subcostal region. examination at this time showed no free fluid, no acute inflammatory changes. liver was grossly normal. gallbladder was noted to be thickened. gallbladder wall with a stone stuck in the neck of the gallbladder and pericholecystic edema, consistent with acute cholecystitis.,the fundus of the gallbladder was retracted superiorly, and dissection was carried at the neck of the gallbladder where a cystic duct was identified and isolated. it was clipped distally and using c-arm fluoroscopy, intraoperative cystic duct cholangiogram was done, which was interpreted as normal. there was slight dilatation noted at the junction of the right and left hepatic duct, but no filling defects or any other pathology was noted. it was presumed that this was probably a congenital anomaly. the cystic duct was clipped twice proximally and divided beyond the clips. cystic artery was identified, isolated, clipped twice proximally, once distally, and divided.,the gallbladder was then removed from its bed using cautery dissection and subsequently delivered through the umbilical port. specimen was sent for histopathology. subhepatic and subdiaphragmatic spaces were irrigated with sterile saline solution. hemostasis was good. trocars were removed under direct vision and peritoneal cavity was evacuated with co2. umbilical area fascia was closed with 0-vicryl figure-of-eight sutures, required extra sutures to close the fascial defect. some difficulty was encountered closing the fascia initially because of the patient's significant amount of subcutaneous fat. in the end, the repair appears to be quite satisfactory. rest of the incisions closed with 3-0 vicryl for the subcutaneous tissues and staples for the skin. sterile dressing was applied.,the patient transferred to recovery room in stable condition.

exam: , left heart cath, selective coronary angiogram, right common femoral angiogram, and starclose closure of right common femoral artery.,reason for exam: , abnormal stress test and episode of shortness of breath.,procedure: , right common femoral artery, 6-french sheath, jl4, jr4, and pigtail catheters were used.,findings:,1. left main is a large-caliber vessel. it is angiographically free of disease,,2. lad is a large-caliber vessel. it gives rise to two diagonals and septal perforator. it erupts around the apex. lad shows an area of 60% to 70% stenosis probably in its mid portion. the lesion is a type a finishing before the takeoff of diagonal 1. the rest of the vessel is angiographically free of disease.,3. diagonal 1 and diagonal 2 are angiographically free of disease.,4. left circumflex is a small-to-moderate caliber vessel, gives rise to 1 om. it is angiographically free of disease.,5. om-1 is angiographically free of disease.,6. rca is a large, dominant vessel, gives rise to conus, rv marginal, pda and one pl. rca has a tortuous course and it has a 30% to 40% stenosis in its proximal portion.,7. lvedp is measured 40 mmhg.,8. no gradient between lv and aorta is noted.,due to contrast concern due to renal function, no lv gram was performed.,following this, right common femoral angiogram was performed followed by starclose closure of the right common femoral artery.,impression:,1. 60% to 70% mid left anterior descending stenosis.,2. mild 30% to 40% stenosis of the proximal right coronary artery.,3. status post starclose closure of the right common femoral artery.,plan: ,plan will be to perform elective pci of the mid lad.

history of present illness:, the patient presents today for followup, recently noted for e. coli urinary tract infection. she was treated with macrobid for 7 days, and only took one nighttime prophylaxis. she discontinued this medication to due to skin rash as well as hives. since then, this had resolved. does not have any dysuria, gross hematuria, fever, chills. daytime frequency every two to three hours, nocturia times one, no incontinence, improving stress urinary incontinence after prometheus pelvic rehabilitation.,renal ultrasound, august 5, 2008, reviewed, no evidence of hydronephrosis, bladder mass or stone. discussed.,previous urine cultures have shown e. coli, november 2007, may 7, 2008 and july 7, 2008.,catheterized urine: , discussed, agreeable done using standard procedure. a total of 30 ml obtained.,impression: , recurrent urinary tract infection in a patient recently noted for another escherichia coli urinary tract infection, completed the therapeutic dose, but stopped the prophylactic macrodantin due to hives. this has resolved.,plan: , we will send the urine for culture and sensitivity, if no infection, patient will call results on monday, and she will be placed on keflex nighttime prophylaxis, otherwise followup as previously scheduled for a diagnostic cystoscopy with dr. x. all questions answered.

history: , the patient is a 19-year-old boy with a membranous pulmonary atresia, underwent initial repair 12/04/1987 consisting of pulmonary valvotomy and placement of 4 mm gore-tex shunt between the ascending aorta and pulmonary artery with a snare. this was complicated by shunt thrombosis __________ utilizing a 10-mm balloon. resulting in significant hypoxic brain injury where he has been left with static encephalopathy and cerebral palsy. on 04/07/1988, he underwent heart catheterization and balloon pulmonary valvuloplasty utilizing a 10-mm balloon. he has been followed conservatively since that time. a recent echocardiogram demonstrated possibly a significant right ventricle outflow tract obstruction with tricuspid valve regurgitation velocity predicting a right ventricular systolic pressure in excess of 180 mmhg. right coronary artery to pulmonary artery fistula was also appreciated. the patient underwent cardiac catheterization to assess hemodynamics associated with his current state of repair.,procedure:, the patient was placed under general endotracheal anesthesia breathing on 30% oxygen throughout the case. cardiac catheterization was performed as outlined in the attached continuation sheets. vascular entry was by percutaneous technique, and the patient was heparinized. monitoring during the procedure included continuous surface ecg, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,using a 7-french sheath, a 6-french wedge catheter was inserted. the right femoral vein advanced through the right heart structures out to the branch pulmonary arteries. this catheter was then exchanged over wire for a 5-french marker pigtail catheter, which was directed into the main pulmonary artery.,using a 5-french sheath, a 5-french pigtail catheter was inserted in the right femoral artery and advanced retrograde to the descending aorta, ascending aorta, and left ventricle. this catheter was then exchanged for a judkins right coronary catheter for selective cannulation of the right coronary artery.,flows were calculated by the fick technique using a measured assumed oxygen consumption and contents derived from radiometer hemoximeter saturations and hemoglobin capacity.,cineangiograms were obtained with injection of the main pulmonary artery and right coronary artery.,after angiography, two normal-appearing renal collecting systems were visualized. the catheters and sheaths were removed and topical pressure applied for hemostasis. the patient was returned to the recovery room in satisfactory condition. there were no complications.,discussion:, oxygen consumption was assumed to be normal. mixed venous saturation was normal with no evidence of intracardiac shunt. left-sided heart was fully saturated. phasic right atrial pressures were normal with an a-wave similar to the normal right ventricular end-diastolic pressure. right ventricular systolic pressure was mildly elevated at 45% systemic level. there was a 25 mmhg peak systolic gradient across the outflow tract to the main branch pulmonary arteries. phasic branch pulmonary artery pressures were normal. right-to-left pulmonary artery capillary wedge pressures were normal with an a-wave similar to the normal left ventricular end-diastolic pressure of 12 mmhg. left ventricular systolic pressure was systemic with no outflow obstruction to the ascending aorta. phasic ascending and descending pressures were similar and normal. the calculated systemic and pulmonary flows were equal and normal. vascular resistances were normal. angiogram with contrast injection in the main pulmonary artery showed catheter induced pulmonary insufficiency. the right ventricle appeared mildly hypoplastic with a good contractility and mild tricuspid valve regurgitation. there is dynamic narrowing of the infundibulum with hypoplastic pulmonary annulus. the pulmonary valve appeared to be thin and moved well. the median branch pulmonary arteries were of good size with normal distal arborization. angiogram with contrast injection in the right coronary artery showed a non-dominant coronary with a small fistula arising from the proximal right coronary artery coursing over the infundibulum and entering the left facing sinus of the main pulmonary artery.,initial diagnoses:,1. membranous pulmonary atresia.,2. atrial septal defect.,3. right coronary artery to pulmonary artery fistula.,surgeries (interventions): ,1. pulmonary valvotomy surgical.,2. aortopulmonary artery central shunt.,3. balloon pulmonary valvuloplasty.,current diagnoses: ,1. pulmonary valve stenosis supplemented to hypoplastic pulmonary annulus.,2. mild right ventricle outflow tract obstruction due to supple pulmonic narrowing.,3. small right coronary artery to main pulmonary fistula.,4. static encephalopathy.,5. cerebral palsy.,management: , the case to be discussed with combined cardiology/cardiothoracic surgery case conference. given the mild degree of outflow tract obstruction in this sedentary patient, aggressive intervention is not indicated. conservative outpatient management is to be recommended. further patient care will be directed by dr. x.

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

procedures,1. left heart catheterization.,2. coronary angiography.,3. left ventriculogram.,preprocedure diagnosis:, atypical chest pain.,postprocedure diagnoses,1. no angiographic evidence of coronary artery disease.,2. normal left ventricular systolic function.,3. normal left ventricular end diastolic pressure.,indication: ,the patient is a 58-year-old male with past medical history significant for polysubstance abuse, chronic tobacco abuse, chronic alcohol dependence with withdrawal, atrial flutter, history of ventricular tachycardia with aicd placement, and hepatitis c. the patient was admitted for atypical chest pain and scheduled for cardiac catheterization.,procedure in detail:, after informed consent was signed by the patient, the patient was taken to the cardiac catheterization laboratory. he was prepped and draped in the usual sterile manner. the right inguinal area was anesthetized with 2% xylocaine. a 4-french sheath was inserted into the right femoral artery using the modified seldinger technique. jl4 and 3drc catheters were used to cannulate the left and right coronary arteries respectively. coronary angiographies were performed. these catheters were removed and exchanged for a 4-french pigtail catheter, which was positioned into the left ventricle. left ventriculography was performed. the patient tolerated the procedure well. at the end of the procedure, all catheters and sheaths were removed. the patient was then transferred to telemetry in a stable condition.,hemodynamic data: , hemodynamic data shows aortic pressures of 100/56 with mean of 70 mmhg and the lv 100/0 with lvedp of 10 mmhg.,aortic valve: ,there is no significant gradient across this valve noted.,lv gram: , a 10 ml of contrast were delivered for 3 seconds for a total of 30 ml. ejection fraction was calculated to be 69%. there were no wall motion abnormalities noted.,angiogram,left main coronary artery: , left main coronary artery is a moderate-caliber vessel free of disease and trifurcates.,lad: , lad is a long, tortuous vessel which wraps around the apex. the lad is small in caliber. in addition, there is a long bifurcating small-caliber diagonal branch noted. lad and its branches are free of disease.,ramus intermedius: , ramus intermedius is a long small-caliber vessel free of disease.,lcx: , lcx is a nondominant small-caliber vessel with long bifurcating small-caliber distal om branch. lcx and its branches are free of disease.,rca:, rca is a dominant small-caliber vessel with long small-caliber pda branch. rca and its branches are free of disease.,impression,1. no angiographic evidence of coronary artery disease.,2. normal left ventricular systolic function.,3. normal left ventricular end diastolic pressure.,recommendation: , recommend to look for alternative causes of chest pain.

history: , the patient is a 34-year-old right-handed female who states her symptoms first started after a motor vehicle accident in september 2005. she may have had a brief loss of consciousness at the time of the accident since shortly thereafter she had some blurred vision, which lasted about a week and then resolved. since that time she has had right low neck pain and left low back pain. she has been extensively worked up and treated for this. mri of the c & t spine and ls spine has been normal. she has improved significantly, but still complains of pain. in june of this year she had different symptoms, which she feels are unrelated. she had some chest pain and feeling of tightness in the left arm and leg and face. by the next morning she had numbness around her lips on the left side and encompassing the whole left arm and leg. symptoms lasted for about two days and then resolved. however, since that time she has had intermittent numbness in the left hand and leg. the face numbness has completely resolved. symptoms are mild. she denies any previous similar episodes. she denies associated dizziness, vision changes incoordination, weakness, change in gait, or change in bowel or bladder function. there is no associated headache.,brief examination reveals normal motor examination with no pronator drift and no incoordination. normal gait. cranial nerves are intact. sensory examination reveals normal facial sensation. she has normal and symmetrical light touch, temperature, and pinprick in the upper extremities. in the lower extremities she has a feeling of dysesthesia in the lateral aspect of the left calf into the lateral aspect of the left foot. in this area she has normal light touch and pinprick. she describes it as a strange unusual sensation.,nerve conduction studies: , motor and sensory distal latencies, evoked response amplitudes, conduction velocities, and f-waves are normal in the left arm and leg.,needle emg: , needle emg was performed in the left leg, lumbosacral paraspinal, right tibialis anterior, and right upper thoracic paraspinal muscles using a disposable concentric needle. it revealed normal insertional activity, no spontaneous activity, and normal motor unit action potential form in all muscles tested.,impression: , this electrical study is normal. there is no evidence for peripheral neuropathy, entrapment neuropathy, plexopathy, or lumbosacral radiculopathy. emg was also performed in the right upper thoracic paraspinal where she has experienced a lot of pain since the motor vehicle accident. this was normal.,based on her history of sudden onset of left face, arm, and leg weakness as well as a normal emg and mri of her spine i am concerned that she had a central event in june of this year. symptoms are now very mild, but i have ordered an mri of the brain with and without contrast and mra of the head and neck with contrast to further elucidate her symptoms. once she has the test done she will phone me and further management will be based on the results.

reason for visit:, weight loss evaluation.,history of present illness:,

history:, the patient is a 25-year-old gentleman who was seen in the emergency room at children's hospital today. he brought his 3-month-old daughter in for evaluation but also wanted to be evaluated himself because he has had "rib cage pain" for the last few days. he denies any history of trauma. he does have increased pain with laughing. per the patient, he also claims to have an elevated temperature yesterday of 101. apparently, the patient did go to the emergency room at abcd yesterday, but due to the long wait, he left without actually being evaluated and then thought that he might be seen today when he came to children's.,past medical history: , the patient has a medical history significant for "staphylococcus infection" that was being treated with antibiotics for 10 days.,current medications: , he states that he is currently taking no medications.,allergies: ,he is not allergic to any medication.,past surgical history: , he denies any past surgical history.,social history: , the patient apparently has a history of methamphetamine use and cocaine use approximately 1 year ago. he also has a history of marijuana used approximately 1 year ago. he currently states that he is in a rehab program.,family history:, unknown by the patient.,physical examination:,vital signs: temperature is 99.9, blood pressure is 108/65, pulse of 84, respirations are 16.,general: he is alert and appeared to be in no acute distress. he had normal hydration.,heent: his pupils were equal, round, reactive. extraocular muscles intact. he had no erythema or exudate noted in his posterior oropharynx.,neck: supple with full range of motion. no lymphadenopathy noted.,respiratory: he had equal breath sounds bilaterally with no wheezes, rales, or rhonchi and no labored breathing; however, he did occasionally have pain with deep inspiration at the right side of his chest.,cardiovascular: regular rate and rhythm. positive s1, s2. no murmurs, rubs, or gallops noted.,gi: nontender, nondistended with normoactive bowel sounds. no masses noted.,skin: appeared normal except on the left anterior tibial area where the patient had a healing skin lesion. there were no vesicles, erythema or induration noted.,musculoskeletal: nontender with normal range of motion.,neuro/psyche: the patient was alert and oriented x3 with nonfocal neurological exam.,assessment: , this is a 25-year-old male with nonspecific right-sided chest/abdominal pain from an unknown etiology.,plan: , due to the fact that this patient is an adult male, we will transfer him to xyz medical center for further evaluation. i have spoken with xyz medical center dr. x who has accepted the patient for transfer. he was advised that the patient will be coming in a private vehicle due to fact that he is completely stable and appears to be in no acute distress. dr. x was happy to accept the transfer and indicated that the patient should come to the emergency room area with the transport paperwork. the plan was explained in detail to the patient who stated that he understood and would comply. the appropriate paperwork was created and one copy was given to the patient.,condition on discharge: , at the time of discharge, he was stable, vital signs stable, in no acute distress.

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.

preoperative diagnosis,bilateral macromastia.,postoperative diagnosis,bilateral macromastia.,operation,bilateral reduction mammoplasty.,anesthesia,general.,findings,the patient had large ptotic breasts bilaterally and had had chronic difficulty with pain in the back and shoulder. right breast was slightly larger than the left this was repaired with a basic wise pattern reduction mammoplasty with anterior pedicle.,procedure,with the patient under satisfactory general endotracheal anesthesia, the entire chest was prepped and draped in usual sterile fashion. a previously placed mark to identify the neo-nipple site was re-identified and carefully measured for asymmetry and appeared to be satisfactory. a keyhole wire ring was then used to outline the basic wise pattern with 6-cm lamps inferiorly. this was then carefully checked for symmetry and appeared to be satisfactory. all marks were then completed and lightly incised on both breasts. the right breast was approached first. the neo-nipple site was de-epithelialized superiorly and then the inferior pedicle was de-epithelialized using cutting cautery. after this had been completed, cutting cautery was used to carry down an incision along the inferior aspect of the periosteum starting immediately. this was taken down to the prepectoral fashion dissected for short distance superiorly, and then blunt dissection was used to mobilize under the superior portion of the breast tissues to the lateral edge of the pectoral muscle. there was very little bleeding with this procedure. after this had been completed, attention was directed to the lateral side, and the inferior incision was made and taken down to the serratus. cautery dissection was then used to carry this up superiorly over the lateral edge of the pectoral muscle to communicate with the previous pocket. after this had been completed, cutting cautery was used to cut around the inferior pedicle completely freeing the superior breast from the inferior breast. hemostasis was obtained with electrocautery. after this had been completed, cutting cautery was used to cut along the superior edge of the redundant tissue and this was tapered under the superior flaps. on the right side, there was a small palpable lobule, which had shown up on mammogram, but nothing except some fat density was identified. this site had been previously marked carefully, and there were no unusual findings and the superior tissue was then sent out separately for pathology. after this had been completed, final hemostasis obtained, and the wound was irrigated and a tagging suture placed to approximate the tissues. the breast cleared and the nipple appeared good.,attention was then directed to the left breast, which was completed in the similar manner. after this had been completed, the patient was placed in a near upright position, and symmetry appeared good, but it was a bit poor on the lateral aspect of the right side, which was little larger and some suction lipectomy was carried out in this area. after completion of this, 1860 grams had been removed from the right and 1505 grams was removed from the left. through separate stab wounds on the lateral aspect, 10-mm flat blake drains were brought out and sutures were then placed **** and irrigated. the wounds were then closed with interrupted 4-0 monocryl on the deep dermis and running intradermal 4-0 monocryl on the skin, packing sutures and staples were removed as they were approached. the nipple was sutured with running intradermal 4-0 monocryl. vascularity appeared good throughout. after this had been completed, all wounds were cleaned and steri-stripped. the patient tolerated the procedure well. all counts were correct. estimated blood loss was less than 150 ml, and she was sent to recovery room in good condition.

identifying data: ,mr. t is a 45-year-old white male.,chief complaint: , mr. t presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus. his confidence and self-esteem are significantly low. he stated he has excessive somnolence, his energy level is extremely low, motivation is low, and he has a lack for personal interests. he has had suicidal ideation, but this is currently in remission. furthermore, he continues to have hopeless thoughts and crying spells. mr. t stated these symptoms appeared approximately two months ago.,history of present illness: , on march 25, 2003, mr. t was fired from his job secondary, to an event at which he stated he was first being harassed by another employee." this other, employee had confronted mr. t with a very aggressive, verbal style, where this employee had placed his face directly in front of mr. t was spitting on him, and called him "bitch." mr. t then retaliated, and went to hit the other employee. due to this event, mr. t was fired. it should be noted that mr. t stated he had been harassed by this individual for over a year and had reported the harassment to his boss and was told to "deal with it.",there are no other apparent stressors in mr. t's life at this time or in recent months. mr. t stated that work was his entire life and he based his entire identity on his work ethic. it should be noted that mr. t was a process engineer for plum industries for the past 14 years.,past psychiatric history:, there is no evidence of any psychiatric hospitalizations or psychiatric interventions other than a recent visit to mr. t's family physician, dr. b at which point mr. t was placed on lexapro with an unknown dose at this time. mr. t is currently seeing dr. j for psychotherapy where he has been in treatment since april, 2003.,past psychiatric review of systems:, mr. t denied any history throughout his childhood, adolescence, and early adulthood for depressive, anxiety, or psychotic disorders. he denied any suicide attempts, or profound suicidal or homicidal ideation. mr. t furthermore stated that his family psychiatric history is unremarkable.,substance abuse history:, mr. t stated he used alcohol following his divorce in 1993, but has not used it for the last two years. no other substance abuse was noted.,legal history: , currently, charges are pending over the above described incident.,medical history: , mr. t denied any hospitalizations, surgeries, or current medications use for any heart disease, lung disease, liver disease, kidney disease, gastrointestinal disease, neurological disease, closed head injury, endocrine disease, infectious, blood or muscles disease other than stating he has a hiatal hernia and hypercholesterolemia.,personal and social history: , mr. t was born in dwyne, missouri, with no complications associated with his birth. originally, he was raised by both parents, but they separated at an early age. when he was about seven years old, he was raised by his mother and stepfather. he did not sustain a relationship with his biological father from that time on. he stated his parents moved a lot, and because this many times he was picked on in his new environments, mr. t stated he was, at times, a rebellious teenager, but he denied any significant inability to socialize, and denied any learning disabilities or the need for special education.,mr. t stated his stepfather was somewhat verbally abusive, and that he committed suicide when mr. t was 18 years old. he graduated from high school and began work at dana corporation for two to three years, after which he worked as an energy, auditor for a gas company. he then became a homemaker while his wife worked for chrysler for approximately two years. mr. t was married for eleven years, and divorced in 1993. he has a son who is currently 20 years old. after being a home maker, mr. t worked for his mother in a restaurant, and moved on from there to work for borg-warner corporation for one to two years before beginning at plum industries, where he worked for 14 years and worked his way up to lead engineer.,mental status exam: mr. t presented with a hyper vigilant appearance, his eye contact was appropriate to the interview, and his motor behavior was tense. at times he showed some involuntary movements that would be more akin to a resting tremor. there was no psychomotor retardation, but there was some mild psychomotor excitement. his speech was clear, concise, but pressured. his attitude was overly negative and his mood was significant for moderate depression, anxiety, anhedonia and loneliness, and mild evidence of anger. there was no evidence of euphoria or diurnal mood variation. his affective expression was restricted range, but there was no evidence of lability. at times, his affective tone and facial expressions were inappropriate to the interview. there was no evidence of auditory, visual, olfactory, gustatory, tactile or visceral hallucinations. there was no evidence of illusions, depersonalizations, or derealizations. mr. t presented with a sequential and goal directed stream of thought. there was no evidence of incoherence, irrelevance, evasiveness, circumstantiality, loose associations, or concrete thinking. there was no evidence of delusions; however, there was some ambivalence, guilt, and self-derogatory thoughts. there was evidence of concreteness for similarities and proverbs. his intelligence was average. his concentration was mildly impaired, and there was no evidence of distractibility. he was oriented to time, place, person and situation. there was no evidence of clouded consciousness or dissociation. his memory was intact for immediate, recent, and remote events.,he presented with poor appetite, easily fatigued, and decreased libidinal drive, as well as excessive somnolence. there was a moderate preoccupation with his physical health pertaining to his headaches. his judgment was poor for finances, family relations, social relations, employment, and, at this time, he had no future plans. mr. t's insight is somewhat moderate as he is aware of his contribution to the problem. his motivation for getting well is good as he accepts offered treatment, complies with recommended treatment, and seeks effective treatments. he has a well-developed empathy for others and capacity for affection.,there was no evidence of entitlement, egocentricity, controllingness, intimidation, or manipulation. his credibility seemed good. there was no evidence for potential self-injury, suicide, or violence. the reliability and completeness of information was very good, and there were no barriers to communication. the information gathered was based on the patient's self-report and objective testing and observation. his attitude toward the examiner was neutral and his attitude toward the examination process was neutral. there was no evidence for indices of malingering as there was no marked discrepancy between claimed impairment and objective findings, and there was no lack of cooperation with the evaluation or poor compliance with treatment, and no evidence of antisocial personality disorder.,impressions: , major depressive disorder, single episode,recommendations and plan: , i recommend mr. t continue with psychopharmacologic care as well as psychotherapy. at this time, the excessive amount of psychiatric symptoms would impede mr. t from seeking employment. furthermore, it appears that the primary precipitating event had occurred on march 25, 2003, when mr. t was fired from his job after being harassed for over a year. as mr. t placed his entire identity and sense of survival on his work, this was a deafening blow to his psychological functioning. furthermore, it only appears logical that this would precipitate a major depressive episode.

preoperative diagnosis:, open calcaneus fracture on the right.,postoperative diagnosis:, open calcaneus fracture on the right.,procedures:, ,1. irrigation and debridement of skin, subcutaneous tissue, fascia and bone associated with an open fracture.,2. placement of antibiotic-impregnated beads.,anesthesia:, general.,blood loss:, minimal.,complications:, none.,findings:, healing skin with no gross purulence identified, some fibrinous material around the beads.,summary:, after informed consent was obtained and verified, the patient was brought to the operating room and placed supine on the operating table. after uneventful general anesthesia was obtained, her right leg was sterilely prepped and draped in a normal fashion. the tourniquet was inflated and the previous wound was opened. dr. x came in to look at the wound and the beads were removed, all 25 beads were extracted, and pulsatile lavage, and curette, etc., were used to debride the wound. the wound margins were healthy with the exception of very central triangular incision area. the edges were debrided and then 19 antibiotic-impregnated beads with gentamicin and tobramycin were inserted and the wound was further closed today.,the skin edges were approximated under minimal tension. the soft dressing was placed. an ace was placed. she was awakened from the anesthesia and taken to recovery room in a stable condition. final needle, instrument, and sponge counts were correct.

reason for consultation: , left hip fracture.,history of present illness: , the patient is a pleasant 53-year-old female with a known history of sciatica, apparently presented to the emergency room due to severe pain in the left lower extremity and unable to bear weight. history was obtained from the patient. as per the history, she reported that she has been having back pain with left leg pain since past 4 weeks. she has been using a walker for ambulation due to disabling pain in her left thigh and lower back. she was seen by her primary care physician and was scheduled to go for mri yesterday. however, she was walking and her right foot got caught on some type of rug leading to place excessive weight on her left lower extremity to prevent her fall. since then, she was unable to ambulate. the patient called paramedics and was brought to the emergency room. she denied any history of fall. she reported that she stepped the wrong way causing the pain to become worse. she is complaining of severe pain in her lower extremity and back pain. denies any tingling or numbness. denies any neurological symptoms. denies any bowel or bladder incontinence.,x-rays were obtained which were remarkable for left hip fracture. orthopedic consultation was called for further evaluation and management. on further interview with the patient, it is noted that she has a history of malignant melanoma, which was diagnosed approximately 4 to 5 years ago. she underwent surgery at that time and subsequently, she was noted to have a spread to the lymphatic system and lymph nodes for which she underwent surgery in 3/2008.,past medical history: , sciatica and melanoma.,past surgical history: ,as discussed above, surgery for melanoma and hysterectomy.,allergies: , none.,social history: , denies any tobacco or alcohol use. she is divorced with 2 children. she lives with her son.,physical examination:,general: the patient is well developed, well nourished in mild distress secondary to left lower extremity and back pain.,musculoskeletal: examination of the left lower extremity, there is presence of apparent shortening and external rotation deformity. tenderness to palpation is present. leg rolling is positive for severe pain in the left proximal hip. further examination of the spine is incomplete secondary to severe leg pain. she is unable to perform a straight leg raising. ehl/edl 5/5. 2+ pulses are present distally. calf is soft and nontender. homans sign is negative. sensation to light touch is intact.,imaging:, ap view of the hip is reviewed. only 1 limited view is obtained. this is a poor quality x-ray with a lot of soft tissue shadow. this x-ray is significant for basicervical-type femoral neck fracture. lesser trochanter is intact. this is a high intertrochanteric fracture/basicervical. there is presence of lytic lesion around the femoral neck, which is not well delineated on this particular x-ray. we need to order repeat x-rays including ap pelvis, femur, and knee.,labs:, have been reviewed.,assessment: , the patient is a 53-year-old female with probable pathological fracture of the left proximal femur.,discussion and plan: , nature and course of the diagnosis has been discussed with the patient. based on her presentation without any history of obvious fall or trauma and past history of malignant melanoma, this appears to be a pathological fracture of the left proximal hip. at the present time, i would recommend obtaining a bone scan and repeat x-rays, which will include ap pelvis, femur, hip including knee. she denies any pain elsewhere. she does have a past history of back pain and sciatica, but at the present time, this appears to be a metastatic bone lesion with pathological fracture. i have discussed the case with dr. x and recommended oncology consultation.,with the above fracture and presentation, she needs a left hip hemiarthroplasty versus calcar hemiarthroplasty, cemented type. indication, risk, and benefits of left hip hemiarthroplasty has been discussed with the patient, which includes, but not limited to bleeding, infection, nerve injury, blood vessel injury, dislocation early and late, persistent pain, leg length discrepancy, myositis ossificans, intraoperative fracture, prosthetic fracture, need for conversion to total hip replacement surgery, revision surgery, dvt, pulmonary embolism, risk of anesthesia, need for blood transfusion, and cardiac arrest. she understands above and is willing to undergo further procedure. the goal and the functional outcome have been explained. further plan will be discussed with her once we obtain the bone scan and the radiographic studies. we will also await for the oncology feedback and clearance.,thank you very much for allowing me to participate in the care of this patient. i will continue to follow up.

history of present illness: , the patient is a charming and delightful 46-year-old woman admitted with palpitations and presyncope.,the patient is active and a previously healthy young woman, who has had nine years of occasional palpitations. symptoms occur three to four times per year and follow no identifiable pattern. she has put thought and effort in trying to identify precipitating factors or circumstances but has been unable to do so. symptoms can last for an hour or more and she feels as if her heart is going very rapidly but has never measured her heart rate. the last two episodes, the most recent of which was yesterday, were associated with feeling of darkness descending as if a shade was being pulled down in front of her vision. on neither occasion did she lose consciousness.,yesterday, she had a modestly active morning taking a walk with her dogs and performing her normal routines. while working on a computer, she had a spell. palpitations persisted for a short time thereafter as outlined in the hospital's admission note prompting her to seek evaluation at the hospital. she was in sinus rhythm on arrival and has been asymptomatic since.,no history of exogenous substance abuse, alcohol abuse, or caffeine abuse. she does have a couple of sodas and at least one to two coffees daily. she is a nonsmoker. she is a mother of two. there is no family history of congenital heart disease. she has had no history of thoracic trauma. no symptoms to suggest thyroid disease.,no known history of diabetes, hypertension, or dyslipidemia. family history is negative for ischemic heart disease.,remote history is significant for an acl repair, complicated by contact urticaria from a neoprene cast.,no regular medications prior to admission.,the only allergy is the neoprene reaction outlined above.,physical examination: , vital signs as charted. pupils are reactive. sclerae nonicteric. mucous membranes are moist. neck veins not distended. no bruits. lungs are clear. cardiac exam is regular without murmurs, gallops, or rubs. abdomen is soft without guarding, rebound masses, or bruits. extremities well perfused. no edema. strong and symmetrical distal pulses.,a 12-lead ekg shows sinus rhythm with normal axis and intervals. no evidence of preexcitation.,laboratory studies: , unremarkable. no evidence of myocardial injury. thyroid function is pending.,two-dimensional echocardiogram shows no evidence of clinically significant structural or functional heart disease.,impression/plan: , episodic palpitations over a nine-year period. outpatient workup would be appropriate. event recorder should be obtained and the patient can be seen again in the office upon completion of that study. suppressive medication (beta-blocker or cardizem) was discussed with the patient for symptomatic improvement, though this would be unlikely to be a curative therapy. the patient expresses a preference to avoid medical therapy if possible.,thank you for this consultation. we will be happy to follow her both during this hospitalization and following discharge. caffeine avoidance was discussed as well.,addendum: , during her initial evaluation, a d-dimer was mildly elevated to 5. ct scan showed no evidence of pulmonary embolus. lower extremity venous ultrasound is pending; however, in the absence of embolization to the pulmonary vasculature, this would be an unlikely cause of palpitations. in addition, no progression over the nine-year period that she has been symptomatic suggests that this is an unlikely cause.,

subjective: , this patient presents to the office today because he has not been feeling well. he was in for a complete physical on 05/02/2008. according to the chart, the patient gives a history of feeling bad for about two weeks. at first he thought it was stress and anxiety and then he became worried it was something else. he says he is having a lot of palpitations. he gets a fluttering feeling in his chest. he has been very tired over two weeks as well. his job has been really getting to him. he has been feeling nervous and anxious. it seems like when he is feeling stressed he has more palpitations, sometimes they cause chest pain. these symptoms are not triggered by exertion. he had similar symptoms about 9 or 10 years ago. at that time he went through a full workup. everything ended up being negative and they gave him something that he took for his nerves and he says that helped. unfortunately, he does not remember what it was. also over the last three days he has had some intestinal problems. he has had some intermittent nausea and his stools have been loose. he has been having some really funny green color to his bowel movements. there has been no blood in the stool. he is not having any abdominal pain, just some nausea. he does not have much of an appetite. he is a nonsmoker.,objective: , his weight today is 168.4 pounds, blood pressure 142/76, temperature 97.7, pulse 68, and respirations 16. general exam: the patient is nontoxic and in no acute distress. there is no labored breathing. psychiatric: he is alert and oriented times 3. ears: tympanic membranes pearly gray bilaterally. mouth: no erythema, ulcers, vesicles, or exudate noted. eyes: pupils equal, round, and reactive to light bilaterally. neck is supple. no lymphadenopathy. lungs: clear to auscultation. no rales, rhonchi, or wheezing. cardiac: regular rate and rhythm without murmur. extremities: no edema, cyanosis, or clubbing.,assessment: ,1. palpitations, possibly related to anxiety.,2. fatigue.,3. loose stools with some green color and also some nausea. there has been no vomiting, possibly a touch of gastroenteritis going on here.,plan: , the patient admits he has been putting this off now for about two weeks. he says his work is definitely contributing to some of his symptoms and he feels stressed. he is leaving for a vacation very soon. unfortunately, he is actually leaving wednesday for xyz, which puts us into a bit of a bind in terms of doing testing on him. my overall opinion is he has some anxiety related issues and he may also have a touch of gastroenteritis. a 12-lead ekg was performed on him in the office today. this ekg was compared with the previous ekg contained in the chart from 2006 and i see that these ekgs look very similar with no significant changes noted, which is definitely a good news. i am going to send him to the lab from our office to get the following tests done: comprehensive metabolic profile, cbc, urinalysis with reflex to culture and we will also get a chest x-ray. tomorrow morning i will manage to schedule him for an exercise stress test at bad axe hospital. we were able to squeeze him in. his appointment is at 8:15 in the morning. he is going to have the stress test done in the morning and he will come back to the office in the afternoon for recheck. i am not going to be here so he is going to see dr. x. dr. x should hopefully be able to call over and speak with the physician who attended the stress test and get a preliminary result before he leaves for xyz. certainly, if something comes up we may need to postpone his trip. we petitioned his medical records from his former physician and with luck we will be able to find out what medication he was on about nine or ten years ago. in the meantime i have given him ativan 0.5 mg one tablet two to three times a day as needed for anxiety. i talked about ativan, how it works. i talked about the side effects. i told him to use it only as needed and we can see how he is doing tomorrow when he comes back for his recheck. i took him off of work today and tomorrow so he could rest.

preoperative diagnosis: ,bladder cancer.,postoperative diagnosis: , bladder cancer.,operation: ,transurethral resection of the bladder tumor (turbt), large.,anesthesia:, general endotracheal.,estimated blood loss: , minimal.,fluids: , crystalloid.,brief history: , the patient is an 82-year-old male who presented to the hospital with renal insufficiency, syncopal episodes. the patient was stabilized from cardiac standpoint on a renal ultrasound. the patient was found to have a bladder mass. the patient does have a history of bladder cancer. options were watchful waiting, resection of the bladder tumor were discussed. risk of anesthesia, bleeding, infection, pain, mi, dvt, pe were discussed. the patient understood all the risks, benefits, and options and wanted to proceed with the procedure.,details of the or: ,the patient was brought to the or, anesthesia was applied. the patient was placed in dorsal lithotomy position. the patient was prepped and draped in the usual sterile fashion. a 23-french scope was inserted inside the urethra into the bladder. the entire bladder was visualized, which appeared to have a large tumor, lateral to the right ureteral opening.,there was a significant papillary superficial fluffiness around the left ________. there was a periureteral diverticulum, lateral to the left ureteral opening. there were moderate trabeculations throughout the bladder. there were no stones. using a french cone tip catheter, bilateral pyelograms were obtained, which appeared normal. subsequently, using 24-french cutting loop resectoscope a resection of the bladder tumor was performed all the way up to the base. deep biopsies were sent separately. coagulation was performed around the periphery and at the base of the tumor. all the tumors were removed and sent for path analysis. there was an excellent hemostasis. the rest of the bladder appeared normal. there was no further evidence of tumor. at the end of the procedure, a 22 three-way catheter was placed, and the patient was brought to the recovery in a stable condition.

chief complaint:, back and hip pain.,history of present illness:, the patient is a 73 year old caucasian male with a history of hypertension, end-stage renal disease secondary to reflux nephropathy / restriction of bladder neck requiring hemodialysis and eventual cadaveric renal transplant now on chronic immunosuppression, peripheral vascular disease with non-healing ulcer of right great toe, and peripheral neuropathy who initially presented to his primary care physician in may 2001 with complaints of low back pain and bilateral hip pain. the pain was described as a constant pain in the middle to lower back and hips. the pain was exacerbated by climbing stairs and in the morning after sleeping. he reported occasional radiation of pain from back into buttocks (greatest on the right side). he has history of chronic feet and leg numbness and paraesthesias related to his neuropathy, but he denied any recent changes in these symptoms in relation to the back pain. he denied any history of trauma. he was treated symptomatically with acetaminophen with only some relief. he continued to complain intermittently of pain in his back and hips, and occasionally even in his elbows during the next 8 months. in january 2002, plain pelvic films showed no fracture or dislocation of the hips. elbow films also showed no acute injury, but there were some erosions along the posterior aspect of the olecranon. an mri was performed of his lumbar spine which showed degenerative disk disease, spondylosis, and annular bulging/herniation at l4-l5 with resultant encroachment on the neural foramen. he was evaluated by neurosurgery, who felt he should not have surgery at this time. his pain continued and progressively worsened, becoming unresponsive to medical therapy including narcotics,in may 2002, as part of a vascular work-up for the patient’s non-healing right toe, an mra showed extensive vascular disease in the vessels of both legs below the knees and evidence of bilateral trochanteric bursitis. it also revealed an abnormal enhancing lesion in the left proximal femur, the left iliac bone, the right iliac bone, and possibly the right tibia.,past medical history:,end stade renal disease secondary to reflux nephropathy,a. numerous related urinary tract infections,b. hemodialysis (1983-1988),c. s/p cadaveric renal transplant (1988),d. baseline creatinine about 2.3.,hypertension,peripheral vascular disease,a. history of right foot infected toenail and non-healing ulcer since 2000; receiving hyperbaric oxygen therapy; recent surgery on infected toe in march, 2002,peripheral neuropathy,chronic anemia (on epogen injections),history of several partial small bowel obstructions - six times during the last 10 years,past surgical history:,1. tonsillectomy and adenoidectomy (1943),2. left ureter re-implantation (1960),3. repair of splenic artery aneurysm (1968),4. left arm av fistula graft placement and numerous procedures for dialysis access (1983-1988),5. cadaveric renal transplant (1988),6. cataract surgery in bilateral eyes,medications:,1. imuran 100mg po qd,2. prednisone 7.5mg po qd,3. aspirin 81mg po qd,4. trental 400mg po tid,5. norvasc 5mg po bid,6. prinivil 20mg po bid,7. hydralazine 50mg po q6h,8. clonidine tts iii on thursdays,9. terasozin 5mg po bid,10. elavil 30mg po qhs,11. vicodin 1-2tabs po q6h prn,12. epoetin sr 10,000units sq qm and f,13. sodium bicarbonate 648mg po qd,14. calcium carbonate 2gm po qid,15. docusate sodium 100mg po qd,16. chocolate ensure one can po qid,17. multivitamin,18. vitamin e,social history:, the patient is married with five children and lives with his wife. he is a retired engineer and real estate broker. he denies tobacco use. he drinks alcohol occasionally with up to three drinks a week. no history of drug abuse.,allergies:, no known drug allergies.,family history:

preoperative diagnoses: , multiple metastatic lesions to the brain, a subtentorial lesion on the left, greater than 3 cm, and an infratentorial lesion on the right, greater than 3 cm.,postoperative diagnoses: , multiple metastatic lesions to the brain, a subtentorial lesion on the left, greater than 3 cm, and an infratentorial lesion on the right, greater than 3 cm.,title of the operation:,1. biparietal craniotomy and excision of left parietooccipital metastasis from breast cancer.,2. insertion of left lateral ventriculostomy under stealth stereotactic guidance.,3. right suboccipital craniectomy and excision of tumor.,4. microtechniques for all the above.,5. stealth stereotactic guidance for all of the above and intraoperative ultrasound.,indications: , the patient is a 48-year-old woman with a diagnosis of breast cancer made five years ago. a year ago, she was diagnosed with cranial metastases and underwent whole brain radiation. she recently has deteriorated such that she came to my office, unable to ambulate in a wheelchair. metastatic workup does reveal multiple bone metastases, but no spinal cord compression. she had a consult with radiation-oncology that decided they could radiate her metastases less than 3 cm with stereotactic radiosurgery, but the lesions greater than 3 cm needed to be removed. consequently, this operation is performed.,procedure in detail: , the patient underwent a planning mri scan with stealth protocol. she was brought to the operating room with fiducial still on her scalp. general endotracheal anesthesia was obtained. she was placed on the mayfield head holder and rolled into the prone position. she was well padded, secured, and so forth. the neck was flexed so as to expose the right suboccipital region as well as the left and right parietooccipital regions. the posterior aspect of the calvarium was shaved and prepared in the usual manner with betadine soak scrub followed by betadine paint. this was done only, of course, after fiducial were registered in planning and an excellent accuracy was obtained with the stealth system. sterile drapes were applied and the accuracy of the system was confirmed. a biparietal incision was performed. a linear incision was chosen so as to increase her chances of successful wound healing and that she is status post whole brain radiation. a biparietal craniotomy was carried out, carrying about 1 cm over toward the right side and about 4 cm over to the left side as guided by the stealth stereotactic system. the dura was opened and reflected back to the midline. an inner hemispheric approach was used to reach the very large metastatic tumor. this was very delicate removing the tumor and the co-surgeons switched off to spare one another during the more delicate parts of the operation to remove the tumor. the tumor was wrapped around and included the choroidal vessels. at least one choroidal vessel was sacrificed in order to obtain a gross total excision of the tumor on the parietal occipital region. bleeding was quite vigorous in some of the arteries and finally, however, was completely controlled. complete removal of the tumor was confirmed by intraoperative ultrasound.,once the tumor had been removed and meticulous hemostasis was obtained, this wound was left opened and attention was turned to the right suboccipital area. a linear incision was made just lateral to the greater occipital nerve. sharp dissection was carried down in the subcutaneous tissues and bovie electrocautery was used to reach the skull. a burr hole was placed down low using a craniotome. a craniotomy was turned and then enlarged as a craniectomy to at least 4 cm in diameter. it was carried caudally to the floor of the posterior fossa and rostrally to the transverse sinus. stealth and ultrasound were used to localize the very large tumor that was within the horizontal hemisphere of the cerebellum. the ventriculostomy had been placed on the left side with the craniotomy and removal of the tumor, and this was draining csf relieving pressure in the posterior fossa. upon opening the craniotomy in the parietal occipital region, the brain was noted to be extremely tight, thus necessitating placement of the ventriculostomy.,at the posterior fossa, a corticectomy was accomplished and the tumor was countered directly. the tumor, as the one above, was removed, both piecemeal and with intraoperative cavitron ultrasonic aspirator. a gross total excision of this tumor was obtained as well.,i then explored underneath the cerebellum in hopes of finding another metastasis in the cp angle; however, this was just over the lower cranial nerves, and rather than risk paralysis of pharyngeal muscles and voice as well as possibly hearing loss, this lesion was left alone and to be radiated and that it is less than 3 cm in diameter.,meticulous hemostasis was obtained for this wound as well.,the posterior fossa wound was then closed in layers. the dura was closed with interrupted and running mattress of 4-0 nurolon. the dura was watertight, and it was covered with blue glue. gelfoam was placed over the dural closure. then, the muscle and fascia were closed in individual layers using #0 ethibond. subcutaneous was closed with interrupted inverted 2-0 and 0 vicryl, and the skin was closed with running locking 3-0 nylon.,for the cranial incision, the ventriculostomy was brought out through a separate stab wound. the bone flap was brought on to the field. the dura was closed with running and interrupted 4-0 nurolon. at the beginning of the case, dural tack-ups had been made and these were still in place. the sinuses, both the transverse sinus and sagittal sinus, were covered with thrombin-soaked gelfoam to take care of any small bleeding areas in the sinuses.,once the dura was closed, the bone flap was returned to the wound and held in place with the lorenz microplates. the wound was then closed in layers. the galea was closed with multiple sutures of interrupted 2-0 vicryl. the skin was closed with a running locking 3-0 nylon.,estimated blood loss for the case was more than 1 l. the patient received 2 units of packed red cells during the case as well as more than 1 l of hespan and almost 3 l of crystalloid.,nevertheless, her vitals remained stable throughout the case, and we hopefully helped her survival and her long-term neurologic status for this really nice lady.

date of admission: , mm/dd/yyyy.,date of discharge: , mm/dd/yyyy.,admitting diagnosis:, peritoneal carcinomatosis from appendiceal primary.,discharge diagnosis: , peritoneal carcinomatosis from appendiceal primary.,secondary diagnosis: , diarrhea.,attending physician: , ab cd, m.d.,service: , general surgery c, surgery oncology.,consulting services:, urology.,procedures during this hospitalization:, on mm/dd/yyyy, ,1. cystoscopy, bilaterally retrograde pyelograms, insertion of bilateral externalized ureteral stents.,2. exploratory laparotomy, right hemicolectomy, cholecystectomy, splenectomy, omentectomy, iphc with mitomycin-c.,hospital course: , the patient is a pleasant 56-year-old gentleman with no significant past medical history who after an extensive workup for peritoneal carcinomatosis from appendiceal primary was admitted on mm/dd/yyyy. he was admitted to general surgery c service for a routine preoperative evaluation including baseline labs, bowel prep, urology consult for ureteral stent placement. the patient was taken to the operative suite on mm/dd/yyyy and was first seen by urology for a cystoscopy with bilateral ureteral stent placement. dr. xyz performed an exploratory laparotomy, right hemicolectomy, cholecystectomy, splenectomy, omentectomy, and iphc with mitomycin-c. the procedure was without complications. the patient was observed closely in the icu for one day postoperatively for persistent tachycardia after extubation. he was then transferred to the floor where he has done exceptionally well.,on postoperative day #2, the patient passed flatus and we were able to start a clear liquid diet. we advanced him as tolerated to a regular health select diet by postoperative day #4. his pain was well controlled throughout this hospitalization, initially with a pca pump, which he very seldomly used. he was then switched over to p.o. pain medicines and has required very little for adequate pain control. by postoperative date #2, the patient had been out of bed and ambulating in the hallways. the patient's only problem was with some mild diarrhea on postoperative days #3 and 4. this was thought to be a result of his right hemicolectomy. a c. diff toxin was sent and came back negative and he was started on imodium to manage his diarrhea. his post-splenectomy vaccines including pneumococcal, hib, and meningococcal vaccines were administered during his hospitalization.,on the day of discharge, the patient was resting comfortably in the bed without complaints. he had been afebrile throughout his hospitalization and his vital signs were stable. pertinent physical exam findings include that his abdomen was soft, nondistended and nontender with bowel sounds present throughout. his midline incision is clean, dry, and intact and staples are in place. he is just six days postop, he will go home with his staples in place and they will be removed on his follow-up appointment.,condition at discharge: ,the patient was discharged in good and stable condition.,discharge medications:,1. multivitamins daily.,2. lovenox 40 mg in 0.4 ml solution inject subcutaneously once daily for 14 days.,3. vicodin 5/500 mg and take one tablet by mouth every four hours as needed for pain.,4. phenergan 12.5 mg tablets, take one tablet by mouth every six hours p.r.n. for nausea.,5. imodium a-d tablets take one tablet by mouth b.i.d. as needed for diarrhea.,discharge instructions:, the patient was instructed to contact us with any questions or concerns that may arise. in addition, he was instructed to contact us, if he would have fevers greater than 101.4, chills, nausea or vomitting, continuing diarrhea, redness, drainage, or warmth around his incision site. he will be seen in about one week's time in dr. xyz's clinic and his staples will be removed at that time.,follow-up appointment: , the patient will be seen by dr. xyz in clinic in one week's time.

admitting diagnoses,1. vomiting, probably secondary to gastroenteritis.,2. goldenhar syndrome.,3. severe gastroesophageal reflux.,4. past history of aspiration and aspiration pneumonia.,discharge diagnoses,1. gastroenteritis versus bowel obstruction.,2. gastroesophageal reflux.,3. goldenhar syndrome.,4. anemia, probably iron deficiency.,history of present illness:, this is a 10-week-old female infant who has goldenhar syndrome and has a gastrostomy tube in place and a j-tube in place. she was noted to have vomiting approximately 18 to 24 hours prior to admission and was seen in the emergency department and then admitted.,because of her goldenhar syndrome and previous problems with aspiration, she is not fed my mouth, but does have a g-tube. however, she has not been tolerating feedings through this prior to admission.,physical examination:,general: at transfer to unm on october 13, 2003 reveals a dysmorphic infant who is small and slightly cachectic. her left side of the face is deformed with microglia present, micrognathia present, and a moderate amount of torticollis.,vital signs: presently, her temperature is 98, pulse 152, respirations 36, weight is 3.98 kg, pulse oximetry on room air is 95%.,heent: head is with anterior fontanelle open. eyes: red reflex elicited bilaterally. left ear is without an external ear canal and the right is not well visualized at this time. nose is presently without any discharge, and throat is nonerythematous. neck: neck with torticollis exhibited.,lungs: presently are clear to auscultation.,heart: regular rate without murmur, click or gallop present. abdomen: moderately distended, but soft. bowel sounds are decreased, and there is a g-tube and a j-tube in place. the skin surrounding the g-tube is moderately erythematous, but without any discharges present. j-tube is with a dressing in place and well evaluated.,extremities: grossly normal. hip defects are not checked at this time.,genitalia: normal female.,neurologic: the infant does have a suck reflex, feeding grasp-reflex, and a feeding moro reflex.,skin: warm and dry and there is a macular area to the left ___ that is approximately 1 cm in length.,laboratory data: , wbc count on october 12, 2003 is 12,600 with 16 segs, 6 bands, 54 lymphocytes, 13% of which are noted to be reactive. hemoglobin is 10.4, hematocrit 30.8, and she has abnormal red blood cell morphology. rdw is 13.1 and mcv is 91. sodium level is 138, potassium 5.4, chloride 103, co2 23, bun 7, creatinine 0.4, glucose 84, calcium 9.9, and at this dictation, the report on the abdominal flat plate is pending.,hospital course: ,the child was placed at bowel rest initially and then re-tried on full strength formula, but she did not tolerate. she was again placed on bowel rest and her medications, pepcid and reglan, were given in an attempt to increase bowel motility. feedings were re-attempted with pedialyte through the j-tube and these did not result in production of any stool and the child then began having vomiting again. the vomitus was noted to be bilious in nature and with particulate matter present.,after consultation with dr. x, it was determined the child probably needed further evaluation, and she had both of her drains placed to gravity and was kept n.p.o. her fluids have been d5 and 0.25 normal saline with 20 meq/l of potassium chloride, which has run at her maintenance of 16 ml/h.,consultations: , with dr. x and dr. y and the child is now ready for transport for continued diagnosis and treatment. her condition at discharge is stable.

reason for consultation: ,abnormal echocardiogram findings and followup. shortness of breath, congestive heart failure, and valvular insufficiency.,history of present illness: ,the patient is an 86-year-old female admitted for evaluation of abdominal pain and bloody stools. the patient has colitis and also diverticulitis, undergoing treatment. during the hospitalization, the patient complains of shortness of breath, which is worsening. the patient underwent an echocardiogram, which shows severe mitral regurgitation and also large pleural effusion. this consultation is for further evaluation in this regard. as per the patient, she is an 86-year-old female, has limited activity level. she has been having shortness of breath for many years. she also was told that she has a heart murmur, which was not followed through on a regular basis.,coronary risk factors: , history of hypertension, no history of diabetes mellitus, nonsmoker, cholesterol status unclear, no prior history of coronary artery disease, and family history noncontributory.,family history: ,nonsignificant.,past surgical history: , no major surgery.,medications: , presently on lasix, potassium supplementation, levaquin, hydralazine 10 mg b.i.d., antibiotic treatments, and thyroid supplementation.,allergies: ,ambien, cardizem, and ibuprofen.,personal history:, she is a nonsmoker. does not consume alcohol. no history of recreational drug use.,past medical history: ,basically gi pathology with diverticulitis, colitis, hypothyroidism, arthritis, questionable hypertension, no prior history of coronary artery disease, and heart murmur.,review of systems,constitutional: weakness, fatigue, and tiredness.,heent: history of cataract, blurred vision, and hearing impairment.,cardiovascular: shortness of breath and heart murmur. no coronary artery disease.,respiratory: shortness of breath. no pneumonia or valley fever.,gastrointestinal: no nausea, vomiting, hematemesis, or melena.,urological: no frequency or urgency.,musculoskeletal: arthritis and severe muscle weakness.,skin: nonsignificant.,neurological: no tia or cva. no seizure disorder.,endocrine/hematological: as above.,physical examination,vital signs: pulse of 84, blood pressure of 168/74, afebrile, and respiratory rate 16 per minute.,heent/neck: head is atraumatic and normocephalic. neck veins flat. no significant carotid bruits appreciated.,lungs: air entry bilaterally fair. no obvious rales or wheezes.,heart: pmi displaced. s1, s2 with systolic murmur at the precordium, grade 2/6.,abdomen: soft and nontender.,extremities: chronic skin changes. feeble pulses distally. no clubbing or cyanosis.,diagnostic data: , ekg: normal sinus rhythm. no acute st-t changes.,echocardiogram report was reviewed.,laboratory data:, h&h 13 and 39. bun and creatinine within normal limits. potassium within normal limits. bnp 9290.,impression:,1. the patient admitted for gastrointestinal pathology, under working treatment.,2. history of prior heart murmur with echocardiogram findings as above. basically revealed normal left ventricular function with left atrial enlargement, large pleural effusion, and severe mitral regurgitation and tricuspid regurgitation.,recommendations:,1. from cardiac standpoint, conservative treatment. possibility of a transesophageal echocardiogram to assess valvular insufficiency adequately well discussed extensively.,2. after extensive discussion, given her age 86, limited activity level, and no intention of undergoing any treatment in this regard from a surgical standpoint, the patient does not wish to proceed with a transesophageal echocardiogram.,3. based on the above findings, we will treat her medically with ace inhibitors and diuretics and see how she fares. she has a normal lv function.

procedures,1. left heart catheterization.,2. coronary angiography.,3. left ventriculogram.,preprocedure diagnosis:, atypical chest pain.,postprocedure diagnoses,1. no angiographic evidence of coronary artery disease.,2. normal left ventricular systolic function.,3. normal left ventricular end diastolic pressure.,indication: ,the patient is a 58-year-old male with past medical history significant for polysubstance abuse, chronic tobacco abuse, chronic alcohol dependence with withdrawal, atrial flutter, history of ventricular tachycardia with aicd placement, and hepatitis c. the patient was admitted for atypical chest pain and scheduled for cardiac catheterization.,procedure in detail:, after informed consent was signed by the patient, the patient was taken to the cardiac catheterization laboratory. he was prepped and draped in the usual sterile manner. the right inguinal area was anesthetized with 2% xylocaine. a 4-french sheath was inserted into the right femoral artery using the modified seldinger technique. jl4 and 3drc catheters were used to cannulate the left and right coronary arteries respectively. coronary angiographies were performed. these catheters were removed and exchanged for a 4-french pigtail catheter, which was positioned into the left ventricle. left ventriculography was performed. the patient tolerated the procedure well. at the end of the procedure, all catheters and sheaths were removed. the patient was then transferred to telemetry in a stable condition.,hemodynamic data: , hemodynamic data shows aortic pressures of 100/56 with mean of 70 mmhg and the lv 100/0 with lvedp of 10 mmhg.,aortic valve: ,there is no significant gradient across this valve noted.,lv gram: , a 10 ml of contrast were delivered for 3 seconds for a total of 30 ml. ejection fraction was calculated to be 69%. there were no wall motion abnormalities noted.,angiogram,left main coronary artery: , left main coronary artery is a moderate-caliber vessel free of disease and trifurcates.,lad: , lad is a long, tortuous vessel which wraps around the apex. the lad is small in caliber. in addition, there is a long bifurcating small-caliber diagonal branch noted. lad and its branches are free of disease.,ramus intermedius: , ramus intermedius is a long small-caliber vessel free of disease.,lcx: , lcx is a nondominant small-caliber vessel with long bifurcating small-caliber distal om branch. lcx and its branches are free of disease.,rca:, rca is a dominant small-caliber vessel with long small-caliber pda branch. rca and its branches are free of disease.,impression,1. no angiographic evidence of coronary artery disease.,2. normal left ventricular systolic function.,3. normal left ventricular end diastolic pressure.,recommendation: , recommend to look for alternative causes of chest pain.

preoperative diagnoses:,1. thickened endometrium and tamoxifen therapy.,2. adnexal cyst.,postoperative diagnoses:,1. thickened endometrium and tamoxifen therapy.,2. adnexal cyst.,3. endometrial polyp.,4. right ovarian cyst.,procedure performed:,1. dilation and curettage (d&c).,2. hysteroscopy.,3. laparoscopy with right salpingooophorectomy and aspiration of cyst fluid.,anesthesia: , general.,estimated blood loss: , less than 20 cc.,complications:, none.,indications: , this patient is a 44-year-old gravida 2, para 1-1-1-2 female who was diagnosed with breast cancer in december of 2002. she has subsequently been on tamoxifen. ultrasound did show a thickened endometrial stripe as well as an adnexal cyst. the above procedures were therefore performed.,findings: ,on bimanual exam, the uterus was found to be slightly enlarged and anteverted. the external genitalia was normal. hysteroscopic findings revealed both ostia well visualized and a large polyp on the anterolateral wall of the endometrium. laparoscopic findings revealed a normal-appearing uterus and normal left ovary. there was no evidence of endometriosis on the ovaries bilaterally, the ovarian fossa, the cul-de-sac, or the vesicouterine peritoneum. there was a cyst on the right ovary which appeared simple in nature. the cyst was aspirated and the fluid was blood tinged. therefore, the decision to perform oophorectomy was made. the liver margins appeared normal and there were no pelvic or abdominal adhesions noted. the polyp removed from the hysteroscopic portion of the exam was found to be 4 cm in size.,procedure in detail: , after informed consent was obtained in layman's terms, the patient was taken back to the operating suite, prepped and draped and placed in the dorsal lithotomy position. her bladder was drained with a red robinson catheter. a bimanual exam was performed, which revealed the above findings. a weighted speculum was then placed in the posterior vaginal vault in the 12 o'clock position and the cervix was grasped with vulsellum tenaculum. the cervix was then sounded in the anteverted position to 10 cm. the cervix was then serially dilated using hank and hegar dilators up to a hank dilator of 20 and hagar dilator of 10. the hysteroscope was then inserted and the above findings were noted. a sharp curette was then introduced and the 4 cm polyp was removed. the hysteroscope was then reinserted and the polyp was found to be completely removed at this point. the polyp was sent to pathology for evaluation. the uterine elevator was then placed as a means to manipulate the uterus. the weighted speculum was removed. gloves were changed. attention was turned to the anterior abdominal wall where 1 cm infraumbilical skin incision was made. while tenting up the abdominal wall, the veress needle was inserted without difficulty. using a sterile saline drop test, appropriate placement was confirmed. the abdomen was then insufflated with appropriate volume inflow of co2. the #11 step trocar was placed without difficulty. the above findings were then visualized. a 5 mm port was placed 2 cm above the pubic symphysis. this was done under direct visualization and the grasper was inserted through this port for better visualization. a 12 mm port was then made in the right lateral aspect of the abdominal wall and the endo-gia was inserted through this port and the fallopian tube and ovary were incorporated across the infundibulopelvic ligament. prior to this, the cyst was aspirated using 60 cc syringe on a needle. approximately, 20 cc of blood-tinged fluid was obtained. after the ovary and fallopian tube were completely transected, this was placed in an endocatch bag and removed through the lateral port site. the incision was found to be hemostatic. the area was suction irrigated. after adequate inspection, the port sites were removed from the patient's abdomen and the abdomen was desufflated. the infraumbilical port site and laparoscope were also removed. the incisions were then repaired with #4-0 undyed vicryl and dressed with steri-strips. 10 cc of 0.25% marcaine was then injected locally. the patient tolerated the procedure well. the sponge, lap, and needle counts were correct x2. she will be followed up on an outpatient basis.

preoperative diagnoses:,1. thickened endometrium and tamoxifen therapy.,2. adnexal cyst.,postoperative diagnoses:,1. thickened endometrium and tamoxifen therapy.,2. adnexal cyst.,3. endometrial polyp.,4. right ovarian cyst.,procedure performed:,1. dilation and curettage (d&c).,2. hysteroscopy.,3. laparoscopy with right salpingooophorectomy and aspiration of cyst fluid.,anesthesia: , general.,estimated blood loss: , less than 20 cc.,complications:, none.,indications: , this patient is a 44-year-old gravida 2, para 1-1-1-2 female who was diagnosed with breast cancer in december of 2002. she has subsequently been on tamoxifen. ultrasound did show a thickened endometrial stripe as well as an adnexal cyst. the above procedures were therefore performed.,findings: ,on bimanual exam, the uterus was found to be slightly enlarged and anteverted. the external genitalia was normal. hysteroscopic findings revealed both ostia well visualized and a large polyp on the anterolateral wall of the endometrium. laparoscopic findings revealed a normal-appearing uterus and normal left ovary. there was no evidence of endometriosis on the ovaries bilaterally, the ovarian fossa, the cul-de-sac, or the vesicouterine peritoneum. there was a cyst on the right ovary which appeared simple in nature. the cyst was aspirated and the fluid was blood tinged. therefore, the decision to perform oophorectomy was made. the liver margins appeared normal and there were no pelvic or abdominal adhesions noted. the polyp removed from the hysteroscopic portion of the exam was found to be 4 cm in size.,procedure in detail: , after informed consent was obtained in layman's terms, the patient was taken back to the operating suite, prepped and draped and placed in the dorsal lithotomy position. her bladder was drained with a red robinson catheter. a bimanual exam was performed, which revealed the above findings. a weighted speculum was then placed in the posterior vaginal vault in the 12 o'clock position and the cervix was grasped with vulsellum tenaculum. the cervix was then sounded in the anteverted position to 10 cm. the cervix was then serially dilated using hank and hegar dilators up to a hank dilator of 20 and hagar dilator of 10. the hysteroscope was then inserted and the above findings were noted. a sharp curette was then introduced and the 4 cm polyp was removed. the hysteroscope was then reinserted and the polyp was found to be completely removed at this point. the polyp was sent to pathology for evaluation. the uterine elevator was then placed as a means to manipulate the uterus. the weighted speculum was removed. gloves were changed. attention was turned to the anterior abdominal wall where 1 cm infraumbilical skin incision was made. while tenting up the abdominal wall, the veress needle was inserted without difficulty. using a sterile saline drop test, appropriate placement was confirmed. the abdomen was then insufflated with appropriate volume inflow of co2. the #11 step trocar was placed without difficulty. the above findings were then visualized. a 5 mm port was placed 2 cm above the pubic symphysis. this was done under direct visualization and the grasper was inserted through this port for better visualization. a 12 mm port was then made in the right lateral aspect of the abdominal wall and the endo-gia was inserted through this port and the fallopian tube and ovary were incorporated across the infundibulopelvic ligament. prior to this, the cyst was aspirated using 60 cc syringe on a needle. approximately, 20 cc of blood-tinged fluid was obtained. after the ovary and fallopian tube were completely transected, this was placed in an endocatch bag and removed through the lateral port site. the incision was found to be hemostatic. the area was suction irrigated. after adequate inspection, the port sites were removed from the patient's abdomen and the abdomen was desufflated. the infraumbilical port site and laparoscope were also removed. the incisions were then repaired with #4-0 undyed vicryl and dressed with steri-strips. 10 cc of 0.25% marcaine was then injected locally. the patient tolerated the procedure well. the sponge, lap, and needle counts were correct x2. she will be followed up on an outpatient basis.

preoperative diagnoses: , cervical disk protrusions at c5-c6 and c6-c7, cervical radiculopathy, and cervical pain.,postoperative diagnoses:, cervical disk protrusions at c5-c6 and c6-c7, cervical radiculopathy, and cervical pain.,procedures:, c5-c6 and c6-c7 anterior cervical discectomy (two levels) c5-c6 and c6-c7 allograft fusions. a c5-c7 anterior cervical plate fixation (sofamor danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used. intraoperative ssep and emg monitoring used.,anesthesia: , general endotracheal.,complications:, none.,indication for the procedure: , this lady presented with history of cervical pain associated with cervical radiculopathy with cervical and left arm pain, numbness, weakness, with mri showing significant disk protrusions with the associate complexes at c5-c6 and c6-c7 with associated cervical radiculopathy. after failure of conservative treatment, this patient elected to undergo surgery.,description of procedure: ,the patient was brought to the or and after adequate general endotracheal anesthesia, she was placed supine on the or table with the head of the bed about 10 degrees. a shoulder roll was placed and the head supported on a donut support. the cervical region was prepped and draped in the standard fashion. a transverse cervical incision was made from the midline, which was lateral to the medial edge of the sternocleidomastoid two fingerbreadths above the right clavicle. in a transverse fashion, the incision was taken down through the skin and subcutaneous tissue and through the platysmata and a subplatysmal dissection done. then, the dissection continued medial to the sternocleidomastoid muscle and then medial to the carotid artery to the prevertebral fascia, which was gently dissected and released superiorly and inferiorly. spinal needles were placed into the displaced c5-c6 and c6-c7 to confirm these disk levels using lateral fluoroscopy. following this, monopolar coagulation was used to dissect the medial edge of the longus colli muscles off the adjacent vertebrae between c5-c7 and then the trimline retractors were placed to retract the longus colli muscles laterally and blunt retractors were placed superiorly and inferiorly. a #15 scalpel was used to do a discectomy at c5-c6 from endplate-to-endplate and uncovertebral joint. on the uncovertebral joint, a pituitary rongeur was used to empty out any disk material ____________ to further remove the disk material down to the posterior aspect. this was done under the microscope. a high-speed drill under the microscope was used to drill down the endplates to the posterior aspect of the annulus. a blunt trocar was passed underneath the posterior longitudinal ligament and it was gently released using the #15 scalpel and then kerrison punches 1-mm and then 2-mm were used to decompress further disk calcified material at the c5-c6 level. this was done bilaterally to allow good decompression of the thecal sac and adjacent neuroforamen. then, at the c6-c7 level, in a similar fashion, #15 blade was used to do a discectomy from uncovertebral joint to uncovertebral joint and from endplate-to-endplate using a #15 scalpel to enter the disk space and then the curette was then used to remove the disk calcified material in the endplate, and then high-speed drill under the microscope was used to drill down the disk space down to the posterior aspect of the annulus where a blunt trocar was passed underneath the posterior longitudinal ligament which was gently released. then using the kerrison punches, we used 1-mm and 2-mm, to remove disk calcified material, which was extending more posteriorly to the left and the right. this was gently removed and decompressed to allow good decompression of the thecal sac and adjacent nerve roots. with this done, the wound was irrigated. hemostasis was ensured with bipolar coagulation. vertebral body distraction pins were then placed to the vertebral body of c5 and c7 for vertebral distraction and then a 6-mm allograft performed grafts were taken and packed in either aspect with demineralized bone matrix and this was tapped in flush with the vertebral bodies above and below c5-c6 and c6-c7 discectomy sites. then, the vertebral body distraction pins were gently removed to allow for graft seating and compression and then the anterior cervical plate (danek windows titanium plates) was then taken and sized and placed. a temporary pin was initially used to align the plate and then keeping the position and then two screw holes were drilled in the vertebral body of c5, two in the vertebral body of c6, and two in the vertebral body of c7. the holes were then drilled and after this self-tapping screws were placed into the vertebral body of c5, c6, and c7 across the plate to allow the plate to fit and stay flush with the vertebral body between c5, c6, and c7. with this done, operative fluoroscopy was used to check good alignment of the graft, screw, and plate, and then the wound was irrigated. hemostasis was ensured with bipolar coagulation and then the locking screws were tightened down. a #10 round jackson-pratt drain was placed into the prevertebral space and brought out from a separate stab wound skin incision site. then, the platysma was approximated using 2-0 vicryl inverted interrupted stitches and the skin closed with 4-0 vicryl running subcuticular stitch. steri-strips and sterile dressings were applied. the patient remained hemodynamically stable throughout the procedure. throughout the procedure, the microscope had been used for the disk decompression and high-speed drilling. in addition, intraoperative ssep, emg monitoring, and motor-evoked potentials remained stable throughout the procedure. the patient remained stable throughout the procedure.

history: ,we had the pleasure of seeing the patient today in our pediatric rheumatology clinic. he was sent here with a chief complaint of joint pain in several joints for few months. this is a 7-year-old white male who has no history of systemic disease, who until 2 months ago, was doing well and 2 months ago, he started to complain of pain in his fingers, elbows, and neck. at this moment, this is better and is almost gone, but for several months, he was having pain to the point that he would cry at some point. he is not a complainer according to his mom and he is a very active kid. there is no history of previous illness to this or had gastrointestinal problems. he has problems with allergies, especially seasonal allergies and he takes claritin for it. other than that, he has not had any other problem. denies any swelling except for that doctor mentioned swelling on his elbow. there is no history of rash, no stomach pain, no diarrhea, no fevers, no weight loss, no ulcers in his mouth except for canker sores. no lymphadenopathy, no eye problems, and no urinary problems.,medications: , his medications consist only of motrin only as needed and claritin currently for seasonal allergies and rhinitis.,allergies: , he has no allergies to any drugs.,birth history: ,pregnancy and delivery with no complications. he has no history of hospitalizations or surgeries.,family history: , positive for arthritis in his grandmother. no history of pediatric arthritis. there is history of psoriasis in his dad.,social history: , he lives with mom, dad, brother, sister, and everybody is healthy. they live in easton. they have 4 dogs, 3 cats, 3 mules and no deer. at school, he is in second grade and he is doing pe without any limitation.,physical examination: ,vital signs: temperature is 98.7, pulse is 96, respiratory rate is 24, height is 118.1 cm, weight is 22.1 kg, and blood pressure is 61/44.,general: he is alert, active, in no distress, very cooperative.,heent: he has no facial rash. no lymphadenopathy. oral mucosa is clear. no tonsillitis. his ear canals are clear and pupils are reactive to light and accommodation.,chest: clear to auscultation.,heart: regular rhythm and no murmur.,abdomen: soft, nontender with no visceromegaly.,musculoskeletal: shows no limitation in any of his joints or active swelling today. he has no tenderness either in any of his joints. muscle strength is 5/5 in proximal muscles.,laboratory data:, includes an arthritis panel. it has normal uric acid, sedimentation rate of 2, rheumatoid factor of 6, and antinuclear antibody that is negative and c-reactive protein that is 7.1. his mother stated that this was done while he was having symptoms.,assessment and plan: , this patient may have had reactive arthritis. he is seen frequently and the patient has family history of psoriatic arthritis or psoriasis. i do not see any problems at this moment on his laboratories or on his physical examination. this may have been related to recent episode of viral infection or infection of some sort. mother was oriented about the finding and my recommendation is to observe him and if there is any recurrence of the symptoms or persistence of swelling or limitation in any of his joints, i will be glad to see him back.,if you have any question on further assessment and plan, please do no hesitate to contact us.

discharge diagnoses:,1. acute respiratory failure, resolved.,2. severe bronchitis leading to acute respiratory failure, improving.,3. acute on chronic renal failure, improved.,4. severe hypertension, improved.,5. diastolic dysfunction.,x-ray on discharge did not show any congestion and pro-bnp is normal.,secondary diagnoses:,1. hyperlipidemia.,2. recent evaluation and treatment, including cardiac catheterization, which did not show any coronary artery disease.,3. remote history of carcinoma of the breast.,4. remote history of right nephrectomy.,5. allergic rhinitis.,hospital course:, this 83-year-old patient had some cold symptoms, was treated as bronchitis with antibiotics. not long after the patient returned from mexico, the patient started having progressive shortness of breath, came to the emergency room with severe bilateral wheezing and crepitations. x-rays however did not show any congestion or infiltrates and pro-bnp was within normal limits. the patient however was hypoxic and required 4l nasal cannula. she was admitted to the intensive care unit. the patient improved remarkably over the night on iv steroids and empirical iv lasix. initial swab was positive for mrsa colonization., ,discussed with infectious disease, dr. x and it was decided no treatment was required for de-colonization. the patient's breathing has improved. there is no wheezing or crepitations and o2 saturation is 91% on room air. the patient is yet to go for exercise oximetry. her main complaint is nasal congestion and she is now on steroid nasal spray. the patient was seen by cardiology, dr. z, who advised continuation of beta blockers for diastolic dysfunction. the patient has been weaned off iv steroids and is currently on oral steroids, which she will be on for seven days.,disposition: , the patient has been discharged home.,discharge medications:,1. metoprolol 25 mg p.o. b.i.d.,2. simvastatin 20 mg p.o. daily.,new medications:,1. prednisone 20 mg p.o. daily for seven days.,2. flonase nasal spray daily for 30 days.,results for oximetry pending to evaluate the patient for need for home oxygen.,follow up:, the patient will follow up with pulmonology, dr. y in one week's time and with cardiologist, dr. x in two to three weeks' time.

preoperative diagnoses,1. left lateral fifth ray amputation site cellulitis with infected left fourth metatarsophalangeal joint.,2. osteomyelitis of left distal fifth metatarsal bone at left proximal fourth toe phalanx.,3. plantar fascitis of left distal lateral foot.,postoperative diagnoses,1. left lateral fifth ray amputation site cellulitis with infected left fourth metatarsophalangeal joint.,2. osteomyelitis of left distal fifth metatarsal bone at left proximal fourth toe phalanx.,3. plantar fascitis of left distal lateral foot.,operation performed,1. debridement of left lateral foot ulcer with excision of infected and infarcted interosseous space muscle tendons and fat.,2. sharp excision of left distal foot plantar fascia.,anesthesia:, none required.,indications:, the patient is a 51-year-old diabetic female with severe peripheral vascular disease, who has had angioplasties and single perineal artery runoff to the left leg who developed gangrene of her left fifth toe requiring left fifth ray amputation. she has developed cellulitis of the lateral foot with osteomyelitis and now requires debridement of the local fascitis and necrotic tissue to evaluate for current infectious status and prepare for future amputation.,procedure in detail:, the procedure was performed in the patient's room. the dressing was removed exposing about a 4 cm x 2.5 cm left distal lateral foot fifth ray amputation open wound. distally, there is infarcted left fourth metatarsophalangeal joint capsule, as well as plantar fat below the joint.,she has neuropathy allowing debridement of the tissues.,using sharp scissors and forceps all the necrotic fat and joint capsule area was easily debrided. there was complete infarction of the lateral joint capsule and the head of the phalanx, as well as distal metatarsal head were chronically infected.,the wound was packed with 4x4 gauze pads and dry gauze pads were placed between the toes followed by kerlix roll pad.,the patient suffered no complications from the procedure.

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

reason for consultation: , icu management.,history of present illness: , the patient is a 43-year-old gentleman who presented from an outside hospital with complaints of right upper quadrant pain in the abdomen, which revealed possible portal vein and superior mesenteric vein thrombus leading to mesenteric ischemia. the patient was transferred to the abcd hospital where he had a weeklong course with progressive improvement in his status after aggressive care including intubation, fluid resuscitation, and watchful waiting. the patient clinically improved; however, his white count remained elevated with the intermittent fevers prompting a ct scan. repeat ct scan showed a loculated area of ischemic bowel with perforation in the left upper abdomen. the patient was taken emergently to the operating room last night by the general surgery service where proximal half of the jejunum was noted to be liquified with 3 perforations. this section of small bowel was resected, and a wound vac placed for damage control. plan was to return the patient to the operating room tomorrow for further exploration and possible re-anastomosis of the bowel. the patient is currently intubated, sedated, and on pressors for septic shock and in the down icu.,past medical history:, prior to coming into the hospital for this current episode, the patient had hypertension, diabetes, and gerd.,past surgical history:, included a cardiac cath with no interventions taken.,home medications:, include lantus insulin as well as oral hypoglycemics.,current meds:, include levophed, ativan, fentanyl drips, cefepime, flagyl, fluconazole, and vancomycin. nexium, synthroid, hydrocortisone, and angiomax, which is currently on hold.,review of systems:, unable to be obtained secondary to the patient's intubated and sedated status.,allergies: , none.,family history:, includes diabetes on his father side of the family. no other information is provided.,social history:, includes tobacco use as well as alcohol use.,physical examination:,general: the patient is currently intubated and sedated on levophed drip.,vital signs: temperature is 100.6, systolic is 110/60 with map of 80, and heart rate is 120, sinus rhythm.,neurologic: neurologically, he is sedated, on ativan with fentanyl drip as well. he does arouse with suctioning, but is unable to open his eyes to commands.,head and neck examination: his pupils are equal, round, reactive, and constricted. he has no scleral icterus. his mucous membranes are pink, but dry. he has an eg tube, which is currently 24-cm at the lip. he has a left-sided subclavian vein catheter, triple lumen.,neck: his neck is without masses or lymphadenopathy or jvd.,chest: chest has diminished breath sounds bilaterally.,abdomen: abdomen is soft, but distended with a wound vac in place. groins demonstrate a left-sided femoral outline.,extremities: his bilateral upper extremities are edematous as well as his bilateral lower extremities; however, his right is more than it is in the left. his toes are cool, and pulses are not palpable.,laboratory examination: , laboratory examination reveals an abg of 7.34, co2 of 30, o2 of 108, base excess of -8, bicarb of 16.1, sodium of 144, potassium of 6.5, chloride of 122, co2 18, bun 43, creatinine 2.0, glucose 172, calcium 6.6, phosphorus 1.1, mag 1.8, albumin is 1.6, cortisone level random is 22. after stimulation with cosyntropin, they were still 22 and then 21 at 30 and 60 minutes respectively. lfts are all normal. amylase and lipase are normal. triglycerides are 73, inr is 2.2, ptt is 48.3, white count 20.7, hemoglobin 9.6, and platelets of 211. ua was done, which also shows a specific gravity of 1.047, 1+ protein, trace glucose, large amount of blood, and many bacteria. chest x-rays performed and show the tip of the eg tube at level of the carina with some right upper lobe congestion, but otherwise clear costophrenic angles. tip of the left subclavian vein catheter is appropriate, and there is no pneumothorax noted.,assessment and plan:, this is a 43-year-old gentleman who is acutely ill, in critical condition with mesenteric ischemia secondary to visceral venous occlusion. he is status post small bowel resection. we plan to go back to operating room tomorrow for further debridement and possible closure. neurologically, the patient initially had question of encephalopathy while in the hospital secondary to slow awakening after previous intubation; however, he did clear eventually, and was able to follow commands. i did not suspect any sort of pathologic abnormality of his neurologic status as he has further ct scan of his brain, which was normal. currently, we will keep him sedated and on fentanyl drip to ease pain and facilitate ventilation on the respirator. we will form daily sedation holidays to assess his neurologic status and avoid over sedating with ativan.,1. cardiovascular. the patient currently is in septic shock requiring vasopressors maintained on map greater than 70. we will continue to try to wean the vasopressin after continued volume loading, also place svo2 catheter to assess his oxygen delivery and consumption given his state of shock. currently, his rhythm is of sinus tachycardia, i do not suspect afib or any other arrhythmia at this time. if he does not improve as expected with volume resuscitation and with resolution of his sepsis, we will obtain an echocardiogram to assess his cardiac function. once he is off the vasopressors, we will try low-dose beta blockade as tolerated to reduce his rate.,2. pulmonology. currently, the patient is on full vent support with a rate of 20, tidal volume of 550, pressure support of 10, peep of 6, and fio2 of 60. we will wean his fio2 as tolerated to keep his saturation greater than 90% and wean his peep as tolerated to reduce preload compromise. we will keep the head of bed elevated and start chlorhexidine as swish and swallow for vap prevention.,3. gastrointestinal. the patient has known mesenteric venous occlusion secondary to the thrombus formation at the portal vein as well as the smv. he is status post immediate resection of jejunum leaving a blind proximal jejunum and blind distal jejunum. we will maintain ng tube as he has a blind stump there, and we will preclude any further administration of any meds through this ng tube. i will keep him on gi prophylaxis as he is intubated. we will currently hold his tpn as he is undergoing a large amount of volume changes as well as he is undergoing electrolyte changes. he will have a long-term tpn after this acute episode. his lfts are all normal currently. once he is postop tomorrow, we will restart the angiomax for his venous occlusion.,4. renal. the patient currently is in the acute renal insufficiency with anuria and an increase in his creatinine as well as his potassium. his critical hyperkalemia which is requiring dosing of dextrose insulin, bicarb, and calcium; we will recheck his potassium levels after this cocktail. he currently is started to make more urine since being volume resuscitated with hespan as well as bicarb drip. hopefully given his increased urine output, he will start to eliminate some potassium and will not need dialysis. we will re-consult nephrology at this time.,5. endocrine. the patient has adrenal insufficiency based on lack of stem to cosyntropin. we will start hydrocortisone 50 q.6h.,6. infectious disease. currently, the patient is on broad-spectrum antibiotic prophylaxis imperially. given his bowel ischemia, we will continue these, and appreciate id service's input.,7. hematology. hematologically, the patient has a hypercoagulable syndrome, also had hit secondary to his heparin administration. we will restart the angiomax once he is back from the or tomorrow. currently, his inr is 2.2. therefore, he should be covered at the moment. appreciate the hematology's input in this matter.,please note the total critical care time spent at the bedside excluding central line placement was 1 hour.

reason for referral: , facial twitching.,history of present illness: , the patient had several episodes where she felt like her face was going to twitch, which she could suppress it with grimacing movements of her mouth and face. she reports she is still having right posterior head pressure like sensations approximately one time per week. these still are characterized by a tingling, pressure like sensation that often has a feeling as though water is running down on her hair. this has also decreased in frequency occurring approximately one time per week and seems to respond to over-the-counter analgesics such as aleve. lastly during conversation today, she brought again the problem of daydreaming at work and noted that she occasionally falls asleep when sitting in non-stimulating environments or in front of the television. she states that she feels fatigued all the time and does not get good sleep. she describes it as insomnia, but upon questioning she works from 4 till mid night and then gets home and cannot go to sleep for approximately two hours and wakes up reliably by 9.00 a.m. each morning and sleeps no more than five to six hours ever, but usually five hours. her sleep is relatively uninterrupted except for the need to get up and go to the bathroom. she thinks she may snore, but she is not sure. she does not recall any events of awakening and gasping for breath.,past medical history: , please see my earlier notes in chart.,family history: ,please see my earlier notes in chart.,social history: , please see my earlier notes in charts.,review of systems: ,today, she mainly endorses the tingling sensation in the right posterior head often bilateral as well as a diagnosis of depression and persistent somewhat sad mood, poor sleep, and possible snoring; otherwise, the 10-system review is negative.,physical examination:,general examination: unremarkable mainly for mild-to-moderate obesity with a weight of 258 pounds. otherwise, general examination is unremarkable.,neurological examination: ,as before is nonfocal. please see note in chart for details.,pertinent findings: , since the last evaluation, she has had an mri performed, which was largely unremarkable except for a 1.2 cm lobular t2 hyperintense abnormality at the right clivus and petrous carotid canal, which does not enhance. the nature of this lesion is unclear. certainly, this abnormality would not explain her left facial twitching and is unlikely to be involved with the right posterior sensory changes she experiences.,labs: , she was supposed to have lyme titers and thyroid tests as well as fasting glucose, which were not done; however, in light of her improvement these may not need to be performed at this time.,impression:,1. left facial twitching-appears to be improving. most likely, this is a peripheral nerve injury related to her abscess as previously described. in light of her negative mri and clinical improvement, we discussed options and elected to just observe for now.,2. posterior pressure like headache, also appears to be improving. the etiology is unclear, but as it responds nicely to nonsteroidal antiinflammatories and is decreasing, no further evaluation is needed.,3. probable circadian sleep disorder related to her nighttime work schedule and awakening at 9.00 a.m. with insufficient sleep. there is also the possibility of consistent obstructive sleep apnea and if symptoms worsen then we should consider doing a sleep study. for the time being, sleep hygiene measures were discussed with the patient including trying to sleep later at least till 10.00 a.m. or 10.30 to get a full-night sleep. she is on vacation next week and is going to try to see if this will help. we also discussed as before weight loss and exercise, which could be helpful.,4. right clivus and petrous lesion of unknown etiology. we will repeat the mri at four months to see for interval change.,5. the patient voiced understanding of these plans and will be following up with me in five months.