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preoperative diagnosis: ,left hemothorax, rule out empyema.,postoperative diagnosis: , left hemothorax rule out empyema.,procedure: , insertion of a 12-french pigtail catheter in the left pleural space.,procedure detail: ,after obtaining informed consent, the patient was taken to the minor or in the same day surgery where his posterior left chest was prepped and draped in a usual fashion. xylocaine 1% was injected and then a 12-french pigtail catheter was inserted in the medial scapular line about the eighth intercostal space. it was difficult to draw fluid by syringe, but we connected the system to a plastic bag and by gravity started draining at least 400 ml while we were in the minor or. samples were sent for culture and sensitivity, aerobic and anaerobic.,the patient and i decided to admit him for a period of observation at least overnight.,he tolerated the procedure well and the postprocedure chest x-ray showed no complications.

reason for consult:, renal insufficiency.,history of present illness:, a 48-year-old african-american male with a history of coronary artery disease, copd, congestive heart failure with ef of 20%-25%, hypertension, renal insufficiency, and recurrent episodes of hypertensive emergency, admitted secondary to shortness of breath and productive cough. the patient denies any chest pain, palpitations, syncope, or fever. denied any urinary disturbances, difficulty, burning micturition, hematuria, or back pain. nephrology is consulted regarding renal insufficiency.,review of systems:, reviewed entirely and negative except for hpi.,past medical history:, hypertension, congestive heart failure with ejection fraction of 20%-25% in december 2005, copd, mild diffuse coronary artery disease, and renal insufficiency.,allergies:, no known drug allergies.,medications:, clonidine 0.3 p.o. q.8, aspirin 325 daily, hydralazine 100 q.8, lipitor 20 at bedtime, toprol xl 100 daily.,family history:, noncontributory.,social history:, the patient denies any alcohol, iv drug abuse, tobacco, or any recreational drugs.,physical examination:,vital signs: blood pressure 180/110. temperature 98.1. pulse rate 60. respiratory rate 23. o2 sat 95% on room air.,general: a 48-year-old african-american male in no acute distress.,heent: pupils equal, round, and reactive to light and accommodation. no pallor or icterus.,neck: no jvd, bruit, or lymphadenopathy.,heart: s1 and s2, regular rate and rhythm, no murmurs, rubs, or gallops.,lungs: clear. no wheezes or crackles.,abdomen: soft, nontender, nondistended, no organomegaly, bowel sounds present.,extremities: no cyanosis, clubbing, or edema.,cns: exam is nonfocal.,labs:, wbc 7, h and h 13 and 40, platelets 330, pt 12, ptt 26, co2 20, bun 27, creatinine 3.1, cholesterol 174, bnp 973, troponin 0.18. previous creatinine levels were 2.7 in december. urine drug screen positive for cocaine.,assessment:, a 48-year-old african-american male with a history of coronary artery disease, congestive heart failure, copd, hypertension, and renal insufficiency with:,1. hypertensive emergency.,2. acute on chronic renal failure.,3. urine drug screen positive.,4. question chf versus copd exacerbation.,plan:,1. most likely, renal insufficiency is a chronic problem. hypertensive etiology worsened by the patient's chronic cocaine abuse.,2. control blood pressure with medications as indicated. hypertensive emergency most likely related to cocaine drug abuse.,thank you for this consult. we will continue to follow the patient with you.

subjective:, the patient is a 62-year-old white female with multiple chronic problems including hypertension and a lipometabolism disorder. she follows with dr. xyz on her hypertension, as well as myself. she continues to gain weight. diabetes is therefore a major concern. in fact, her dad had diabetes and she has a brother who has diabetes. the patient also has several additional concerns she brings up today. one is that her left knee continues to bother her and it hurts. she cannot really isolate where the pain is, it just seems to hurt through her knee. she has had this for some time now and in fact as we reviewed her records, her left knee has been x-rayed in 1999. there was some minimal narrowing of the weightbearing joint with some minor hypertrophic spurring medially. she would like to have this x-rayed again today. she is certainly not interested in any surgery. she has noted that it particularly hurts to kneel. in addition, she complains of her stools being a baby-yellow. she has rectal bleeding off and on. it is bright red. she had a colonoscopy done in 1999. she does have a family history of colon cancer questionable in her mother, who is deceased. she complains of some diffuse abdominal pain off and on. she has given up fast foods and her pop and this has not seemed to help. she does admit however, that she is not eating right. sometimes her stools are hard. sometimes they are runny. the blood does not really seem to be related to necessarily a hard stool. it is always bright red and will sometimes drip into the toilet. over the last couple of days, she had also been sneezing and has had an itchy throat. she tried some claritin and this did not help. she has had some body aches. she is finally feeling better today with this. she also is questioning whether she has some sleep apnea. she will awaken suddenly in the middle of the night. she was told that she does snore. she does not smoke. as stated, she has gained significant weight.,gynecological history: , she does not bleed. she has both ovaries, as well as her uterus and cervix. she is on no hormonal therapy.,preventative history:, she is not exercising. she does not do self breast examinations. she has recently had her mammogram and it was unremarkable. she does take her low-dose aspirin daily as well as her multivitamin. she does wear her seatbelt. as previously noted, she does not smoke or drink alcohol.,past medical, family and social history:, per health summary sheet, unchanged.,review of systems:, unremarkable with the exception of that above. ,allergies: , no known drug allergies.,current medications:, benicar 20 mg daily; multivitamin; glucosamine; vitamin b complex; vitamin e and a low-dose aspirin.,objective:,general: well-nourished, well-developed, a very pleasant 61-year-old in no acute distress.,vitals: her weight today is 246 pounds. in march of 2002 she weighed 231 pounds. in march 2001 she weighed 203 pounds. her blood pressure is 160/78. pulse is 84. respiratory rate of 20. she is afebrile.,heent: head is of normocephalic, atraumatic. perla. conjunctivae clear. tms are unremarkable and canals are patent. nasal mucosa is slightly reddened. nares are patent. throat shows some clear posterior pharyngeal drainage. throat is slightly reddened. non-exudative. no oral lesions or dental caries noted.,neck: supple, no adenopathy. thyroid without any nodules or enlargements, no jvd or carotid bruits.,heart: regular rate and rhythm without murmurs, clicks or rubs. pmi is nondisplaced.,lungs: clear to a&p. no cva tenderness.,breast exam: negative for any axillary nodes, skin changes, discrete nodules or nipple discharge. breasts were examined both lying and sitting.,abdomen: soft, nondistended, normoactive bowel sounds, no hepatosplenomegaly or masses. non tender.,pelvic exam: bus unremarkable. speculum exam shows normal physiologic discharge. there are some atrophic vaginal changes. cervix visualized, no gross abnormalities. pap smear obtained. bimanual is negative for any adnexal masses or tenderness. rectal exam is negative for any adnexal masses or tenderness. no rectal masses. she does have some external hemorrhoids, none of which are inflamed at this time. no palpable rectal masses.,neuromusculoskeletal exam: cranial nerves ii-xii are grossly intact. no cerebellar signs are noted. no evidence of a gait disturbance. dtrs are 1+/4+ and equal throughout. good uptoeing. skin: inspection of her skin, subcuticular tissues negative for any concerning skin lesions, rashes or subcuticular masses.,assessment:,1. weight-gain.,2. hypertension.,3. lipometabolism disorder.,4. rectal bleeding.,5. left knee pain.,6. question of sleep apnea.,7. upper respiratory infection, improving.,8. gynecological examination is unremarkable for her age.,plan:, we discussed at length, the issue of sleep apnea and its negative sequela. i have recommended that she be referred for a sleep study. she is certainly at risk for sleep apnea. she refuses this. i do not think that her upper respiratory tract infection needs any further treatment at this time since she is feeling better. i did x-ray her knee and with the exception of some degenerative changes, it was unremarkable. i reviewed this with her. i do think that since she is having rectal bleeding, while this is not real unusual for her, with her family history of colon cancer, i am going to have her discuss this further with dr. xyz and leave further studies up to them. i will dictate dr. xyz a note. i am not going to order any further studies at this time in terms of her yellow stools and right upper quadrant discomfort. she has had a gallbladder sonogram done in the past, this has been unremarkable and these symptoms really have not changed for her. this however, has been some time ago. i suspect she has an element of irritable bowel syndrome. i have strongly encouraged weight reduction, both through diet and exercise. i would like to see her back in the office in six months. i did retake her blood pressure today and it was 130/70. she is fasting this morning, so we will get a fasting blood sugar, chem-12, lipid profile, and cpk. i will her mail the results. i have strongly encouraged medication management if her lipids are elevated. i think she is amenable to this. her dexa scan is up to date having been done on 04/09/03. i do not recommend one this year.

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

chief complaint: ,severe tonsillitis, palatal cellulitis, and inability to swallow.,history of present illness: , this patient started having sore throat approximately one week ago; however, yesterday it became much worse. he was unable to swallow. he complained to his parent. he was taken to med care and did not get any better, and therefore presented this morning to er, where seen and evaluated by dr. x and concerned as whether he had an abscess either pharyngeal, palatal, or peritonsillar. he was noted to have extreme tonsillitis with kissing tonsils, marked exudates especially right side and right palatal cellulitis. a ct scan at er did not show abscess. he has not had airway compromise, but he has had difficulty swallowing. he may have had a low-grade fever, but nothing marked at home. his records from hospital are reviewed as well as the pediatric notes by dr. x. he did have some equivalent leukocytosis. he had a negative monospot and negative strep screen.,past medical history: ,the patient takes no medications, has had no illnesses or surgeries and he is generally in good health other than being significantly overweight. he is a sophomore at high school.,family history: ,noncontributory to this illness.,surgeries: , none.,habits: , nonsmoker, nondrinker. denies illicit drug use.,review of systems:,ent: the patient other than having dysphagia, the patient denies other associated ent symptomatology.,gu: denies dysuria.,orthopedic: denies joint pain, difficulty walking, etc.,neuro: denies headache, blurry vision, etc.,eyes: says vision is intact.,lungs: denies shortness of breath, cough, etc.,skin: he states he has a rash, which occurred from penicillin that he was given im yesterday at covington med care. mildly itchy. mother has penicillin allergy.,endocrine: the patient denies any weight loss, weight gain, skin changes, fatigue, etc, essentially no symptoms of hyper or hypothyroidism.,physical exam:,general: this is a morbidly obese white male adolescent, in no acute disease, alert and oriented x 4. voice is normal. he is handling his secretions. there is no stridor.,vital signs: see vital signs in nurses notes.,ears: tm and eacs are normal. external, normal.,nose: opening clear. external nose is normal.,mouth: has bilateral marked exudates, tonsillitis, right greater than left. uvula is midline. tonsils are touching. there is some redness of the right palatal area, but is not consistent with peritonsillar abscess. tongue is normal. dentition intact. no mucosal lesions other than as noted.,neck: no thyromegaly, masses, or adenopathy except for some small minimally enlarged high jugular nodes.,chest: clear to auscultation.,heart: no murmurs, rubs, or gallops.,abdomen: obese. complete exam deferred.,skin: visualized skin dry and intact, except for rash on his inner thighs and upper legs, which is red maculopapular and consistent with possible allergic reaction.,neuro: cranial nerves ii through xii are intact. eyes, pupils are equal, round, and reactive to light and accommodation, full range.,impression: , marked exudative tonsillitis, non-strep, non-mono, probably mixed anaerobic infection. no significant prior history of tonsillitis. possible rash to penicillin.,recommendations: , i concur with iv clindamycin and iv solu-medrol as per dr. x. i anticipate this patient may need several days of iv antibiotics and then be able to switch over to oral. i do not insist that this patient will need surgical intervention since there is no evidence of abscess. this one episode of severe tonsillitis does not mean the patient needs tonsillectomy, but if he continues to have significant tonsil problems after this he should be referred for ent evaluation as an outpatient. the patient's parents in the room had expressed good understanding, have a chance to ask questions. at this time, i will see the patient back on an as needed basis.

history:, this is a digital eeg performed on a 75-year-old male with seizures.,background activity:, the background activity consists of a 8 hz to 9 hz rhythm arising in the posterior head region. this rhythm is also accompanied by some beta activity which occurs infrequently. there are also muscle contractions occurring at 4 hz to 5 hz which suggests possible parkinson's. part of the eeg is obscured by the muscle contraction artifact. there are also left temporal sharps occurring infrequently during the tracing. at one point of time, there was some slowing occurring in the right frontal head region.,activation procedures:, photic stimulation was performed and did not show any significant abnormality.,sleep patterns:, no sleep architecture was observed during this tracing.,impression:, this awake/alert/drowsy eeg is abnormal due to the presence of slowing in the right frontal head region, due to the presence of sharps arising in the left temporal head region, and due to the tremors. the slowing can be consistent with underlying structural abnormalities, so a stroke, subdural hematoma, etc., should be ruled out. the tremor probably represents a parkinson's tremor and the sharps arising in the left temporal head region can potentially give way to seizures or may also represent underlying structural abnormalities, so clinical correlation is recommended.

preoperative diagnosis:, right buccal and canine's base infection from necrotic teeth. icd9 code: 528.3.,postoperative diagnosis: , right buccal and canine's base infection from necrotic teeth. icd9 code: 528.3.,procedure: , incision and drainage of multiple facial spaces; cpt code: 40801. surgical removal of the following teeth. the teeth numbers 1, 2, 3, 4, and 5. cpt code: 41899 and dental code 7210.,specimens: , cultures and sensitivities were taken and sent for aerobic and anaerobic to the micro lab.,drains: ,a 1.5 inch penrose drain placed in the right buccal and canine space.,estimated blood loss:, 40 ml.,fluid: ,700 ml of crystalloid.,complications: ,none.,condition: ,the patient was extubated breathing spontaneously to the pacu in good condition.,indication for procedure: ,the patient is a 41-year-old that has a recent history of toothache and tooth pain. she saw her dentist in sacaton before thanksgiving who placed her on antibiotics and told her to return to the clinic for multiple teeth extractions. the patient neglected to return to the dentist until this weekend for iv antibiotics and definitive treatment. she noticed on friday that her face was starting to swell up a little bit and it progressively got worse. the patient was admitted to the hospital on monday for iv antibiotics. oral surgery was consulted today to aid in the management of the increased facial swelling and tooth pain. the patient was worked up preoperatively by anesthesia and oromaxillary facial surgery. it was determined that she would benefit from being having multiple teeth removed and drainage of the facial abscess under general anesthesia. risks, benefits, and alternatives of treatment were thoroughly discussed with the patient and consent was obtained.,description of procedure:, the patient was taken to the operating room and laid on the operating room table on supine fashion. asa monitors were attached as stated. general anesthesia was induced with iv anesthetic and maintained with a nasal endotracheal intubation and inhalation of anesthetics. the patient was prepped and draped in usual oromaxillary facial surgery fashion.,an 18-gauze needle of 20 ml syringe was used to aspirate the pus out of the right buccal space. this pus was then cultured and sent to micro lab for cultures and sensitivities. approximately 7 ml of 1% lidocaine with 1:1000 epinephrine was injected in the maxillary vestibule and palate. after waiting appropriate time for local anesthesia to take affect a moist latex sponge was placed in the posterior oropharynx to throat pack throughout the case. mouth rinse was then poured into the oral cavity. the mucosa was scrubbed with a tooth brush and peridex was evacuated with suction. using a #15 blade a clavicular incision from tooth #5 back to 1 with tuberosity release was performed.,a full thickness mucoperiosteal flap was developed and approximately 6 ml of pus was instantly drained from the buccal space. it was noted on exam that the tooth #1 was fractured off to the gum line with gross decay. tooth #2, 3, 4, and 5 had pus leaking from the clavicular epithelium and had rampant decay on tooth #2 and 3 and some mobility on teeth #4 and 5. it was decided that teeth #1 through 5 would be surgically removed to ensure that all potential teeth causing the abscess were removed. using a rongeur both buccal bone and the tooth 1, 2, 3, 4, and 5 were surgically removed. the extraction sites were curetted with curettes and the bone was smoothed with the rongeur and the bone file. dissection was then carried further up in the canine space and the face was palpated extra orally from the temporalis muscle down to the infraorbital rim and more pus was expressed. this site was then irrigated with copious amounts of sterile water. there was still noted to be induration in the buccal mucosa so #15 blade was used anterior to stensen duct. a 2 cm incision was made and using a hemostat blunt dissection in to the buccal mucosa was performed. a little-to-no pus was received. using a half-inch penrose the drain was placed up on the anterior border of the maxilla and zygoma and sutured in place with 2-0 ethilon suture. remainder of the flap was left open to drain. further examination of the floor of mouth was soft. the lateral pharynx was nonindurated or swollen. at this point, the throat pack was removed and og tube was placed and the stomach contents were evacuated. the procedure was then determined to be over. the patient was extubated, breathing spontaneously, and transferred to the pacu in excellent condition.

history of present illness:, this is a 53-year-old widowed woman, she lives at abc hotel. she presented with a complaint of chest pain, evaluations revealed severe aortic stenosis. she has been refusing cardiac catheter and she may well need aortic valve replacement. she states that she does not want heart surgery or valve replacement. she has a history of bipolar disorder and has been diagnosed at times with schizophrenia. she is on depakote 500 mg three times a day and geodon 80 mg twice a day. the patient receives mental health care through the xyz health system and there is a psychiatrist who makes rounds at the abc hotel. she denies hallucinations, psychosis, paranoia, and suicidal ideation at this time. states that she does not want surgery because the chest pain that was a presenting complaint has gone away that she did not feel her problem is severe enough to require surgery, and medical records does show in this obese individual that cardiac surgery would present substantial risks and for this individual with the chronic mental illness and behavioral problems of a chronic nature, surgery does present some additional risks. the patient notes that she has a long history of substance abuse, primarily inhalation of paint vapors that she had more than 100 incarcerations in the xyz county jail related to offenses related to her lifestyle at that time such as shoplifting, violation of orders to abstain from substance abuse and the longest confinement of these was 100 days.,the patient is able to write a fairly reasonable explanation for why she does not want to pursue medical care.,past and developmental history: , she was born in xyz. she is a high-school graduate from abcd high school. she did have an abusive childhood. she is married four times. she notes she developed depression when a number of her children died.,physical examination: ,general: , this is an obese woman in bed. she is somewhat restless and moving during the interview.,vital signs,: temperature of 97.3, pulse 70, respirations 18, blood pressure 113/68, and oxygen saturation 94% on 3 l of oxygen.,psychiatry: ,speech is normal, rate, volume, grammar, and vocabulary consistent with her educational level. there is no overt thought disorder. she does not appear psychotic. she is not suicidal on formal testing. she gives the date as sunday, 05/19/2007 when it is the 20th and 207 when it is 2007. she is oriented to place. she can memorize four times, repeats two at five minutes, gets the other two with category hints, this places short-term memory in normal limits. she had difficulty with serial three subtractions, counting on her fingers and had difficulty naming the months in reverse order stating, "december, november, september, october, june, july, august, september," but recognizes this was not right and then said, "march, april, may." she is able to name objects appropriately.,laboratory data: , chest x-ray showing no acute changes. carotid duplex shows no stenosis. electrolytes and liver function tests are normal. tsh normal. hematocrit 31%. triglycerides 152.,diagnoses: ,1. bipolar disorder, apparently stable on medications.,2. mild organic brain syndrome, presumably secondary to her chronic inhalant, paint, abuse.,3. aortic stenosis.,4. sleep apnea.,5. obesity.,6. anemia.,7. gastroesophageal reflux disease.,recommendations:, it is my impression at present that the patient retains ability to make decisions on her own behalf. given this lady's underlying mental problems, i would recommend that her treating physicians discuss her circumstances with physicians who round on her at the abc hotel. while she may well need surgery and cardiac catheter, she may be more willing to accept this in the context of some continued encouragement from care providers who usually provide care for her. she clearly at this time wants to leave this hospital; she normally gets her care through xyz health. again, in summary, i would consider her to retain the ability to make decisions on her own behalf.,please feel free to contact me at digital pager if additional information is needed.

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

referral indication,1. tachybrady syndrome.,2. chronic atrial fibrillation.,procedures planned and performed,1. implantation of a single-chamber pacemaker.,2. fluoroscopic guidance for implantation of single-chamber pacemaker.,fluoroscopy time: ,1.2 minutes.,medications at the time of study,1. ancef 1 g.,2. benadryl 50 mg.,3. versed 3 mg.,4. fentanyl 150 mcg.,clinical history: , the patient is a pleasant 73-year-old female with chronic atrial fibrillation. she has been found to have tachybrady syndrome, has been referred for pacemaker implantation.,risks and benefits: , risks, benefits, and alternatives of implantation of a single-chamber pacemaker were discussed with the patient. the patient agreed both verbally and via written consent. risks that were discussed included but were not limited to bleeding, infection, vascular injury, cardiac perforation, stroke, myocardial infarction, need for urgent cardiovascular surgery, and death were discussed with the patient. the patient agreed both verbally and via written consent.,description of procedure: , the patient was transported to the cardiac catheterization laboratory in a fasting state. the region of the left deltopectoral groove was prepped and draped in the usual sterile manner. lidocaine 1% (20 ml) was administered to the area. percutaneous access of the left axillary vein was then performed. a wire was then advanced in the left axillary vein using fluoroscopy. following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath. lidocaine 1% (10 ml) was then administered to the medial aspect of the incision and a pocket was fashioned in the medial direction. using the previously placed guidewire, a 7-french sidearm sheath was advanced over the wire into the vein. the dilator and wire were removed. an active pacing lead was then advanced down in the right atrium. the peel-away sheath was removed. lead was passed across the tricuspid valve and positioned in an apical septal location. this was an active fixed lead and the screw was deployed. adequate pacing and sensing function were established. the suture sleeve was then advanced to the entry point of the tissue and connected securely to the tissue. the pocket was washed with antibiotic-impregnated saline. a pulse generator was obtained and connected securely to the lead. the lead was then carefully wrapped behind the pulse generator, and the entire system was placed in the pocket. pocket was then closed with 2-0, 3-0, and 4-0 vicryl using a running mattress stitch. no acute complications were noted.,device data,1. pulse generator, manufacturer st. jude model 12345, serial #123456.,2. right ventricular lead, manufacturer st. jude model 12345, serial #abcd123456.,measured intraoperative data:, right ventricular lead impedance 630 ohms. r wave measures 17.5 mv. pacing threshold of 0.8 v at 0.5 msec.,device settings: , vvi 70 to 120.,conclusions,1. successful implantation of the single-chamber pacemaker with adequate pacing and sensing function.,2. no acute complications.,plan,1. the patient will be admitted for overnight observation and dismissed at the discretion of primary service.,2. chest x-ray to rule out pneumothorax and verify lead position.,3. completion of course of antibiotics.,4. device interrogation in the morning.,5. home dismissal instructions provided in a written format.,6. wound check in 7 to 10 days.,7. enrollment in device clinic.

exam: , ct abdomen and pelvis without contrast, stone protocol, reconstruction.,reason for exam: , flank pain.,technique: , noncontrast ct abdomen and pelvis with coronal reconstructions.,findings: , there is no intrarenal stone bilaterally. however, there is very mild left renal pelvis and proximal ureteral dilatation with a small amount of left perinephric stranding asymmetric to the right. the right renal pelvis is not dilated. there is no stone along the course of the ureter. i cannot exclude the possibility of recent stone passage, although the findings are ultimately technically indeterminate and clinical correlation is advised. there is no obvious solid-appearing mass given the lack of contrast.,scans of the pelvis disclose no evidence of stone within the decompressed bladder. no pelvic free fluid or adenopathy.,there are few scattered diverticula. there is a moderate amount of stool throughout the colon. there are scattered diverticula, but no ct evidence of acute diverticulitis. the appendix is normal.,there are mild bibasilar atelectatic changes.,given the lack of contrast, visualized portions of the liver, spleen, adrenal glands, and the pancreas are grossly unremarkable. the gallbladder is present. there is no abdominal free fluid or pathologic adenopathy.,there are degenerative changes of the lumbar spine.,impression:,1.very mild left renal pelvic dilatation and proximal ureteral dilatation with mild left perinephric stranding. there is no stone identified along the course of the left ureter or in the bladder. could this patient be status post recent stone passage? clinical correlation is advised.,2.diverticulosis.,3.moderate amount of stool throughout the colon.,4.normal appendix.

preoperative diagnosis:, left renal mass, 5 cm in diameter.,postoperative diagnosis:, left renal mass, 5 cm in diameter.,operation performed: , left partial nephrectomy.,anesthesia: , general with epidural.,complications: , none.,estimated blood loss: , about 350 ml.,replacement: , crystalloid and cell savers from the case.,indications for surgery: ,this is a 64-year-old man with a left renal mass that was confirmed to be renal cell carcinoma by needle biopsy. due to the peripheral nature of the tumor located in the mid to lower pole laterally, he has elected to undergo a partial nephrectomy. potential complications include but are not limited to,,1. infection.,2. bleeding.,3. postoperative pain.,4. herniation from the incision.,procedure in detail:, epidural anesthesia was administered in the holding area, after which the patient was transferred into the operating room. general endotracheal anesthesia was administered, after which the patient was positioned in the flank standard position. a left flank incision was made over the area of the twelfth rib. the subcutaneous space was opened by using the bovie. the ribs were palpated clearly and the fascia overlying the intercostal space between the eleventh and twelfth rib was opened by using the bovie. the fascial layer covering of the intercostal space was opened completely until the retroperitoneum was entered. once the retroperitoneum had been entered, the incision was extended until the peritoneal envelope could be identified. the peritoneum was swept medially. the finochietto retractor was then placed for exposure. the kidney was readily identified and was mobilized from outside gerota's fascia. the ureter was dissected out easily and was separated with a vessel loop. the superior aspect of the kidney was mobilized from the superior attachment. the pedicle of the left kidney was completely dissected revealing the vein and the artery. the artery was a single artery and was dissected easily by using a right-angle clamp. a vessel loop was placed around the renal artery. the tumor could be easily palpated in the lateral lower pole to mid pole of the left kidney. the gerota's fascia overlying that portion of the kidney was opened in the area circumferential to the tumor. once the renal capsule had been identified, the capsule was scored using a bovie about 0.5 cm lateral to the border of the tumor. bulldog clamp was then placed on the renal artery. the tumor was then bluntly dissected off of the kidney with a thin rim of a normal renal cortex. this was performed by using the blunted end of the scalpel. the tumor was removed easily. the argon beam coagulation device was then utilized to coagulate the base of the resection. the visible larger bleeding vessels were oversewn by using 4-0 vicryl suture. the edges of the kidney were then reapproximated by using 2-0 vicryl suture with pledgets at the ends of the sutures to prevent the sutures from pulling through. two horizontal mattress sutures were placed and were tied down. the gerota's fascia was then also closed by using 2-0 vicryl suture. the area of the kidney at the base was covered with surgicel prior to tying the sutures. the bulldog clamp was removed and perfect hemostasis was evident. there was no evidence of violation into the calyceal system. a 19-french blake drain was placed in the inferior aspect of the kidney exiting the left flank inferior to the incision. the drain was anchored by using silk sutures. the flank fascial layers were closed in three separate layers in the more medial aspect. the lateral posterior aspect was closed in two separate layers using vicryl sutures. the skin was finally reapproximated by using metallic clips. the patient tolerated the procedure well.

reason for referral: ,the patient was referred to me by dr. x of children's hospital after he was hospitalized for what eventually was diagnosed as a conversion disorder. i had met the patient and his mother in the hospital and had begun getting information regarding his symptoms and background at that time. after his discharge, the patient was scheduled to see me for followup services. this was a 90-minute intake that was completed on 10/10/2007 with the patient's mother. i reviewed with her the treatment consent form as well as the boundaries of confidentiality, and she stated that she understood these concepts.,presenting problems:, please see the inpatient hospital progress note contained in his chart for additional background information. the patient's mother reported that he continues with his conversion episodes. she noted that they are occurring approximately 6 times a day. they consist primarily of tremors, arching his back, and, by her report, doing some gang signs during the episode. she reported that the conversion reactions had decreased after his hospitalization, and he had none for 3 days, but then, they began picking up again. from information gathered from mother, it would suggest that she frequently does "status checks," where she asks him how he is doing, and that after she began checking on him more that he began having more conversion reactions. in terms of what she does when he has a conversion reaction, she reported that primarily that she tries to keep him safe. she puts a sheath under him because the carpeting is dirty. she removes any furniture, she wraps his legs together so they do not knock together, she sits with him and she gives him attention and says "calm down, breathe" and after it is over, she continues to tell him to be calm and to breathe. she denied that she gives them any more attention. i strongly encouraged her to stop doing status checks, as this likely is reinforcing the behavior. i also noted that while he certainly needs to be kept safe, that she does not want to give a lot of attention to this behavior, and that over time we will teach him ways of coping with this independently. in regards to his mood, she reported that his mood is quite good. she denied any sadness or irritability. she denied anhedonia. she reports that he is a little bit hard to get up in the morning. he is going to bed at about 11, getting up at 8 or 9. no changes in weight or eating were noted. no changes in concentration, suicidal ideation, and any suicidal history was denied. she denied symptoms of anxiety, although she did note that she thought he worried a little about going to school and some financial stress. other symptoms of psychopathology were denied.,developmental history: , the patient was reportedly a 7 pounds 12 ounces product of an unplanned and uncomplicated pregnancy and planned cesarean delivery. mother reported that she did receive prenatal care. the use of alcohol, drugs, or tobacco during the pregnancy were denied. she denied that he had any feeding or sleeping problems in the perinatal period. she described him as a fussy and active baby, but he was described as a cuddly baby. she noted that the pediatricians never expressed any concerns regarding his developmental milestones. she reported that he is allergic to penicillin. serious injures or toileting problems were denied as were a history of seizures.,family background: , the patient currently lives with his mother who is age 57 and with her partner who is age 40. they have been together since 1994, and he is the only father figure that the patient has even known. the father was previously in a relationship that resulted in an 11-year-old daughter who visits the patient's home every other weekend. the patient's father's whereabouts are unknown. there is no information on his family. mother stated that he discontinued his involvement in her life when she was about 3 months pregnant with the patient, and the patient has never met him. as noted, there is no information on the paternal side of the family. in terms of the mother's side of family, the maternal grandfather died in his 60s due to what mother described as "hardening of the arteries," and the maternal grandmother died in 2003 due to stroke. there were 4 maternal aunts, one of them died at age 9 months from pneumonia, one of them died at 19 years old from what was described as a brain tumor, and there are 3 maternal uncles. in terms of family relationships, it was reported that overall the patient tends to get along fairly well with his parents, who reported that the patient and her partner tend to compete for mother's attention, and she noted this is difficult at times. she reported that the patient and her partner do not really do anything together. mother reported that there is no domestic violence in the home, but there is some marital conflict, and this is may be difficult for the patient, as it is carried on in spanish, and he does not speak spanish. there also is some stress in the home due to the stepdaughter, as there are some concerns that her mother may be involved in drugs. the mother reported that she attended high school, did not attend any college. she denied learning problems. she denied psychological problems or any drug/alcohol history. in terms of the biological father, she reported he did not graduate from high school. she did not know of learning problems, psychological problems. she denied that he had a drug/alcohol history. there is a family history of alcoholism in one of the maternal uncles as well as in the maternal grandfather. it should be noted that the patient and his family live in a small 4-bedroom apartment, where privacy is very difficult.,social background:, she reported that the patient is able to make and keep friends, but he enjoys lifting weights, skateboarding, and that he recently had an opportunity to do rock climbing, he really enjoyed that. i encouraged her to have him involved in physical activity, as this is good for discharge the stress, to encourage the weightlifting, as well as the skateboarding. mother is going to check further information regarding the rock climbing that the patient had been involved in, which was at it sounds like by her description as some sort of boys' and girls' type of club. abuse of drugs or alcohol were denied. the patient was not described as being sexually active.,academic background: , the patient is currently in the 10th grade. at present, he is on independent studies, which began after his hospitalization. the mother reported that the teacher, who had come to school saw one of his episodes, and stated that, they would not want him to be attending school. i spoke with her very clearly and directly regarding the fact that it was probably not best for the patient to be on independent studies, that he needed to be returned to his normal school environment. he has never had an episode at school, and he needs to be back with his peers, back in a regular environment, where he is under normal expectations. i spoke with her regarding my concerns, regarding the fact that he is unsupervised during the day, and we do not want this turning into one big long vacation, where he is not getting his work done, and he gets himself in trouble. normally, he would be attending at high school. the mother stated that she would contact them as well as check into possibly a 504-plan. she reported that he really does not to go back to high school. he says, the "kids are bad;" however, she denied that he has any history of fighting. she noted that he is stressed by the school, there have been some peer problems, possibly some bullying. i noted these need to be addressed with the school, as she had not done so. she stated that she would speak with a counselor. she noted, however, that he has a history of not liking school and avoiding going to school. she noted that he is somewhat behind in his work due to the hospitalization. his grades traditionally are c's. she denied any special education services.,previous counseling: , denied.,diagnostic summary and impression: , similar to my impression at the hospital, it would appear that the patient clearly qualifies for a diagnosis of conversion disorder. it appears that there are multiple stressors in the family, and that the mother is reinforcing his conversion reaction. i am also very concerned regarding the fact that he is not attending school and want him back in the normal school environment as quickly as possible. my plan is to meet the patient at the next session to update the information regarding his functioning and to begin to teach him skills for reducing his stress and relaxing.,dsm-iv diagnoses: ,axis i: conversion disorder (300.11).,axis ii: no diagnosis (v71.09).,axis iii: no diagnosis.,axis iv: problems with primary support group, educational problems, and peer problems.,axis v: global assessment of functioning equals 60.

lexiscan myoview stress study,reason for the exam: , chest discomfort.,interpretation: , the patient exercised according to the lexiscan study, received a total of 0.4 mg of lexiscan iv injection. at peak hyperemic effect, 24.9 mci of myoview were injected for the stress imaging and earlier 8.2 mci were injected for the resting and the usual spect and gated spect protocol was followed and the data was analyzed using cedars-sinai software. the patient did not walk because of prior history of inability to exercise long enough on treadmill.,the resting heart rate was 57 with the resting blood pressure 143/94. maximum heart rate achieved was 90 with a maximum blood pressure unchanged.,ekg at rest showed sinus rhythm with no significant st-t wave changes of reversible ischemia or injury. subtle nonspecific in iii and avf were seen. maximum stress test ekg showed inverted t wave from v4 to v6. normal response to lexiscan.,conclusion: ,maximal lexiscan perfusion with subtle abnormalities non-conclusive. please refer to the myoview interpretation.,myoview interpretation: , the left ventricle appeared to be normal in size on both stress and rest with no change between the stress and rest with left ventricular end-diastolic volume of 115 and end-systolic of 51. ef estimated and calculated at 56%.,cardiac perfusion reviewed, showed no reversible defect indicative of myocardium risk and no fixed defect indicative of myocardial scarring.,impression:,1. normal stress/rest cardiac perfusion with no indication of ischemia.,2. normal lv function and low likelihood of significant epicardial coronary narrowing.,

informant:, dad on phone. transferred from abcd memorial hospital, rule out sepsis.,history: ,this is a 3-week-old, nsvd, caucasian baby boy transferred from abcd memorial hospital for rule out sepsis and possible congenital heart disease. the patient had a fever of 100.1 on 09/13/2006 taken rectally, and mom being a nurse, took the baby to the hospital and he was admitted for rule out sepsis. all the sepsis workup was done, cbc, ua, lp, and cmp, and since a murmur was noted 2/5, he also had an echo done. the patient was put on ampicillin and cefotaxime. echo results came back and they showed patent foramen ovale/asd with primary pulmonary stenosis and then considering severe congenital heart disease, he was transferred here on vancomycin, ampicillin, and cefotaxime. the patient was n.p.o. when he came in. he was on 3/4 l of oxygen. according to the note, it conveyed that he had some subcostal retractions. on arriving here, baby looks very healthy. he has no subcostal retractions. he is not requiring any oxygen and he is positive for urine and stool. the stool is although green in color, and in the morning today, he spiked a fever of 100.1, but right now he is afebrile. ed called that case is a direct admit.,review of systems: ,the patient supposedly had fever, some weight loss, poor appetite. the day he had fever, no rash, no ear pain, no congestion, no rhinorrhea, no throat pain, no neck pain, no visual changes, no conjunctivitis, no cough, no dyspnea, no vomiting, no diarrhea, and no dysuria. according to mom, baby felt floppy on the day of fever and he also used to have stools every day 4 to 6 which is yellowish-to-green in color, but today the stool we noticed was green in color. he usually has urine 4 to 5 a day, but the day he had fever, his urine also was low. mom gave baby some pedialyte.,past medical history:, none.,hospitalizations:, recent transfer from abcd for the rule out sepsis and heart disease.,birth history: ,born on 08/23/2006 at memorial hospital, nsvd, no complications. hospital stay 24 hours. breast-fed, no formula, no jaundice, 7 pounds 8 ounces.,family history:, none.,surgical history: , none.,social history: ,lives with mom and dad. dad is a service manager at gmc; 4-year-old son, who is healthy; and 2 cats, 2 dogs, 3 chickens, 1 frog. they usually visit to a ranch, but not recently. no sick contact and no travel.,medications: , has been on vancomycin, cefotaxime, and ampicillin.,allergies:, no allergies.,diet:, breast feeds q.2h.,immunizations: , no immunizations.,physical examination:,vital signs: temperature 99, pulse 158, respiratory rate 68, blood pressure 87/48, oxygen 100% on room air.,measurements: weight 3.725 kg.,general: alert and comfortable and sleeping.,skin: no rash.,heent: intact extraocular movements. perrla. no nasal discharge. no nasal cannula, but no oxygen is flowing active, and anterior fontanelle is flat.,neck: soft, nontender, supple.,chest: ctap.,gi: bowel sounds present. nontender, nondistended.,gu: bilaterally descended testes.,back: straight.,neurologic: nonfocal.,extremities: no edema. bilateral pedal pulses present and upper arm pulses are also present.,laboratory data:, as drawn on 09/13/2006 at abcd showed wbc 4.2, hemoglobin 11.8, hematocrit 34.7, platelets 480,000. sodium 140, potassium 4.9, chloride 105, bicarbonate 28, bun 7, creatinine 0.4, glucose 80, crp 0.5. neutrophils 90, bands 7, lymphocytes 27, monocytes 12, and eosinophils 4. chest x-ray done on 09/13/2006 read as mild left upper lobe infiltrate, but as seen here, and discussed with dr. x, we did not see any infiltrate and cbg was normal. ua and lp results are pending. also pending are cultures for blood, lp, and urine.,assessment and plan: , this is a 3-week-old caucasian baby boy admitted for rule out sepsis and congenital heart disease.,infectious disease/pulmonary: , afebrile with so far 20-hour blood cultures, lp and urine cultures are negative. we will get all the results from abcd and until then we will continue to rule out sepsis protocol and put the patient on ampicillin and cefotaxime. the patient could be having fever due to mild gastroenteritis or urinary tract infection, so to rule out all these things we have to wait for all the results.,cvs: , he had a grade 2/5 murmur status post echo, which showed a patent foramen ovale, as well as primary pulmonary stenosis. these are the normal findings in a newborn as discussed with dr. y, so we will just observe the patient. he does not need any further workup.,gastrointestinal:

exam: , ultrasound of pelvis.,history:, menorrhagia.,findings: , uterus is enlarged measuring 11.0 x 7.5 x 11.0 cm. it appears to be completely replaced by multiple ill-defined fibroids. the endometrial echo complex was not visualized due to the contents of replacement of the uterus with fibroids. the right ovary measures 3.9 x 1.9 x 2.3 cm. the left ovary is not seen. no complex cystic adnexal masses are identified.,impression: ,essential replacement of the uterus by fibroids. it is difficult to measure given their heterogenous and diffuse nature. mri of the pelvis could be performed for further evaluation to evaluate for possible uterine fibroid embolization.

title of operation: , right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty.,indication for surgery: , the patient with a large 3.5 cm acoustic neuroma. the patient is having surgery for resection. there was significant cerebellar peduncle compression. the tumor was very difficult due to its size as well as its adherence to the brainstem and the nerve complex. the case took 12 hours. this was more difficult and took longer than the usual acoustic neuroma.,preop diagnosis: , right acoustic neuroma.,postop diagnosis: , right acoustic neuroma.,procedure:, the patient was brought to the operating room. general anesthesia was induced in the usual fashion. after appropriate lines were placed, the patient was placed in mayfield 3-point head fixation, hold into a right park bench position to expose the right suboccipital area. a time-out was settled with nursing and anesthesia, and the head was shaved, prescrubbed with chlorhexidine, prepped and draped in the usual fashion. the incision was made and cautery was used to expose the suboccipital bone. once the suboccipital bone was exposed under the foramen magnum, the high speed drill was used to thin out the suboccipital bone and the craniectomy carried out with leksell and insertion with kerrison punches down to the rim of the foramen magnum as well as laterally to the edge of the sigmoid sinus and superiorly to the edge of the transverse sinus. the dura was then opened in a cruciate fashion, the cisterna magna was drained, which nicely relaxed the cerebellum. the dura leaves were held back with the 4-0 nurolon. the microscope was then brought into the field, and under the microscope, the cerebellar hemisphere was elevated. laterally, the arachnoid was very thick. this was opened with bipolar and microscissors and this allowed for the cerebellum to be further mobilized until the tumor was identified. the tumor was quite large and filled up the entire lateral aspect of the right posterior fossa. initially two retractors were used, one on the tentorium and one inferiorly. the arachnoid was taken down off the tumor. there were multiple blood vessels on the surface, which were bipolared. the tumor surface was then opened with microscissors and the cavitron was used to began debulking the lesion. this was a very difficult resection due to the extreme stickiness and adherence to the cerebellar peduncle and the lateral cerebellum; however, as the tumor was able to be debulked, the edge began to be mobilized. the redundant capsule was bipolared and cut out to get further access to the center of the tumor. working inferiorly and then superiorly, the tumor was taken down off the tentorium as well as out the 9th, 10th or 11th nerve complex. it was very difficult to identify the 7th nerve complex. the brainstem was identified above the complex. similarly, inferiorly the brainstem was able to be identified and cotton balls were placed to maintain this plain. attention was then taken to try identify the 7th nerve complex. there were multitude of veins including the lateral pontine vein, which were coming right into this area. the lateral pontine vein was maintained. microscissors and bipolar were used to develop the plain, and then working inferiorly, the 7th nerve was identified coming off the brainstem. a number 1 and number 2 microinstruments were then used to began to develop the plane. this then allowed for the further appropriate plane medially to be identified and cotton balls were then placed. a number 11 and number 1 microinstrument continued to be used to free up the tumor from the widely spread out 7th nerve. cavitron was used to debulk the lesion and then further dissection was carried out. the nerve stimulated beautifully at the brainstem level throughout this. the tumor continued to be mobilized off the lateral pontine vein until it was completely off. the cavitron was used to debulk the lesion out back laterally towards the area of the porus. the tumor was debulked and the capsule continued to be separated with number 11microinstrument as well as the number 1 microinstrument to roll the tumor laterally up towards the porus. at this point, the capsule was so redundant, it was felt to isolate the nerve in the porus. there was minimal bulk remaining intracranially. all the cotton balls were removed and the nerve again stimulated beautifully at the brainstem. dr. x then came in and scrubbed into the case to drill out the porus and remove the piece of the tumor that was left in the porus and coming out of the porus.,i then scrubbed back into case once dr. x had completed removing this portion of the tumor. there was no tumor remaining at this point. i placed some norian in the porus to seal any air cells, although there were no palpated. an intradural space was then irrigated thoroughly. there was no bleeding. the nerve was attempted to be stimulated at the brainstem level, but it did not stimulate at this time. the dura was then closed with 4-0 nurolons in interrupted fashion. a muscle plug was used over one area. duragen was laid and strips over the suture line followed by hemaseel. gelfoam was set over this and then a titanium cranioplasty was carried out. the wound was then irrigated thoroughly. o vicryls were used to close the deep muscle and fascia, 3-0 vicryl for subcutaneous tissue, and 3-0 nylon on the skin.,the patient was extubated and taken to the icu in stable condition.

reason for referral:, the patient is a 58-year-old african-american right-handed female with 16 years of education who was referred for a neuropsychological evaluation by dr. x. she is presenting for a second opinion following a recent neuropsychological evaluation that was ordered by her former place of employment that suggested that she was in the "early stages of a likely dementia" and was thereafter terminated from her position as a psychiatric nurse. a comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning. note that this evaluation was undertaken as a clinical exam and intended for the purposes of aiding with treatment planning. the patient was fully informed about the nature of this evaluation and intended use of the results.,relevant background information: ,historical information was obtained from a review of available medical records and clinical interview with the patient. a summary of pertinent information is presented below. please refer to the patient's medical chart for a more complete history.,history of presenting problem:, the patient reported that she had worked as a nurse supervisor for hospital center for four years. she was dismissed from this position in september 2009, although she said that she is still under active status technically, but is not able to work. she continues to receive some compensation through fmla hours. she said that she was told that she had three options, to resign, to apply for disability retirement, and she had 90 days to complete the process of disability retirement after which her employers would file for charges in order for her to be dismissed from state services. she said that these 90 days are up around the end of november. she said the reason for her dismissal was performance complaints. she said that they began "as soon as she arrived and that these were initially related to problems with her taking too much sick time off secondary to diabetes and fibromyalgia management and at one point she needed to obtain a doctor's note for any days off. she said that her paperwork was often late and that she received discipline for not disciplining her staff frequently enough for tardiness or missed workdays. she described it as a very chaotic and hectic work environment in which she was often putting in extra time. she said that since september 2008 she only took two sick days and was never late to work, but that she continued to receive a lot of negative feedback.,in july of this year, she reportedly received a letter from personnel indicating that she was being referred to a state medical doctor because she was unable to perform her job duties and due to excessive sick time. following a brief evaluation with this doctor whose records we do not have, she was sent to a neuropsychologist, dr. y, ph.d. he completed a comprehensive independent medical evaluation on 08/14/2009. she said that on 08/27/2009, she returned to see the original doctor who told her that based on that evaluation she was not able to work anymore. please note that we do not have copies of any of her work-related correspondence. the patient never received a copy of the neuropsychological evaluation because she was told that it was "too derogatory." a copy of that evaluation was provided directly to this examiner for the purpose of this evaluation. to summarize, the results indicated "diagnostically, the patient presents cognitive deficits involving visual working memory, executive functioning, and motor functioning along with low average intellectual functioning that is significantly below her memory functioning and below expectation based on her occupational and academic history. this suggests that her intellectual functioning has declined." it concluded that "results overall suggest early stages of a likely dementia or possibly the effects of diabetes, although her deficits are greater than expected for diabetes-related executive functioning problems and peripheral neuropathy… the patient' deficits within the current test battery suggest that she would not be able to safely and effectively perform the duties of a nurse supervisor without help handling documentary demands and some supervision of her visual processing. the prognosis for improvement is not good, although she might try stimulant medication if compatible with her other. following her dismissal, the patient presented to her primary physician, henry fein, m.d., who referred her to dr. x for a second opinion regarding her cognitive deficits. his neurological examination on 09/23/2009 was unremarkable. the patient scored 20/30 on the mini-mental status exam missing one out of three words on recall, but was able to do so with prompting. a repeat neurocognitive testing was suggested in order to assess for subtle deficits in memory and concentration that were not appreciated on this gross cognitive measure.,imaging studies: , mri of the brain on 09/14/2009 was unremarkable with no evidence of acute intracranial abnormality or abnormal enhancing lesions. note that the mri was done with and without gadolinium contrast.,current functioning: ,the patient reported that she had experienced some difficulty completing paperwork on time due primarily to the chaoticness of the work environment and the excessive amount of responsibility that was placed upon her. when asked about changes in cognitive functioning, she denied noticing any decline in problem solving, language, or nonverbal skills. she also denied any problems with attention and concentration or forgetfulness or memory problems. she continues to independently perform all activities of daily living. she is in charge of the household finances, has had no problems paying bills on time, has had no difficulties with driving or accidents, denied any missed appointments and said that no one has provided feedback to her that they have noticed any changes in her cognitive functioning. she reported that if her children had noticed anything they definitely would have brought it to her attention. she said that she does not currently have a lawyer and does not intend to return to her previous physician. she said she has not yet proceeded with the application for disability retirement because she was told that her doctors would have to fill out that paperwork, but they have not claimed that she is disabled and so she is waiting for the doctors at her former workplace to initiate the application. other current symptoms include excessive fatigue. she reported that she was diagnosed with chronic fatigue syndrome in 1991, but generally symptoms are under better control now, but she still has difficulty secondary to fibromyalgia. she also reported having fallen approximately five times within the past year. she said that this typically occurs when she is climbing up steps and is usually related to her right foot "like dragging." dr. x's physical examination revealed no appreciable focal peripheral deficits on motor or sensory testing and notes that perhaps these falls are associated with some stiffness and pain of her right hip and knee, which are chronic symptoms from her fibromyalgia and osteoarthritis. she said that she occasionally bumps into objects, but denied noticing it happening one on any particular part of her body. muscle pain secondary to fibromyalgia reportedly occurs in her neck and shoulders down both arms and in her left hip.,other medical history: , the patient reported that her birth and development were normal. she denied any significant medical conditions during childhood. as mentioned, she now has a history of fibromyalgia. she also experiences some restriction in the range of motion with her right arm. mri of the c-spine 04/02/2009 showed a hemangioma versus degenerative changes at c7 vertebral body and bulging annulus with small central disc protrusion at c6-c7. mri of the right shoulder on 06/04/2009 showed small partial tear of the distal infraspinatus tendon and prominent tendinopathy of the distal supraspinatus tendon. as mentioned, she was diagnosed with chronic fatigue syndrome in 1991. she thought that this may actually represent early symptoms of fibromyalgia and said that symptoms are currently under control. she also has diabetes, high blood pressure, osteoarthritis, tension headaches, gerd, carpal tunnel disease, cholecystectomy in 1976, and ectopic pregnancy in 1974. her previous neuropsychological evaluation referred to an outpatient left neck cystectomy in 2007. she has some difficulty falling asleep, but currently typically obtains approximately seven to eight hours of sleep per night. she did report some sleep disruption secondary to unusual dreams and thought that she talked to herself and could sometimes hear herself talking in her sleep.,current medications:, novolog, insulin pump, metformin, metoprolol, amlodipine, topamax, lortab, tramadol, amitriptyline, calcium plus vitamin d, fluoxetine, pantoprazole, naprosyn, fluticasone propionate, and vitamin c.,substance use: , the patient reported that she rarely drinks alcohol and she denied smoking or using illicit drugs. she drinks two to four cups of coffee per day.,social history: ,the patient was born and raised in north carolina. she was the sixth of nine siblings. her father was a chef. he completed third grade and died at 60 due to complications of diabetes. her mother is 93 years old. her last job was as a janitor. she completed fourth grade. she reported that she has no cognitive problems at this time. family medical history is significant for diabetes, heart disease, hypertension, thyroid problems, sarcoidosis, and possible multiple sclerosis and depression. the patient completed a bachelor of science in nursing through state university in 1979. she denied any history of problems in school such as learning disabilities, attentional problems, difficulty learning to read, failed grades, special help in school or behavioral problems. she was married for two years. her ex-husband died in 1980 from acute pancreatitis secondary to alcohol abuse. she has two children ages 43 and 30. her son whose age is 30 lives nearby and is in consistent contact with her and she is also in frequent contact and has a close relationship with her daughter who lives in new york. in school, the patient reported obtaining primarily a's and b's. she said that her strongest subject was math while her worst was spelling, although she reported that her grades were still quite good in spelling. the patient worked for hospital center for four years. prior to that, she worked for an outpatient mental health center for 2-1/2 years. she was reportedly either terminated or laid off and was unsure of the reason for that. prior to that, she worked for walter p. carter center reportedly for 21 years. she has also worked as an ob nurse in the past. she reported that other than the two instances reported above, she had never been terminated or fired from a job. in her spare time, the patient enjoys reading, participating in women's groups doing puzzles, playing computer games.,psychiatric history: , the patient reported that she sought psychotherapy on and off between 1991 and 1997 secondary to her chronic fatigue. she was also taking prozac during that time. she then began taking prozac again when she started working at secondary to stress with the work situation. she reported a chronic history of mild sadness or depression, which was relatively stable. when asked about her current psychological experience, she said that she was somewhat sad, but not dwelling on things. she denied any history of suicidal ideation or homicidal ideation.,tasks administered:,clinical interview,adult history questionnaire,wechsler test of adult reading (wtar),mini mental status exam (mmse),cognistat neurobehavioral cognitive status examination,repeatable battery for the assessment of neuropsychological status (rbans; form xx),mattis dementia rating scale, 2nd edition (drs-2),neuropsychological assessment battery (nab),wechsler adult intelligence scale, third edition (wais-iii),wechsler adult intelligence scale, fourth edition (wais-iv),wechsler abbreviated scale of intelligence (wasi),test of variables of attention (tova),auditory consonant trigrams (act),paced auditory serial addition test (pasat),ruff 2 & 7 selective attention test,symbol digit modalities test (sdmt),multilingual aphasia examination, second edition (mae-ii), token test, sentence repetition, visual naming, controlled oral word association, spelling test, aural comprehension, reading comprehension,boston naming test, second edition (bnt-2),animal naming test

procedure:, upper endoscopy with biopsy.,procedure indication: , this is a 44-year-old man who was admitted for coffee-ground emesis, which has been going on for the past several days. an endoscopy is being done to evaluate for source of upper gi bleeding.,informed consent was obtained. outlining the risks, benefits and alternatives of the procedure included, but not to risks of bleeding, infection, perforation, the patient agreed for the procedure.,medications: , versed 4 mg iv push and fentanyl 75 mcg iv push given throughout the procedure in incremental fashion with careful monitoring of patient's pressures and vital signs.,procedure in detail: ,the patient was placed in the left lateral decubitus position. medications were given. after adequate sedation was achieved, the olympus video endoscope was inserted into the mouth and advanced towards the duodenum.

left lower extremity venous doppler ultrasound,reason for exam: , status post delivery five weeks ago presenting with left calf pain.,interpretations: , there was normal flow, compression and augmentation within the right common femoral, superficial femoral and popliteal veins. lymph nodes within the left inguinal region measure up to 1 cm in short-axis.,impression: , lymph nodes within the left inguinal region measure up to 1 cm in short-axis, otherwise no evidence for left lower extremity venous thrombosis.

physical examination:, patient is a 46-year-old white male seen for annual physical exam and had an incidental psa elevation of 4.0. all other systems were normal.,procedures: ,sextant biopsy of the prostate.,radical prostatectomy: excised prostate including capsule, pelvic lymph nodes, seminal vesicles, and small portion of bladder neck.,pathology:,prostate biopsy: right lobe, negative. left lobe, small focus of adenocarcinoma, gleason's 3 + 3 in approximately 5% of the tissue.,radical prostatectomy: negative lymph nodes. prostate gland showing moderately differentiated infiltrating adenocarcinoma, gleason 3 + 2 extending to the apex involving both lobes of the prostate, mainly right. tumor overall involved less than 5% of the tissue. surgical margin was reported and involved at the apex. the capsule and seminal vesicles were free.,discharge note:, patient has made good post-op recovery other than mild urgency incontinence. his post-op psa is 0.1 mg/ml.

spirometry:, spirometry reveals the fvc to be adequate.,fev1 is also adequate 93% predicted. fev1/fvc ratio is 114% predicted which is normal and fef25 75% is 126% predicted.,after the use of bronchodilator, there is no significant improvement of the abovementioned parameters.,mvv is also normal.,lung volumes: , reveal a tlc to be 80% predicted. frc is mildly decreased and rv is also mildly decreased. rv/tlc ratio is also normal 97% predicted.,diffusion capacity:, after correction for alveolar ventilation, is 112% predicted which is normal.,oxygen saturation on room air:, 98%.,final interpretation: , pulmonary function test shows mild restrictive pulmonary disease. there is no significant obstructive disease present. there is no improvement after the use of bronchodilator and diffusion capacity is normal. oxygen saturation on room air is also adequate. clinical correlation will be necessary in this case.,

history of present illness:, the patient is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room. she was intubated and fishbone.,past medical history: , significant for diabetes, hypertension, asthma, cholecystectomy, and total hysterectomy and cataract.,allergies: ,no known drug allergies.,current medications: , prevacid, humulin, diprivan, proventil, unasyn, and solu-medrol.,family history: , noncontributory.,social history: , negative for illicit drugs, alcohol, and tobacco.,physical examination: ,please see the hospital chart.,laboratory data: , please see the hospital chart.,hospital course: , the patient was taken to the operating room by dr. x who is covering for ent and noted that she had airway compromise and a rather large fishbone noted and that was removed. the patient was intubated and it was felt that she should be observed to see if the airway would improve upon which she could be extubated. if not she would require tracheostomy. the patient was treated with iv antibiotics and ventilatory support and at the time of this dictation, she has recently been taken to the operating room where it was felt that the airway sufficient and she was extubated. she was doing well with good p.o.s, good airway, good voice, and desiring to be discharged home. so, the patient is being prepared for discharge at this point. we will have dr. x evaluate her before she leaves to make sure i do not have any problem with her going home. dr. y feels she could be discharged today and will have her return to see him in a week.

history of present illness: , the patient is an 85-year-old male who was brought in by ems with a complaint of a decreased level of consciousness. the patient apparently lives with his wife and was found to have a decreased status since the last one day. the patient actually was seen in the emergency room the night before for injuries of the face and for possible elderly abuse. when the adult protective services actually went to the patient's house, he was found to be having decreased consciousness for a whole day by his wife. actually the night before, he fell off his wheelchair and had lacerations on the face. as per his wife, she states that the patient was given an entire mg of xanax rather than 0.125 mg of xanax, and that is why he has had decreased mental status since then. the patient's wife is not able to give a history. the patient has not been getting sinemet and his other home medications in the last 2 days. ,past medical history: ,parkinson disease.,medications:, requip, neurontin, sinemet, ambien, and xanax.,allergies: , no known drug allergies.,social history: , the patient lives with his wife.,physical examination:,general:

preoperative diagnosis:, acute left subdural hematoma.,postoperative diagnosis:, acute left subdural hematoma.,procedure:, left frontal temporal craniotomy for evacuation of acute subdural hematoma.,description of procedure: , this is a 76-year-old man who has a history of acute leukemia. he is currently in the phase of his therapy where he has developed a profound thrombocytopenia and white cell deficiency. he presents after a fall in the hospital in which he apparently struck his head and now has a progressive neurologic deterioration consistent with an intracerebral injury. his ct imaging reveals an acute left subdural hematoma, which is hemispheric.,the patient was brought to the operating room, placed under satisfactory general endotracheal anesthesia. he had previously been intubated and taken to the intensive care unit and now is brought for emergency craniotomy. the images were brought up on the electronic imaging and confirmed that this was a left-sided condition. he was fixed in a three-point headrest. his scalp was shaved and prepared with betadine, iodine and alcohol. we made a small curved incision over the temporal, parietal, frontal region. the scalp was reflected. a single bur hole was made at the frontoparietal junction and then a 4x6cm bur hole was created. after completing the bur hole flap, the dura was opened and a gelatinous mass of subdural was peeled away from the brain. the brain actually looked relatively relaxed; and after removal of the hematoma, the brain sort of slowly came back up. we investigated the subdural space forward and backward as we could and yet careful not to disrupt any venous bleeding as we close to the midline. after we felt that we had an adequate decompression, the dura was reapproximated and we filled the subdural space with saline. we placed a small drain in the extra dural space and then replaced the bone flap and secured this with the bone plates. the scalp was reapproximated, and the patient was awakened and taken to the ct scanner for a postoperative scan to ensure that there was no new hemorrhage or any other intracerebral pathology that warranted treatment. given that this actual skin looked good with apparent removal of about 80% of the subdural we elected to take patient to the intensive care unit for further management.,i was present for the entire procedure and supervised this. i confirmed prior to closing the skin that we had correct sponge and needle counts and the only foreign body was the drain.

exam: , two views of the pelvis.,history:, this is a patient post-surgery, 2-1/2 months. the patient has a history of slipped capital femoral epiphysis (scfe) bilaterally.,technique: , frontal and lateral views of the hip and pelvis were evaluated and correlated with the prior film dated mm/dd/yyyy. lateral view of the right hip was evaluated.,findings:, frontal view of the pelvis and a lateral view of the right hip were evaluated and correlated with the patient's most recent priors dated mm/dd/yyyy. current films reveal stable appearing post-surgical changes. again demonstrated is a single intramedullary screw across the left femoral neck and head. there are 2 intramedullary screws through the greater trochanter of the right femur. there is a lucency along the previous screw track extending into the right femoral head and neck. there has been interval removal of cutaneous staples and/or surgical clips. these were previously seen along the lateral aspect of the right hip joint.,deformity related to the previously described slipped capital femoral epiphysis is again seen.,impression:,1. stable-appearing right hip joint status-post pinning.,2. interval removal of skin staples as described above.

operative note: ,the patient was taken to the operating room and was placed in the supine position on the operating room table. a general inhalation anesthetic was administered. the patient was prepped and draped in the usual sterile fashion. the urethral meatus was calibrated with a small mosquito hemostat and was gently dilated. next a midline ventral type incision was made opening the meatus. this was done after clamping the tissue to control bleeding. the meatus was opened for about 3 mm. next the meatus was calibrated and easily calibrated from 8 to 12 french with bougie sounds. next the mucosal edges were everted and reapproximated to the glans skin edges with approximately five interrupted 6-0 vicryl sutures. the meatus still calibrated between 10 and 12 french. antibiotic ointment was applied. the procedure was terminated. the patient was awakened and returned to the recovery room in stable condition.

preoperative diagnosis: , left distal radius fracture, metaphyseal extraarticular.,postoperative diagnosis: , left distal radius fracture, metaphyseal extraarticular.,procedure: , open reduction and internal fixation of left distal radius.,implants: ,wright medical micronail size 2.,anesthesia: , lma.,tourniquet time: , 49 minutes.,blood loss: , minimal.,complications: , none.,pathology: , none.,time out: , time out was performed before the procedure started.,indications:, the patient was a 42-year-old female who fell and sustained a displaced left metaphyseal distal radius fracture indicated for osteosynthesis. the patient was in early stage of gestation. benefits and risks including radiation exposure were discussed with the patient and consulted her primary care doctor.,description of procedure: , supine position, lma anesthesia, well-padded arm, tourniquet, hibiclens, alcohol prep, and sterile drape.,exsanguination achieved, tourniquet inflated to 250 mmhg. first, under fluoroscopy the fracture was reduced. a 0.045 k-wire was inserted from dorsal ulnar corner of the distal radius and crossing fracture line to maintain the reduction. a 2-cm radial incision, superficial radial nerve was exposed and protected. dissecting between the first and second dorsal extensor retinaculum, the second dorsal extensor compartment was elevated off from the distal radius. the guidewire was inserted under fluoroscopy. a cannulated drill was used to drill antral hole. antral awl was inserted. then we reamed the canal to size 2. size 2 micronail was inserted to the medullary canal. using distal locking guide, three locking screws were inserted distally. the second dorsal incision was made. the deep radial dorsal surface was exposed. using locking guide, two proximal shaft screws were inserted and locked the nail to the radius. fluoroscopic imaging was taken and showing restoration of the height, tilt, and inclination of the radius. at this point, tourniquet was deflated, hemostasis achieved, wounds irrigated and closed in layers. sterile dressing applied. the patient then was extubated and transferred to the recovery room under stable condition.,postoperatively, the patient will see a therapist within five days. we will immobilize wrist for two weeks and then starting flexion-extension and prosupination exercises.

cystoscopy & visual urethrotomy,operative note:, the patient was placed in the dorsal lithotomy position and prepped and draped in the usual manner under satisfactory general anesthesia. a storz urethrotome sheath was inserted into the urethra under direct vision. visualization revealed a stricture in the bulbous urethra. this was intubated with a 0.038 teflon-coated guidewire, and using the straight cold urethrotomy knife, it was incised to 12:00 to allow free passage of the scope into the bladder. visualization revealed no other lesions in the bulbous or membranous urethra. prostatic urethra was normal for age. no foreign bodies, tumors or stones were seen within the bladder. over the guidewire, a #16-french foley catheter with a hole cut in the tip with a cook cutter was threaded over the guidewire and inserted into the bladder and inflated with 10 ml of sterile water.,he was sent to the recovery room in stable condition.

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.

history: ,i had the pleasure of meeting and evaluating the patient today, referred for evaluation of tracheostomy tube placement and treatment recommendations. as you are well aware, he is a pleasant 64-year-old gentleman who unfortunately is suffering from end-stage copd, who required tracheostomy tube placement about three months ago when being treated for acute exacerbation of copd and having difficulty coming off ventilatory support. he now resides in an extended care facility with a capped tracheostomy tube, and he unfortunately states he has had not had to use the tracheostomy tube since his discharge and admission to the extended care facility. he requires constant oxygen administration and has been having no problems with shortness of breath, worsening, requiring opening the tracheostomy tube site. he states there has been some tenderness associated with the tracheostomy tube and difficulty with swallowing and he wishes to have it removed. apparently there is no history of any airway issues while sleeping or need for uncapping the tube and essentially the tube has just remained present for months capped in his neck. no history of any previous tracheostomy tube insertion.,past medical history: , copd, history of hypercarbic hypoxemia, history of coronary artery disease, history of previous myocardial infarction, and history of liver cirrhosis secondary to alcohol use.,past surgical history: ,tonsillectomy, adenoidectomy, cholecystectomy, appendectomy, hernia repair, and tracheostomy.,family history: ,strong for heart disease, coronary artery disease, hypertension, diabetes mellitus, and cerebrovascular accident.,current medications:, prevacid, folic acid, aspirin, morphine sulfate, pulmicort, risperdal, colace, clonazepam, lotrisone, roxanol, ambien, zolpidem tartrate, simethicone, robitussin, and prednisone.,allergies: , nitroglycerin.,social history: , the patient has a 25-year-smoking history, which i believe is quite heavy and he has a significant alcohol use in the past.,physical examination: ,vital signs: age 64, blood pressure is 110/78, pulse 96, and temperature is 98.6.,general: the patient was examined in his wheelchair, resting comfortably, in no acute distress.,head: normocephalic. no masses or lesions noted.,face: no facial tenderness or asymmetry noted.,eyes: pupils are equal, round and reactive to light and accommodation bilaterally. extraocular movements are intact bilaterally.,ears: the tympanic membranes are intact bilaterally with a good light reflex. the external auditory canals are clear with no lesions or masses noted. weber and rinne tests are within normal limits.,nose: the nasal cavities are patent bilaterally. the nasal septum is midline. there are no nasal discharges. no masses or lesions noted.,throat: the oral mucosa appears healthy. dental hygiene is maintained well. no oropharyngeal masses or lesions noted. no postnasal drip noted.,neck: the patient has a stable-appearing tracheostomy tube site and the stoma appears to be without signs of infection. the previous incision was vertical in nature and there is no hypertrophic scar formation. no adenopathy noted. no stridor noted.,neurologic: cranial nerve vii intact bilaterally. no signs of tremor.,lungs: diminished breath sounds in all four quadrants. no wheezes noted.,heart: regular rate and rhythm.,procedure: , limited bronchoscopy and then fiberoptic laryngoscopy.,impression: ,1. end-stage chronic obstructive pulmonary disease with a history of respiratory failure requiring mechanical ventilatory support with tracheostomy tube placement.,2. difficulty tolerating tracheostomy tubes secondary to swallow discomfort and neck irritation with no further need for tracheostomy tube over the past few months with the patient tolerating capped tracheostomy tube 24 hours a day.,3. history of coronary artery disease.,4. history of myocardial infarction.,5. history of cirrhosis of liver.,recommendations: , i discussed with the patient in detail after fiberoptic laryngoscopy and limited bronchoscopy was performed in the office whether or not to pull out the tracheostomy tube. his vocal cords moved well, and i do not see any signs of granuloma or airway obstruction either in the supraglottic or subglottic region, and i felt he would tolerate the tube being removed with close monitoring by nursing at his extended care facility. i did impress the fact that i believe he probably will have other events requiring airway support, which could include intubation, and if the intubation is prolonged a tracheostomy may be needed. creation of a long-term tracheostoma may be beneficial whereas the patient would not need such a long tracheostomy tube, and i informed the patient there are other options other than the tube he has at the present time. the patient still wished to have the tube removed and he is aware he may need to have it replaced or he may have trouble with the area healing or scarring or he could end up having an emergent airway situation with the tube gone, but wishes to have it removed, and i did remove it today. dressing was applied and we will see him back next week to make sure everything is healing properly.

preoperative diagnoses:, bladder cancer and left hydrocele.,postoperative diagnoses: , bladder cancer and left hydrocele.,operation: ,left hydrocelectomy, cystopyelogram, bladder biopsy, and fulguration for hemostasis.,anesthesia:, spinal.,estimated blood loss: ,minimal.,fluids:, crystalloid.,brief history: ,the patient is a 66-year-old male with history of smoking and hematuria, had bladder tumor, which was dissected. he has received bcg. the patient is doing well. the patient was supposed to come to the or for surveillance biopsy and pyelograms. the patient had a large left hydrocele, which was increasingly getting worse and was making it very difficult for the patient to sit to void or put clothes on, etc. options such as watchful waiting, drainage in the office, and hydrocelectomy were discussed. risks of anesthesia, bleeding, infection, pain, mi, dvt, pe, infection in the scrotum, enlargement of the scrotum, recurrence, and pain were discussed. the patient understood all the options and wanted to proceed with the procedure.,procedure in detail: , 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 usual sterile fashion.,a transverse scrotal incision was made over the hydrocele sac and the hydrocele fluid was withdrawn. the sac was turned upside down and sutures were placed. careful attention was made to ensure that the cord was open. the testicle was in normal orientation throughout the entire procedure. the testicle was placed back into the scrotal sac and was pexed with 4-0 vicryl to the outside dartos to ensure that there was no risk of torsion. orchiopexy was done at 3 different locations. hemostasis was obtained using electrocautery. the sac was closed using 4-0 vicryl. the sac was turned upside down so that when it heals, the fluid would not recollect. the dartos was closed using 2-0 vicryl and the skin was closed using 4-0 monocryl and dermabond was applied. incision measured about 2 cm in size. subsequently using acmi cystoscope, a cystoscopy was performed. the urethra appeared normal. there was some scarring at the bulbar urethra, but the scope went in through that area very easily into the bladder. there was a short prostatic fossa. the bladder appeared normal. there was some moderate trabeculation throughout the bladder, some inflammatory changes in the bag part, but nothing of much significance. there were no papillary tumors or stones inside the bladder. bilateral pyelograms were obtained using 8-french cone-tip catheter, which appeared normal. a cold cup biopsy of the bladder was done and was fulgurated for hemostasis. the patient tolerated the procedure well. the patient was brought to recovery at the end of the procedure after emptying the bladder.,the patient was given antibiotics and was told to take it easy. no heavy lifting, pushing, or pulling. plan was to follow up in about 2 months.

name of procedure: , left heart catheterization with ventriculography, selective coronary angiography.,indications: , acute coronary syndrome.,technique of procedure: , standard judkins, right groin. catheters used were a 6 french pigtail, 6 french jl4, 6 french jr4. ,anticoagulation: ,the patient was on heparin at the time.,complications: , none.,i reviewed with the patient the pros, cons, alternatives, risks of catheterization and sedation including myocardial infarction, stroke, death, damage to nerve, artery or vein in the leg, perforation of a cardiac chamber, dissection of an artery requiring countershock, infection, bleeding, atn allergy, need for cardiac surgery. all questions were answered, and the patient desired to proceed.,hemodynamic data: ,aortic pressure was in the physiologic range. no significant gradient across the aortic valve.,angiographic data,1. ventriculogram: the left ventricle is of normal size and shape, normal wall motion, normal ejection fraction.,2. right coronary artery: dominant. there was insignificant disease in the system.,3. left coronary: left main, left anterior descending and circumflex systems showed no significant disease.,conclusions,1. normal left ventricular systolic function.,2. insignificant coronary disease.,plan: , based upon this study, medical therapy is warranted. six-french angio-seal was used in the groin.

reason for referral:, the patient is a 76-year-old caucasian gentleman who works full-time as a tax attorney. he was referred for a neuropsychological evaluation by dr. x after a recent hospitalization for possible transient ischemic aphasia. two years ago, a similar prolonged confusional spell was reported as well. a comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,relevant background information: , historical information was obtained from a review of available medical records and clinical interview with the patient. a summary of pertinent information is presented below. please refer to the patient's medical chart for a more complete history.,history of presenting problem: , the patient was brought to the hospital emergency department on 09/30/09 after experiencing an episode of confusion for which he has no recall the previous day. he has no recollection of the event. the following information is obtained from his medical record. on 09/29/09, he reportedly went to a five-hour meeting and stated several times "i do not feel well" and looked "glazed." he does not remember anything from midmorning until the middle of the night and when his wife came home, she found him in bed at 6 p.m., which is reportedly unusual. she thought he was warm and had chills. he later returned to his baseline. he was seen by dr. x in the hospital on 09/30/09 and reported to him at that time that he felt that he had returned entirely to baseline. his neurological exam at that time was unremarkable aside from missing one of three items on recall for the mini-mental status examination. due to mild memory complaints from himself and his wife, he was referred for more extensive neuropsychological testing. note that reportedly when his wife found him in bed, he was shaking and feeling nauseated, somewhat clammy and kept saying that he could not remember anything and he was repeating himself, asking the same questions in an agitated way, so she brought him to the emergency room. the patient had an episode two years ago of transient loss of memory during which he was staring blankly while sitting at his desk at work and the episode lasted approximately two hours. he was hospitalized at hospital at that time as well and evaluation included negative eeg, mri showing mild atrophy, and a neurological consultation, which did not result in a specific diagnosis, but during this episode he was also reportedly nauseous. he was also reportedly amnestic for this episode.,in 2004, he had a sense of a funny feeling in his neck and electrodes in his head and had an mri at that time which showed some small vessel changes.,during this interview, the patient reported that other than a coworker noticing a few careless errors in his completion of some documents and his wife reporting some mild memory changes that he had not noticed any significant decline. he thought that his memory abilities were similar to those of his peers of his same age. when i asked about this episode, he said he had no recall of it at all and that he "felt fine the whole time." he appeared to be somewhat questioning of the validity of reports that he was amnestic and confused at that time. so, the patient reported some age related "memory lapses" such as going into a room and forgetting why, sometimes putting something down and forgetting where he had put it. however, he reported that these were entirely within normal expectations and he denied any type of impairment in his ability to continue to work full-time as a tax attorney other than his wife and one coworker, he had not received any feedback from his children or friends of any problems. he denied any missed appointments, any difficulty scheduling and maintaining appointments. he does not have to recheck information for errors. he is able to complete tasks in the same amount of time as he always has. he reported that he has not made additional errors in tasks that he completed. he said he does write everything down, but has always done things that way. he reported that he works in a position that requires a high level of attentiveness and knowledge and that will become obvious very quickly if he was having difficulties or making mistakes. he did report some age related changes in attention as well, although very mild and he thought these were normal and not more than he would expect for his age. he remains completely independent in his adls. he denied any difficulty with driving or maintaining any activities that he had always participated in. he is also able to handle their finances. he did report significant stress recently particularly in relation to his work environment.,past medical history:, includes coronary artery disease, status post cabg in 1991, radical prostate cancer, status post radical prostatectomy, nephrectomy for the same cancer, hypertension, lumbar surgery done twice previously, lumbar stenosis many years ago in the 1960s and 1970s, now followed by dr. y with another lumbar surgery scheduled to be done shortly after this evaluation, and hyperlipidemia. note that due to back pain, he had been taking percocet daily prior to his hospitalization.,current medications: , celebrex 200 mg, levothyroxine 0.025 mg, vytorin 10/40 mg, lisinopril 10 mg, coreg 10 mg, glucosamine with chondroitin, prostate 2.2, aspirin 81 mg, and laxative stimulant or stool softener. note that medical records say that he was supposed to be taking lipitor 40 mg, but it is not clear if he was doing so and also there was no specific reason found for why he was taking the levothyroxine.,other medical history: , surgical history is significant for hernia repair in 2007 as well. the patient reported drinking an occasional glass of wine approximately two days of the week. he quit smoking cigarettes 25 to 30 years ago and he was diagnosed with cancer. he denied any illicit drug use. please add that his prostatectomy was done in 1993 and nephrectomy in 1983 for carcinoma. he also had right carpal tunnel surgery in 2005 and has cholelithiasis. upon discharge from the hospital, the patient's sleep deprived eeg was recommended.,mri completed on 09/30/09 showed "mild cerebral and cerebellar atrophy with no significant interval change from a prior study dated june 15, 2007. no evidence of acute intracranial processes identified. ct scan was also unremarkable showing only mild cerebral and cerebellar atrophy. eeg was negative. deferential diagnosis was transient global amnesia versus possible seizure disorder. note that he also reportedly has some hearing changes, but has not followed up with an evaluation for hearing aid.,family medical history:, reportedly significant for tias in his mother, although the patient did not report this during our evaluation and so that she had no memory problems or dementia when she passed away of old age at the age of 85. in addition, his father had a history of heart disease and passed away at the age of 75. he has one sister with diabetes and thought his mom might have had diabetes as well.,social history:, the patient obtained a law degree from the university of baltimore. he did not complete his undergraduate degree from the university of maryland because he was able to transfer his credits in order to attend law school at that time. he reported that he did not obtain very good grades until he reached law school, at which point he graduated in the top 10 of his class and had no problem passing the bar. he thought that effort and motivation were important to his success in his school and he had not felt very motivated previously. he reported that he repeated math classes "every year of school" and attended summer school every year due to that. he has worked as a tax attorney for the past 48 years and reported having a thriving practice with clients all across the country. he served also in the u.s. coast guard between 1951 and 1953. he has been married for the past 36 years to his wife, linda, who is a homemaker. they have four children and he reported having good relationship with them. he described being very active. he goes for dancing four to five times a week, swims daily, plays golf regularly and spends significant amounts of time socializing with friends.,psychiatric history: , the patient denied any history of psychological or psychiatric treatment. he reported that some stressors occasionally contribute to mildly low mood at this time, but that these are transient.,tasks administered:,clinical interview,adult history questionnaire,wechsler test of adult reading (wtar),mini mental status exam (mmse),cognistat neurobehavioral cognitive status examination,repeatable battery for the assessment of neuropsychological status (rbans; form xx),mattis dementia rating scale, 2nd edition (drs-2),neuropsychological assessment battery (nab),wechsler adult intelligence scale, third edition (wais-iii),wechsler adult intelligence scale, fourth edition (wais-iv),wechsler abbreviated scale of intelligence (wasi),test of variables of attention (tova),auditory consonant trigrams (act),paced auditory serial addition test (pasat),ruff 2 & 7 selective attention test,symbol digit modalities test (sdmt),multilingual aphasia examination, second edition (mae-ii), token test, sentence repetition, visual naming, controlled oral word association, spelling test, aural comprehension, reading comprehension,boston naming test, second edition (bnt-2),animal naming test

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

preoperative diagnosis: , angina and coronary artery disease.,postoperative diagnosis: , angina and coronary artery disease.,name of operation: , coronary artery bypass grafting (cabg) x2, left internal mammary artery to the left anterior descending and reverse saphenous vein graft to the circumflex, st. jude proximal anastomosis used for vein graft. off-pump medtronic technique for left internal mammary artery, and a bivad technique for the circumflex.,anesthesia: , general.,procedure details: , the patient was brought to the operating room and placed in the supine position upon the table. after adequate general anesthesia, the patient was prepped with betadine soap and solution in the usual sterile manner. elbows were protected to avoid ulnar neuropathy, chest wall expansion avoided to avoid ulnar neuropathy, phrenic nerve protectors used to protect the phrenic nerve and removed at the end of the case.,a midline sternal skin incision was made and carried down through the sternum which was divided with the saw. pericardial and thymus fat pad was divided. the left internal mammary artery was harvested and spatulated for anastomosis. heparin was given.,vein resected from the thigh, side branches secured using 4-0 silk and hemoclips. the thigh was closed multilayer vicryl and dexon technique. a pulsavac wash was done, drain was placed.,the left internal mammary artery is sewn to the left anterior descending using 7-0 running prolene technique with the medtronic off-pump retractors. after this was done, the patient was fully heparinized, cannulated with a 6.5 atrial cannula and a 2-stage venous catheter and begun on cardiopulmonary bypass and maintained normothermia. medtronic retractors used to expose the circumflex. prior to going on pump, we stapled the vein graft in place to the aorta.,then, on pump, we did the distal anastomosis with a 7-0 running prolene technique. the right side graft was brought to the posterior descending artery using running 7-0 prolene technique. deairing procedure was carried out. the bulldogs were removed. the patient maintained good normal sinus rhythm with good mean perfusion. the patient was weaned from cardiopulmonary bypass. the arterial and venous lines were removed and doubly secured. protamine was delivered. meticulous hemostasis was present. platelets were given for coagulopathy. chest tube was placed and meticulous hemostasis was present. the anatomy and the flow in the grafts was excellent. closure was begun.,the sternum was closed with wire, followed by linea alba and pectus fascia closure with running 0 vicryl sutures in double-layer technique. the skin was closed with subcuticular 4-0 dexon suture technique. the patient tolerated the procedure well and was transferred to the intensive care unit in stable condition.,we minimized the pump time to 16 minutes for just the distal anastomosis of the circumflex in order to lessen the insult to the kidneys as the patient already has kidney failure with a creatinine of 3.0.

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

reason for consultation: , management of end-stage renal disease (esrd), the patient on chronic hemodialysis, being admitted for chest pain.,history of present illness:, this is a 66-year-old native american gentleman, a patient of dr. x, my associate, who has a past medical history of coronary artery disease, status post stent placement, admitted with chest pressure around 4 o'clock last night. he took some nitroglycerin tablets at home with no relief. he came to the er. he is going to have a coronary angiogram done today by dr. y. i have seen this patient first time in the morning, approximately around the 4 o'clock. this is a late entry dictation. presently lying in bed, but he feels fine. denies any chest pain, shortness of breath, nausea, vomiting, abdominal pain, diarrhea. denies hematuria, dysuria, or bright red blood per rectum.,past medical history:,1. coronary artery disease, status post stent placement two years ago.,2. diabetes mellitus for the last 12 years.,3. hypertension.,4. end-stage renal disease.,5. history of tia in the past.,past surgical history:,1. as mentioned above.,2. cholecystectomy.,3. appendectomy.,4. right ij permacath placement.,5. av fistula graft in the right wrist.,personal and social history:, he smoked 2 to 3 packets per day for at least last 10 years. he quit smoking roughly about 20 years ago. occasional alcohol use.,family history: , noncontributory.,allergies: ,no known drug allergies.,medications at home: , metoprolol, plavix, rocaltrol, lasix, norvasc, zocor, hydralazine, calcium carbonate, and loratadine.,physical examination,general: he is alert, seems to be in no apparent distress.,vital signs: temperature 98.2, pulse 61, respiratory 20, and blood pressure 139/63.,heent: atraumatic and normocephalic.,neck: no jvd, no thyromegaly, supra and infraclavicular lymphadenopathy.,lungs: clear to auscultation. air entry bilateral equal.,heart: s1 and s2. no pericardial rub.,abdomen: soft and nontender. normal bowel sounds.,extremities: no edema.,neurologic: the patient is alert without focal deficit.,laboratory data:, laboratory data shows hemoglobin 13, hematocrit 38.4, sodium 130, potassium 4.2, chloride 96.5, carbonate 30, bun 26, creatinine 6.03, and glucose 162.,impression:,1. end-stage renal disease, plan for dialysis today.,2. diabetes mellitus.,3. chest pain for coronary angiogram today.,4. hypertension, blood pressure stable.,plan: , currently follow the patient. dr. z is going to assume the care.

operations,1. mitral valve repair using a quadrangular resection of the p2 segment of the posterior leaflet.,2. mitral valve posterior annuloplasty using a cosgrove galloway medtronic fuser band.,3. posterior leaflet abscess resection.,anesthesia: ,general endotracheal anesthesia,times: ,aortic cross-clamp time was ** minutes. cardiopulmonary bypass time total was ** minutes.,procedure in detail: , after obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered. next, the patient's chest and legs were prepped and draped in standard surgical fashion. a #10-blade scalpel was used to make a midline median sternotomy incision. dissection was carried down to the level of the sternum using bovie electrocautery. the sternum was opened with a sternal saw, and full-dose heparinization was given. next, the chest retractor was positioned. the pericardium was opened with bovie electrocautery and pericardial stay sutures were positioned. we then prepared to place the patient on cardiopulmonary bypass. a 2-0 ethibond double pursestring was placed in the ascending aorta. through this was passed our aortic cannula and connected to the arterial side of the cardiopulmonary bypass machine. next, double cannulation with venous cannulas was instituted. a 3-0 prolene pursestring was placed in the right atrial appendage. through this was passed our sec cannula. this was connected to the venous portion of the cardiopulmonary bypass machine in a y-shaped circuit. next, a 3-0 prolene pursestring was placed in the lower border of the right atrium. through this was passed our inferior vena cava cannula. this was likewise connected to the y connection of our venous cannula portion. we then used a 4-0 u-stitch in the right atrium for our retrograde cardioplegia catheter, which was inserted. cardiopulmonary bypass was instituted. metzenbaum scissors were used to dissect out the svc and ivc, which were subsequently encircled with umbilical tape. sondergaard's groove was taken down. next, an antegrade cardioplegia needle and associated sump were placed in the ascending aorta. this was connected appropriately as was the retrograde cardioplegia catheter. next, the aorta was cross-clamped, and antegrade and retrograde cardioplegia was infused so as to arrest the heart in diastole. next a #15-blade scalpel was used to open the left atrium. the left atrium was decompressed with pump sucker. next, our self-retaining retractor was positioned so as to bring the mitral valve up into view. of note was the fact that the mitral valve p2 segment of the posterior leaflet had an abscess associated with it. the borders of the p2 segment abscess were defined by using a right angle to define the chordae which were encircled with a 4-0 silk. after doing so, the p2 segment of the posterior leaflet was excised with a #11-blade scalpel. given the laxity of the posterior leaflet, it was decided to reconstruct it with a 2-0 ethibond pledgeted suture. this was done so as to reconstruct the posterior annular portion. prior to doing so, care was taken to remove any debris and abscess-type material. the pledgeted stitch was lowered into place and tied. next, the more anterior portion of the p2 segment was reconstructed by running a 4-0 prolene stitch so as to reconstruct it. this was done without difficulty. the apposition of the anterior and posterior leaflet was confirmed by infusing solution into the left ventricle. there was noted to be a small amount of central regurgitation. it was felt that this would be corrected with our annuloplasty portion of the procedure. next, 2-0 non-pledgeted ethibond sutures were placed in the posterior portion of the annulus from trigone to trigone in interrupted fashion. care was taken to go from trigone to trigone. prior to placing these sutures, the annulus was sized and noted to be a *** size for the cosgrove-galloway suture band ring from medtronic. after, as mentioned, we placed our interrupted sutures in the annulus, and they were passed through the cg suture band. the suture band was lowered into position and tied in place. we then tested our repair and noted that there was very mild regurgitation. we subsequently removed our self-retaining retractor. we closed our left atriotomy using 4-0 prolene in a running fashion. this was done without difficulty. we de-aired the heart. we then gave another round of antegrade and retrograde cardioplegia in warm fashion. the aortic cross-clamp was removed, and the heart gradually resumed electromechanical activity. we then removed our retrograde cardioplegia catheter from the coronary sinus and buttressed this site with a 5-0 prolene. we placed 2 ventricular and 2 atrial pacing leads which were brought out through the skin. the patient was gradually weaned off cardiopulmonary bypass and our venous cannulas were removed. we then gave full-dose protamine; and after noting that there was no evidence of a protamine reaction, we removed our aortic cannula. this site was buttressed with a 4-0 prolene on an sh needle. the patient tolerated the procedure well. we placed a mediastinal #32-french chest tube as well as a right chest blake drain. the mediastinum was inspected for any signs of bleeding. there were none. we closed the sternum with #7 sternal wires in interrupted figure-of-eight fashion. the fascia was closed with a #1 vicryl followed by a 2-0 vicryl, followed by 3-0 vicryl in a running subcuticular fashion. the instrument and sponge count was correct at the end of the case. the patient tolerated the procedure well and was transferred to the intensive care unit in good condition.

reason for consult:, anxiety.,chief complaint:, "i felt anxious yesterday.",hpi:, a 69-year-old white female with a history of metastatic breast cancer, depression, anxiety, recent uti, and obstructive uropathy, admitted to the abcd hospital on february 6, 2007, for lightheadedness, weakness, and shortness of breath. the patient was consulted by psychiatry for anxiety. i know this patient from a previous consult. during this recent admission, the patient has experienced anxiety and had a panic attack yesterday with "syncopal episodes." she was given ativan 0.25 mg on a p.r.n. basis with relief after one to two hours. the patient was seen by abc, md, and def, ph.d. the laboratories were reviewed and were positive for uti, and anemia is also present. the tsh level was within normal limits. she previously responded well to trazodone for depression, poor appetite, and decreased sleep and anxiety. a low dose of klonopin was also helpful for sedation.,past medical history:, metastatic breast cancer to bone. the patient also has a history of hypertension, hypothyroidism, recurrent uti secondary to obstruction of left ureteropelvic junction, cholelithiasis, chronic renal insufficiency, port-a-cath placement, and hydronephrosis.,past psychiatric history:, the patient has a history of depression and anxiety. she was taking remeron 15 mg q.h.s., ambien 5 mg q.h.s. on a p.r.n. basis, ativan 0.25 mg every 6 hours on a p.r.n. basis, and klonopin 0.25 mg at night while she was at home.,family history:, there is a family history of colorectal cancer, lung cancer, prostate cancer, cardiac disease, and alzheimer disease in the family.,social history:, the patient is married and lives at home with her husband. she has a history of smoking one pack per day for 18 years. the patient quit in 1967. according to the chart, the patient also drinks wine everyday for the last 50 years, usually one to two drinks per day.,medications:,1. klonopin 0.25 mg p.o. every evening.,2. fluconazole 200 mg p.o. daily.,3. synthroid 125 mcg p.o. everyday.,4. remeron 15 mg p.o. at bedtime.,5. ceftriaxone iv 1 g in 1/2 ns every 24 hours.,p.r.n. medications:,1. tylenol 650 mg p.o. every 4 hours.,2. klonopin 0.5 mg p.o. every 8 hours.,3. promethazine 12.5 mg every 4 hours.,4. ambien 5 mg p.o. at bedtime.,allergies:,no known drug allergies,laboratory data:,these laboratories were done on february 6,2007, sodium 137, potassium 3.9, chloride 106, bicarbonate 21, bun 35, creatinine 1.5, glucose 90. white blood cell 5.31, hemoglobin 11.2, hematocrit 34.7, platelet count 152000. tsh level 0.88. the urinalysis was positive for uti.,mental status examination:,general appearance: the patient is dressed in a hospital gown. she is lying in bed during the interview. she is well groomed with good hygiene.,motor activity: no psychomotor retardation or agitation noted. good eye contact.,attitude: pleasant and cooperative.,attention and concentration: normal. the patient does not appear to be distracted during the interview.,mood: okay.,affect: mood congruent normal affect.,thought process: logical and goal directed.,thought content: no delusions noted.,perception: did not assess.,memory: not tested.,sensorium: alert.,judgment: good.,insight: good.,impression:,1. axis i: possibly major depression or generalized anxiety disorder.,2. axis ii: deferred.,3. axis iii: breast cancer with metastasis, hydronephrosis secondary to chronic uteropelvic junction obstruction status post stent placement, hypothyroidism.,4. axis iv: interpersonal stressors.

preoperative diagnoses:,1. chronic pelvic pain.,2. endometriosis.,3. prior right salpingo-oophorectomy.,4. history of intrauterine device perforation and exploratory surgery.,postoperative diagnoses:,1. endometriosis.,2. interloop bowel adhesions.,procedure performed:,1. total abdominal hysterectomy (tah).,2. left salpingo-oophorectomy.,3. lysis of interloop bowel adhesions.,anesthesia:, general.,estimated blood loss: ,400 cc.,fluids: , 2300 cc of lactated ringers, as well as lactated ringers for intraoperative irrigation.,urine: , 500 cc of clear urine output.,intraoperative findings: , the vulva and perineum are without lesions. on bimanual exam, the uterus was enlarged, movable, and anteverted. the intraabdominal findings revealed normal liver margin, kidneys, and stomach upon palpation. the uterus was found to be normal in size with evidence of endometriosis on the uterus. the right ovary and fallopian tube were absent. the left fallopian tube and ovary appeared normal with evidence of a small functional cyst. there was evidence of left adnexal adhesion to the pelvic side wall which was filmy, unable to be bluntly dissected. there were multiple interloop bowel adhesions that were filmy in nature noted.,the appendix was absent. there did appear to be old suture in a portion of the bowel most likely from a prior procedure.,indications: , this patient is a 45-year-old african-american gravida7, para3-0-0-3, who is here for definitive treatment of chronic pelvic pain with a history of endometriosis. she did have a laparoscopic ablation of endometriosis on a laparoscopy and also has a history of right salpingo-oophorectomy. she has tried lupron and did stop secondary to the side effects.,procedure in detail: , after informed consent was obtained in layman's terms, the patient was taken back to the operating suite and placed under general anesthesia. she was then prepped and draped in the sterile fashion and placed in the dorsal supine position. an indwelling foley catheter was placed. with the skin knife, an incision was made removing the old cicatrix. a bovie was used to carry the tissue through to the underlying layer of the fascia which was incised in the midline and extended with the bovie. the rectus muscle was then sharply and bluntly dissected off the superior aspect of the rectus fascia in the superior as well as the inferior aspect using the bovie. the rectus muscle was then separated in the midline using a hemostat and the peritoneum was entered bluntly. the peritoneal incision was then extended superiorly and inferiorly with metzenbaum scissors with careful visualization of the bladder. at this point, the intraabdominal cavity was manually explored and the above findings were noted. a lahey clamp was then placed on the fundus of the uterus and the uterus was brought to the surgical field. the bowel was then packed with moist laparotomy sponges. prior to this, the filmy adhesions leftover were taken down. at this point, the left round ligament was identified, grasped with two hemostats, transected, and suture ligated with #0 vicryl. at this point, the broad ligament was dissected down and the lost portion of the bladder flap was created. the posterior aspect of the peritoneum was also dissected. at this point, the infundibulopelvic ligament was isolated and three tie of #0 vicryl was used to isolate the pedicle. two hemostats were then placed across the pedicle and this was transected with the scalpel. this was then suture ligated in heaney fashion. the right round ligament was then identified and in the similar fashion, two hemostats were placed across the round ligament and using the mayo scissors the round ligament was transected and dissected down the broad ligament to create the bladder flap anteriorly as well as dissect the posterior peritoneum and isolate the round ligament. this was then ligated with three tie of #0 vicryl. also incorporated in this was the remnant from the previous right salpingo-oophorectomy. at this point, the bladder flap was further created with sharp dissection as well as the moist ray-tech to push the bladder down off the anterior portion of the cervix.,the left uterine artery was then skeletonized and a straight heaney was placed. in a similar fashion, the contralateral uterine artery was skeletonized and straight heaney clamp was placed. these ligaments bilaterally were transected and suture ligated in a left heaney stitch. at this point, curved masterson was used to incorporate the cardinal ligament complex, thus was transected and suture ligated. straight masterson was then used to incorporate the uterosacrals bilaterally and this was also transected and suture ligated. prior to ligating the uterine arteries, the uterosacral arteries were tagged bilaterally with #0 vicryl. at this point, the roticulator was placed across the vaginal cuff and snug underneath the entire cervix. the roticulator was then clamped and removed and the staple line was in place. this was found to be hemostatic. a suture was then placed through each cuff angle bilaterally and cardinal ligament complex was found to be fixed to each apex bilaterally. at this point, mccall culdoplasty was performed with an #0 vicryl incorporating each uterosacral as well as the posterior peritoneum. there did appear to be good support on palpation. prior to this, the specimen was handed off and sent to pathology. at this point, there did appear to be small amount of oozing at the right peritoneum. hemostasis was obtained using a #0 vicryl in two single stitches. good hemostasis was then obtained on the cuff as well as the pedicles. copious irrigation was performed at this point with lactate ringers. the round ligaments were then incorporated into the cuff bilaterally. again, copious amount of irrigation was performed and good hemostasis was obtained. at this point, the peritoneum was reapproximated in a single interrupted stitch on the left and right lateral aspects to cover each pedicle bilaterally. at this point, the bowel packing as well as moist ray-tech was removed and while re-approximating the bowel it was noted that there were multiple interloop bowel adhesions which were taken down using the metzenbaum scissors with good visualization of the underlying bowel. good hemostasis was obtained of these sites as well. the sigmoid colon was then returned to its anatomic position and the omentum as well. the rectus muscle was then reapproximated with two interrupted sutures of #2-0 vicryl. the fascia was then reapproximated with #0 vicryl in a running fashion from lateral to medial meeting in the midline. the scarpa's fascia was then closed with #3-0 plain in a running suture. the skin was then re-approximated with #4-0 undyed vicryl in a subcuticular closure. this was dressed with an op-site. the patient tolerated the procedure well. the sponge, lap, and needle were correct x2. after the procedure, the patient was extubated and brought out of general anesthesia. she will go to the floor where she will be followed postoperatively in the hospital.

reason for visit: , followup evaluation and management of chronic medical conditions.,history of present illness:, the patient has been doing quite well since he was last seen. he comes in today with his daughter. he has had no symptoms of cad or chf. he had followup with dr. x and she thought he was doing quite well as well. he has had no symptoms of hyperglycemia or hypoglycemia. he has had no falls. his right knee does pain him at times and he is using occasional doses of tylenol for that. he wonders whether he could use a knee brace to help him with that issue as well. his spirits are good. he has had no incontinence. his memory is clear, as is his thinking.,medications:,1. bumex - 2 mg daily.,2. aspirin - 81 mg daily.,3. lisinopril - 40 mg daily.,4. nph insulin - 65 units in the morning and 25 units in the evening.,5. zocor - 80 mg daily.,6. toprol-xl - 200 mg daily.,7. protonix - 40 mg daily.,8. chondroitin/glucosamine - no longer using.,major findings:, weight 240, blood pressure by nurse 160/80, by me 140/78, pulse 91 and regular, and o2 saturation 94%. he is afebrile. jvp is normal without hjr. ctap. rrr. s1 and s2. aortic murmur unchanged. abdomen: soft, nt without hsm, normal bs. extremities: no edema on today's examination. awake, alert, attentive, able to get up on to the examination table under his own power. able to get up out of a chair with normal get up and go. bilateral oa changes of the knee.,creatinine 1.7, which was down from 2.3. a1c 7.6 down from 8.5. total cholesterol 192, hdl 37, and triglycerides 487.,assessments:,1. congestive heart failure, stable on current regimen. continue.,2. diabetes type ii, a1c improved with increased doses of nph insulin. doing self-blood glucose monitoring with values in the morning between 100 and 130. continue current regimen. recheck a1c on return.,3. hyperlipidemia, at last visit, he had 3+ protein in his urine. tsh was normal. we will get a 24-hour urine to rule out nephrosis as the cause of his hypertriglyceridemia. in the interim, both dr. x and i have been considering together as to whether the patient should have an agent added to treat his hypertriglyceridemia. specifically we were considering tricor (fenofibrate). given his problems with high cpk values in the past for now, we have decided not to engage in that strategy. we will leave open for the future. check fasting lipid panel today.,4. chronic renal insufficiency, improved with reduction in dose of bumex over time.,5. arthritis, stable. i told the patient he could use extra strength tylenol up to 4 grams a day, but i suggest that he start with a regular dose of 1 to 2 to 3 grams per day. he states he will inch that up slowly. with regard to a brace, he stated he used one in the past and that did not help very much. i worry a little bit about the tourniquet type effect of a brace that could increase his edema or put him at risk for venous thromboembolic disease. for now he will continue with his cane and walker.,6. health maintenance, flu vaccination today.,plans: , followup in 3 months, by phone sooner as needed.

preoperative diagnosis: , left testicular torsion.,postoperative diagnoses: ,1. left testicular torsion.,2. left testicular abscess.,3. necrotic testes.,surgery:, left orchiectomy, scrotal exploration, right orchidopexy.,drains:, penrose drain on the left hemiscrotum.,the patient was given vancomycin, zosyn, and levaquin preop.,brief history: ,the patient is a 49-year-old male who came into the emergency room with 2-week history of left testicular pain, scrotal swelling, elevated white count of 39,000. the patient had significant scrotal swelling and pain. ultrasound revealed necrotic testicle. options such as watchful waiting and removal of the testicle were discussed. due to elevated white count, the patient was told that he must have the testicle removed due to the infection and possible early signs of urosepsis. the risks of anesthesia, bleeding, infection, pain, mi, dvt, pe, scrotal issues, other complications were discussed. the patient was told about the morbidity and mortality of the procedure and wanted to proceed.,procedure in detail: , the patient was brought to the or. anesthesia was applied. the patient was prepped and draped in usual sterile fashion. a midline scrotal incision was made. there was very, very thick scrotal skin. there was no necrotic skin. as soon as the left hemiscrotum was entered, significant amount of pus poured out of the left hemiscrotum. the testicle was completely filled with pus and had completely disintegrated with pus. the pus just poured out of the left testicle. the left testicle was completely removed. debridement was done of the scrotal wall to remove any necrotic tissue. over 2 l of antibiotic irrigation solution was used to irrigate the left hemiscrotum. there was good tissue left after all the irrigation and debridement. a penrose drain was placed in the bottom of the left hemiscrotum. i worried about the patient may have torsed and then the testicle became necrotic, so the plan was to pex the right testicle, plus the right side also appeared very abnormal. so, the right hemiscrotum was opened. the testicle had significant amount of swelling and scrotal wall was very thick. the testicle appeared normal. there was no pus coming out of the right hemiscrotum. at this time, a decision was made to place 4-0 prolene nonabsorbable stitches in 3 different quadrants to prevent it from torsion. the hemiscrotum was closed using 2-0 vicryl in interrupted stitches and the skin was closed using 2-0 pds in horizontal mattress. there was very minimal pus left behind and the skin was very healthy. decision was made to close it to help the patient heal better in the long run. the patient was brought to the recovery in stable condition.

history of present illness:, this is a 1-year-old male patient who was admitted on 12/23/2007 with a history of rectal bleeding. he was doing well until about 2 days prior to admission and when he passes hard stools, there was bright red blood in the stool. he had one more episode that day of stool; the stool was hard with blood in it. then, he had one episode of rectal bleeding yesterday and again one stool today, which was soft and consistent with dark red blood in it. no history of fever, no diarrhea, no history of easy bruising. excessive bleeding from minor cut. he has been slightly fussy.,past medical history: ,nothing significant.,pregnancy delivery and nursery course: , he was born full term without complications.,past surgical history: , none.,significant illness and review of systems: , negative for heart disease, lung disease, history of cancer, blood pressure problems, or bleeding problems.,diet:, regular table food, 24 ounces of regular milk. he is n.p.o. now.,travel history: , negative.,immunization: , up-to-date.,allergies: , none.,medications: , none, but he is on iv zantac now.,social history: , he lives with parents and siblings.,family history:, nothing significant.,laboratory evaluation: , on 12/24/2007, wbc 8.4, hemoglobin 7.6, hematocrit 23.2 and platelets 314,000. sodium 135, potassium 4.7, chloride 110, co2 20, bun 6 and creatinine 0.3. albumin 3.3. ast 56 and alt 26. crp less than 0.3. stool rate is still negative.,diagnostic data: , ct scan of the abdomen was read as normal.,physical examination: ,vital signs: temperature 99.5 degrees fahrenheit, pulse 142 per minute and respirations 28 per minute. weight 9.6 kilogram.,general: he is alert and active child in no apparent distress.,heent: atraumatic and normocephalic. pupils are equal, round and reactive to light. extraocular movements, conjunctivae and sclerae fair. nasal mucosa pink and moist. pharynx is clear.,neck: supple without thyromegaly or masses.,lungs: good air entry bilaterally. no rales or wheezing.,abdomen: soft and nondistended. bowel sounds positive. no mass palpable.,genitalia: normal male.,rectal: deferred, but there was no perianal lesion.,musculoskeletal: full range of movement. no edema. no cyanosis.,cns: alert, active and playful.,impression: , a 1-year-old male patient with history of rectal bleeding. possibilities include meckel's diverticulum, polyp, infection and vascular malformation.,plan:, to proceed with meckel scan today. if meckel scan is negative, we will consider upper endoscopy and colonoscopy. we will start colon clean out if meckel scan is negative. we will send his stool for c. diff toxin, culture, blood for rast test for cow milk, soy, wheat and egg. monitor hemoglobin.

exam:,mri right foot,clinical:,pain and swelling in the right foot.,findings: ,obtained for second opinion interpretation is an mri examination performed on 11-04-05.,there is a transverse fracture of the anterior superior calcaneal process of the calcaneus. the fracture is corticated however and there is an active marrow stress phenomenon. there is a small ganglion measuring approximately 8 x 5 x 5mm in size extending along the bifurcate ligament.,there is no substantial joint effusion of the calcaneocuboid articulation. there is minimal interstitial edema involving the short plantar calcaneal cuboid ligament.,normal plantar calcaneonavicular spring ligament.,normal talonavicular articulation.,there is minimal synovial fluid within the peroneal tendon sheaths.,axial imaging of the ankle has not been performed orthogonal to the peroneal tendon distal to the retromalleolar groove. the peroneus brevis tendon remains intact extending to the base of the fifth metatarsus. the peroneus longus tendon can be identified in its short axis extending to its distal plantar insertion upon the base of the first metatarsus with minimal synovitis.,there is minimal synovial fluid within the flexor digitorum longus and flexor hallucis longus tendon sheath with pooling of the fluid in the region of the knot of henry.,there is edema extending along the deep surface of the extensor digitorum brevis muscle.,normal anterior, subtalar and deltoid ligamentous complex.,normal naviculocuneiform, intercuneiform and tarsometatarsal articulations.,the lisfranc’s ligament is intact.,the achilles tendon insertion has been excluded from the field-of-view.,normal plantar fascia and intrinsic plantar muscles of the foot.,there is mild venous distention of the veins of the foot within the tarsal tunnel.,there is minimal edema of the sinus tarsus. the lateral talocalcaneal and interosseous talocalcaneal ligaments are normal.,normal deltoid ligamentous complex.,normal talar dome and no occult osteochondral talar dome defect.,impression:,transverse fracture of the anterior calcaneocuboid articulation with cortication and cancellous marrow edema.,small ganglion intwined within the bifurcate ligament.,interstitial edema of the short plantar calcaneocuboid ligament.,minimal synovitis of the peroneal tendon sheaths but no demonstrated peroneal tendon tear.,minimal synovitis of the flexor tendon sheaths with pooling of fluid within the knot of henry.,minimal interstitial edema extending along the deep surface of the extensor digitorum brevis muscle.

cc:, fall and laceration.,hpi: , mr. b is a 42-year-old man who was running to catch a taxi when he stumbled, fell and struck his face on the sidewalk. he denies loss of consciousness but says he was dazed for a while after it happened. he complains of pain over the chin and right forehead where he has abrasions. he denies neck pain, back pain, extremity pain or pain in the abdomen.,pmh: , hypertension.,meds:, none.,ros: , as above. otherwise negative.,physical exam: , this is a gentleman in full c-spine precautions on a backboard brought by ems. he is in no apparent distress. ,vital signs: bp 165/95 hr 80 rr 12 temp 98.4 spo2 95% ,heent: no palpable step offs, there is blood over the right fronto-parietal area where there is a small 1cm laceration and surrounding abrasion. also, 2 cm laceration over the base of the chin without communication to the oro-pharynx. no other trauma noted. no septal hematoma. no other facial bony tenderness. ,neck: nontender ,chest: breathing comfortably; equal breath sounds. ,heart: regular rhythm.,abd: benign.,ext: no tenderness or deformity; pulses are equal throughout; good cap refill ,neuro: awake and alert; slight slurring of speech and cognitive slowing consistent with alcohol; moves all extremities; cranial nerves normal. ,course in the ed:, patient arrived and was placed on monitors. an iv had been placed in the field and labs were drawn. x-rays of the c spine show no fracture and i've removed the c-collar. the lacerations were explored and no foreign body found. they were irrigated and closed with simple interrupted sutures. labs showed normal cbc, chem-7, and u/a except there was moderate protein in the urine. the blood alcohol returned at 0.146. a banana bag is ordered and his care will be turned over to dr. g for further evaluation and care.

exam:,mri spinal cord cervical without contrast,clinical:,right arm pain, numbness and tingling.,findings:,vertebral alignment and bone marrow signal characteristics are unremarkable. the c2-3 and c3-4 disk levels appear unremarkable.,at c4-5, broad based disk/osteophyte contacts the ventral surface of the spinal cord and may mildly indent the cord contour. a discrete cord signal abnormality is not identified. there may also be some narrowing of the neuroforamina at this level.,at c5-6, central disk-osteophyte contacts and mildly impresses on the ventral cord contour. distinct neuroforaminal narrowing is not evident.,at c6-7, mild diffuse disk-osteophyte impresses on the ventral thecal sac and contacts the ventral cord surface. distinct cord compression is not evident. there may be mild narrowing of the neuroforamina at his level.,a specific abnormality is not identified at the c7-t1 level.,impression:,disk/osteophyte at c4-5 through c6-7 with contact and may mildly indent the ventral cord contour at these levels. some possible neuroforaminal narrowing is also noted at levels as stated above.

subjective:, this is a followup dietary consultation for polycystic ovarian syndrome and hyperlipidemia. the patient reports that she has resumed food record keeping which she feels like it has given her greater control. her physical activity level has remained high. her struggle times are in the mid-afternoon if she has not had enough food to eat, as well as in the evening after dinner.,objective:, vital signs: weight is 189-1/2 pounds. food records were reviewed,assessment:, the patient has experienced a weight loss of 1-1/2 pounds in the last month. she is commended for these efforts. we have reviewed food records identifying that she has done a nice job keeping a calorie count for the last two or three weeks. we discussed the value of this and how it was very difficulty to resume it, however, after she suspended the record keeping. we also discussed its reflection that she is not getting very many fruits and vegetables on a regular basis. we identified some ways of preventing her from feeling sluggish and having problems with low blood sugar in the middle of the afternoon by routinely planning an afternoon snack that can prevent these symptoms. this will likely be around 2:30 or 3 p.m. for her. we also discussed strategies for evening snacking to help put some definition and boundaries to the snacking.,plan:, i recommended the patient routinely include an afternoon snack around 2:30 to 3 p.m. it will be helpful if this snack includes some protein such as nuts or low-fat cheese. she is also encouraged to continue with her record keeping for food choices and calorie points. i also recommended she maintain her high level of physical activity. will plan to follow the patient in one month for ongoing support. this was a 30-minute consultation.

preoperative diagnosis: , left pleural effusion, parapneumonic, loculated.,postoperative diagnosis: , left pleural effusion, parapneumonic, loculated.,operation: , left chest tube placement.,iv sedation: , 5 mg of versed total given under pulse ox monitoring, 1% lidocaine local infiltration.,procedure: , with the patient semi recumbent and supine the left anterolateral chest was prepped and draped in the usual sterile fashion. a 1% lidocaine was liberally infiltrated into the skin, subcutaneous tissue, deep fascia and the anterior axillary line just below the level of the nipple. the incision was made and deepened through the different layers to reach the intercostal space. the pleura was entered on top of the underlying rib and finger digital palpation was performed. multiple loculations were encountered. break up of loculations was performed posteriorly and a chest tube was directed posteriorly. only a small amount of fluid was noted to come out initially. this was sent for various studies. soft adhesions were encountered. the plan was to obtain a chest x-ray and start activase installation.

ct abdomen with contrast and ct pelvis with contrast,reason for exam: , generalized abdominal pain with swelling at the site of the ileostomy.,technique:, axial ct images of the abdomen and pelvis were obtained utilizing 100 ml of isovue-300.,ct abdomen: ,the liver, spleen, pancreas, adrenal glands, and kidneys are unremarkable. punctate calcifications in the gallbladder lumen likely represent a gallstone.,ct pelvis: ,postsurgical changes of a left lower quadrant ileostomy are again seen. there is no evidence for an obstruction. a partial colectomy and diverting ileostomy is seen within the right lower quadrant. the previously seen 3.4 cm subcutaneous fluid collection has resolved. within the left lower quadrant, a 3.4 cm x 2.5 cm loculated fluid collection has not significantly changed. this is adjacent to the anastomosis site and a pelvic abscess cannot be excluded. no obstruction is seen. the appendix is not clearly visualized. the urinary bladder is unremarkable.,impression:,1. resolution of the previously seen subcutaneous fluid collection.,2. left pelvic 3.4 cm fluid collection has not significantly changed in size or appearance. these findings may be due to a pelvic abscess.,3. right lower quadrant ileostomy has not significantly changed.,4. cholelithiasis.

anatomical summary,1. sharp force wound of neck, left side, with transection of left internal jugular vein.,2. multiple stab wounds of chest, abdomen, and left thigh: penetrating stab wounds of chest and abdomen with right hemothorax and hemoperitoneum.,3. multiple incised wounds of scalp, face, neck, chest and left hand (defense wound).,4. multiple abrasions upper extremities and hands (defense wounds).,notes and procedures,1. the body is described in the standard anatomical position. reference is to this position only.,2. where necessary, injuries are numbered for reference. this is arbitrary and does not correspond to any order in which they may have been incurred. all the injuries are antemortem, unless otherwise specified.,3. the term "anatomic" is used as a specification to indicate correspondence with the description as set forth in the textbooks of gross anatomy. it denotes freedom from significant, visible or morbid alteration.,external examination:, the body is that of a well developed, well nourished caucasian male stated to be 25 years old. the body weighs 171 pounds, measuring 69 inches from crown to sole. the hair on the scalp is brown and straight. the irides appear hazel with the pupils fixed and dilated. the sclerae and conjunctive are unremarkable, with no evidence of petechial hemorrhages on either. both upper and lower teeth are natural, and there are no injuries of the gums, cheeks, or lips.,there is a picture-type tattoo on the lateral aspect of the left upper arm. there are no deformities, old surgical scars or amputations.,rigor mortis is fixed.,the body appears to the examiner as stated above. identification is by toe tag and the autopsy is not material to identification. the body is not embalmed.,the head is normocephalic, and there is extensive evidence of external traumatic injury, to be described below. otherwise, the eyes, nose and mouth are not remarkable. the neck shows sharp force injuries to be described below. the front of the chest and abdomen likewise show injuries to be described below. the genitalia are that of an adult male, with the penis circumcised, and no evidence of injury.,examination of the posterior surface of the trunk reveals no antemortem traumatic injuries.,refer to available photographs and diagrams and to the specific documentation of the autopsy protocol.,clothing:, the clothes were examined both before and after removal from the body.,the decedent was wearing a long-sleeved type of shirt/sweater; it was extensively bloodstained.,on the front, lower right side, there was a 1 1/2 inch long slit-like tear. also on the lower right sleeve there was a 1 inch slit-like tear. on the back there was a 1/2 inch slit-like tear on the right lower side.,decedent was wearing a pair of levi jeans bloodstained. on the outside of the left hip region there was a 1-1/2 inch long slit-like tear. the decedent also was wearing 2 canvas type boots and 2 sweat socks.,evidence of therapeutic intervention:, none.,evidence of injury,sharp force injuries of neck,1. sharp force injury of neck, left side, transecting left internal jugular vein. this sharp force injury is complex, and appears to be a combination of a stabbing and cutting wound. it begins on the left side of the neck, at the level of the midlarynx, over the left sternocleidomastoid muscle; it is gaping, measuring 3 inches in length with smooth edges. it tapers superiorly to 1 inch in length cut skin. dissection discloses that the wound path is through the skin, the subcutaneous tissue, and the sternocleidomastoid muscle with hemorrhage along the wound path and transection of the left internal jugular vein, with dark red-purple hemorrhage in the adjacent subcutaneous tissue and fascia. the direction of the pathway is upward and slightly front to back for a distance of approximately 4 inches where it exits, post-auricular, in a 2 inch in length gaping stab/incised wound which has undulating or wavy borders, but not serrated. intersecting the wound at right angle superior inferior is a 2 inch in length interrupted superficial, linear incised wound involving only the skin. also, intervening between the 2 gaping stab-incised wounds is a horizontally oriented 3-1/2 inch in length interrupted superficial, linear incised wound of the skin only. in addition, there is a 1/2 inch long, linear-triangular in size wound of the inferior portion of the left earlobe. the direction of the sharp force injury is upward (rostral), and slightly front to back with no significant angulation or deviation. the total length of the wound path is approximately 4 inches. however, there is a 3/4 inch in length, linear, cutting or incised wound of the top or superior aspect of the pinna of the left ear; a straight metallic probe placed through the major sharp force injury shows that the injury of the superior part of the ear can be aligned with the straight metallic rod, suggesting that the 3 injuries are related; in this instance the total length of the wound path is approximately 6 inches. also, in the left postauricular region, transversely oriented, extending from the auricular attachment laterally to the scalp is a 1-1/8 inch in length linear superficial incised skin wound.,opinion: , this sharp force injury of the neck is fatal, associated with transection of the left internal jugular vein.,2. sharp force wound of the right side of neck. this is a complex injury, appearing to be a combination stabbing and cutting wound. the initial wound is present on the right side of the neck, over the sternocleidomastoid muscle, 3 inches directly below the right external auditory canal. it is diagonally oriented, and after approximation of the edges measures 5/8 inch in length; there is a pointed or tapered end inferiorly and a split or forked end superiorly approximately 1/16 inch in maximal width. subsequent autopsy shows that the wound path is through the skin and subcutaneous tissue, without penetration of injury of a major,artery or vein; the direction is front to back and upward for a total wound path length of 2 inches and the wound exits on the right side of the back of the neck, posterior to the right sternocleidomastoid muscle where a 2 inch long gaping incised/stab wound is evident on the skin; both ends are tapered; superiorly there is a 1 inch long superficial incised wounds extension on the skin to the back of the head; inferiorly there is a 2 inch long incised superficial skin extension, extending inferiorly towards the back of the neck. there is fresh hemorrhage and bruising along the wound path; the direction, as stated, is upward and slightly front to back.,opinion: ,this is a nonfatal sharp force injury, with no injury or major artery or vein.,3. at the level of the superior border of the larynx there is a transversely oriented, superficial incised wound of the neck, extending from 3 inches to the left of the anterior midline; it is 3 inches in length and involves the skin only; a small amount of cutaneous hemorrhage is evident.,opinion:, this is a nonfatal superficial incised wound.,4. immediately inferior and adjacent to incised wound #3 is a transversely oriented, superficial incised wound involving the skin and subcutaneous tissue; there is a small amount of dermal hemorrhage.,opinion:, this is a nonfatal superficial incised wound.,sharp force injuries of face,1. there is a stab wound, involving the right earlobe; it is vertically oriented, and after approximation of the edges measures 1 inch in length with forked or split ends superiorly and inferiorly approximately 1/16 inch in total width both superior and inferior. subsequent dissection discloses that the wound path is from right to left, in the horizontal plane for approximately 1-1/4 inches; there is fresh hemorrhage along the wound path; the wound path terminates in the left temporal bone and does not penetrate the cranial cavity.,opinion:, this is a nonfatal stab wound.,2. there is a group of 5 superficial incised or cutting wounds on the right side of the face, involving the right cheek and the right side of the jaw. they are varied in orientation both diagonal and horizontal; the smallest is 1/4 inch in length; the largest 5/8 inch in length. they are superficial, involving the skin only, associated with a small amount of cutaneous hemorrhage.,3. on the back of the neck, right side, posterior to the ear and posterior border of the right sternocleidomastoid muscle there is vertically oriented superficial incised skin wound, measuring 3/4 inch in length.,4. there are numerous superficial incised wounds or cuts, varied in orientation, involving the skin of the right cheek, intersection and mingled with the various superficial incised wounds described above. the longest is a 3 inch long diagonally oriented superficial incised wound extending from the right side of the forehead to the cheek; various other superficial wound vary from 1/2 to 1 inch.,5. on the right side of the cheek, adjacent to the ramus of the mandible, right, there is a 1-1/2 x 3/4 inch superficial nonpatterned red-brown abrasion with irregular border, extending superiorly towards the angle of the jaw where there are poorly defined and circumscribed abrasions adjacent to the superficial cuts or abrasions described above. it should be noted that the 5th superficial incised wound of the right side of the mandible which measures 5/8 inch in length is tapered on the posterior aspect and forked on the anterior aspect where it has a width of 1/32 inch.,6. on the left ear, there is a superficial incised wound measuring 1/4 inch, adjacent to the posterior border of the pinna. just below this on the inferior pinna, extending to the earlobe, there is an interrupted superficial linear abrasion measuring 1 inch in length.

procedure:, sleep study.,clinical information:, this patient is a 56-year-old gentleman who had symptoms of obstructive sleep apnea with snoring, hypertension. the test was done 01/24/06. the patient weighed 191 pounds, five feet, seven inches tall.,sleep questionnaire:, according to the patient's own estimate, the patient took about 15 minutes to fall asleep, slept for six and a half hours, did have some dreams. did not wake up and the sleep was less refreshing. he was sleepy in the morning.,study protocol:, an all night polysomnogram was recorded with a compumedics e series digital polysomnograph. after the scalp was prepared, ag/agcl electrodes were applied to the scalp according to the international 10-20 system. eeg was monitored from c4-a1, c3-a2, o2-a1 and o2-a1. eog and emg were continuously monitored by electrodes placed at the outer canthi and chin respectively. nasal and oral airflow were monitored using a triple port thermistor. respiratory effort was measured by piezoelectric technology employing an abdominal and thoracic belt. blood oxygen saturation was continuously monitored by pulse oximetry. heart rate and rhythm were monitored by surface electrocardiography. anterior tibialis emg was studied by using surface mounted electrodes placed 5 cm apart on both legs. body position and snoring level were also monitored.,technical quality of study:, good.,electrophysiologic measurements:, total recording time 406 minutes, total sleep time 365 minutes, sleep latency 25.5 minutes, rem latency 49 minutes, _____ 90%, sleep latency measured 86%. _____ period was obtained. the patient spent 10% of the time awake in bed.,stage i: 3.8,stage ii: 50.5,stage iii: 14%,stage rem: 21.7%,the patient had relatively good sleep architecture, except for excessive waking.,respiratory measurements:, total apnea/hypopnea 75, age index 12.3 per hour. rem age index 15 per hour. total arousal 101, arousal index 15.6 per hour. oxygen desaturation was down to 88%. longest event 35 second hypopnea with an fio2 of 94%. total limb movements 92, prm index 15.1 per hour. prm arousal index 8.9 per hour.,electrocardiographic observations:, heart rate while asleep 60 to 64 per minute, while awake 70 to 78 per minute.,conclusions:, obstructive sleep apnea syndrome with moderately loud snoring and significant apnea/hypopnea index.,recommendations:,axis b: overnight polysomnography.,axis c: hypertension.,the patient should return for nasal cpap titration. sleep apnea if not treated, may lead to chronic hypertension, which may have cardiovascular consequences. excessive daytime sleepiness, dysfunction and memory loss may also occur.

exam: ,thoracic spine.,reason for exam: , injury.,interpretation: , the thoracic spine was examined in the ap, lateral and swimmer's projections. there is mild chronic-appearing anterior wedging of what is believed to represent t11 and 12 vertebral bodies. a mild amount of anterior osteophytic lipping is seen involving the thoracic spine. there is a suggestion of generalized osteoporosis. the intervertebral disc spaces appear generally well preserved.,the pedicles appear intact.,impression:,1. mild chronic-appearing anterior wedging of what is believed to represent the t11 and 12 vertebral bodies.,2. mild degenerative changes of the thoracic spine.,3. osteoporosis.

subjective:, the patient is a 78-year-old female with the problem of essential hypertension. she has symptoms that suggested intracranial pathology, but so far work-up has been negative.,she is taking hydrochlorothiazide 25-mg once a day and k-dur 10-meq once a day with adequate control of her blood pressure. she denies any chest pain, shortness of breath, pnd, ankle swelling, or dizziness.,objective:, heart rate is 80 and blood pressure is 130/70. head and neck are unremarkable. heart sounds are normal. abdomen is benign. extremities are without edema.,assessment and plan:, the patient reports that she had an echocardiogram done in the office of dr. sample doctor4 and was told that she had a massive heart attack in the past. i have not had the opportunity to review any investigative data like chest x-ray, echocardiogram, ekg, etc. so, i advised her to have a chest x-ray and an ekg done before her next appointment, and we will try to get hold of the echocardiogram on her from the office of dr. sample doctor4. in the meantime, she is doing quite well, and she was advised to continue her current medication and return to the office in three months for followup.

reason for exam:, cva.,indications: , cva.,this is technically acceptable. there is some limitation related to body habitus.,dimensions: ,the interventricular septum 1.2, posterior wall 10.9, left ventricular end-diastolic 5.5, and end-systolic 4.5, the left atrium 3.9.,findings: , the left atrium was mildly dilated. no masses or thrombi were seen. the left ventricle showed borderline left ventricular hypertrophy with normal wall motion and wall thickening, ef of 60%. the right atrium and right ventricle are normal in size.,mitral valve showed mitral annular calcification in the posterior aspect of the valve. the valve itself was structurally normal. no vegetations seen. no significant mr. mitral inflow pattern was consistent with diastolic dysfunction grade 1. the aortic valve showed minimal thickening with good exposure and coaptation. peak velocity is normal. no ai.,pulmonic and tricuspid valves were both structurally normal.,interatrial septum was appeared to be intact in the views obtained. a bubble study was not performed.,no pericardial effusion was seen. aortic arch was not assessed.,conclusions:,1. borderline left ventricular hypertrophy with normal ejection fraction at 60%.,2. mitral annular calcification with structurally normal mitral valve.,3. no intracavitary thrombi is seen.,4. interatrial septum was somewhat difficult to assess, but appeared to be intact on the views obtained.

operative procedure,1. thromboendarterectomy of right common, external, and internal carotid artery utilizing internal shunt and dacron patch angioplasty closure.,2. coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending, and reverse autogenous saphenous vein graft to the obtuse marginal, posterior descending branch of the right coronary artery. total cardiopulmonary bypass,cold blood potassium cardioplegia, antegrade and retrograde, for myocardial protection, placement of temporary pacing wires.,description:, the patient was brought to the operating room, placed in supine position. adequate general endotracheal anesthesia was induced. appropriate monitoring lines were placed. the chest, abdomen and legs were prepped and draped in a sterile fashion. the greater saphenous vein was harvested from the right upper leg through interrupted skin incisions and was prepared by ligating all branches with 4-0 silk and flushing with vein solution. the leg was closed with running 3-0 dexon subcu, and running 4-0 dexon subcuticular on the skin, and later wrapped. a median sternotomy incision was made and the left internal mammary artery was dissected free from its takeoff at the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze. the sternum was closed. a right carotid incision was made along the anterior border of the sternocleidomastoid muscle and carried down to and through the platysma. the deep fascia was divided. the facial vein was divided between clamps and tied with 2-0 silk. the common carotid artery, takeoff of the external and internal carotid arteries were dissected free, with care taken to identify and preserve the hypoglossal and vagus nerves. the common carotid artery was double-looped with umbilical tape, takeoff of the external was looped with a heavy silk, distal internal was double-looped with a heavy silk. shunts were prepared. a patch was prepared. heparin 50 mg was given iv. clamp was placed on the beginning of the takeoff of the external and the proximal common carotid artery. distal internal was held with a forceps. internal carotid artery was opened with 11-blade. potts scissors were then used to extend the aortotomy through the lesion into good internal carotid artery beyond. the shunt was placed and proximal and distal snares were tightened. endarterectomy was carried out under direct vision in the common carotid artery and the internal reaching a fine, feathery distal edge using eversion on the external. all loose debris was removed and dacron patch was then sutured in place with running 6-0 prolene suture, removing the shunt just prior to completing the suture line. suture line was completed and the neck was packed.,the pericardium was opened. a pericardial cradle was created. the patient was heparinized for cardiopulmonary bypass, cannulated with a single aortic and single venous cannula. a retrograde cardioplegia cannula was placed with a pursestring of 4-0 prolene into the coronary sinus, and secured to a rumel tourniquet. an antegrade cardioplegia needle sump was placed in the ascending aorta and cardiopulmonary bypass was instituted. the ascending aorta was cross-clamped and cold blood potassium cardioplegia was given antegrade, a total of 5 cc per kg. this was followed sumping of the ascending aorta and retrograde cardioplegia, a total of 5 cc per kg to the coronary sinus. the obtuse marginal 1 coronary was identified and opened, and an end-to-side anastomosis was then performed with running 7-0 prolene suture. the vein was cut to length. antegrade and retrograde cold blood potassium cardioplegia was given. the obtuse marginal 2 was not felt to be suitable for bypass, therefore, the posterior descending of the right coronary was identified and opened, and an end-to-side anastomosis was then performed with running 7-0 prolene suture to reverse autogenous saphenous vein. the vein was cut to length. the mammary was clipped distally, divided and spatulated for anastomosis. antegrade and retrograde cold blood potassium cardioplegia was given. the anterior descending was identified and opened. the mammary was then sutured to this with running 8-0 prolene suture. warm blood potassium cardioplegia was given, and the cross-clamp was removed. a partial-occlusion clamp was placed. two aortotomies were made. the veins were cut to fit these and sutured in place with running 5-0 prolene suture. the partial- occlusion clamp was removed. all anastomoses were inspected and noted to be patent and dry. atrial and ventricular pacing wires were placed. ventilation was commenced. the patient was fully warmed. the patient was weaned from cardiopulmonary bypass and de-cannulated in a routine fashion. protamine was given. good hemostasis was noted. a single mediastinal chest tube and bilateral pleural blake drains were placed. the sternum was closed with figure-of-eight stainless steel wire, the linea alba with figure-of-eight #1 vicryl, the sternal fascia with running #1 vicryl, the subcu with running 2-0 dexon and the skin with a running 4-0 dexon subcuticular stitch.

preoperative diagnosis:, right both bone forearm refracture.,postoperative diagnosis: , right both bone forearm refracture.,procedure:, closed reduction and pinning of the right ulna with placement of a long-arm cast.,anesthesia: , surgery performed under general anesthesia. local anesthetic was 10 ml of 0.25% marcaine plain.,complications: , no intraoperative complications.,drains: , none.,specimens: , none.,hardware: ,hardware was 0.79 k-wire.,history and physical: , the patient is a 5-year-old male who sustained refracture of his right forearm on 12/05/2007. the patient was seen in the emergency room. the patient had a complete fracture of both bones with shortening bayonet apposition. treatment options were offered to the family including casting versus closed reduction and pinning. the parents opted for the latter. risks and benefits of surgery were discussed. risks of surgery included risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, and need for later hardware removal, cast tightness. all questions were answered, and the parents agreed to the above plan.,procedure in detail: , the patient was taken to the operating room and placed supine on the operating room table. general anesthesia was then administered. the patient received ancef preoperatively. the right upper extremity was then prepped and draped in standard surgical fashion. a small incision was made at the tip of the olecranon. initially, a 1.11 guidewire was placed, but this was noted to be too wide for this canal. this was changed for a 0.79 k-wire. this was driven up to the fracture site. the fracture was manually reduced and then the k-wire passed through the distal segment. this demonstrated adequate fixation and reduction of both bones. the pin was then cut short. the fracture site and pin site was infiltrated with 0.25% marcaine. the incision was closed using 4-0 monocryl. the wounds were cleaned and dried. dressed with xeroform, 4 x 4. the patient was then placed in a well-moulded long-arm cast. he tolerated the procedure well. he was subsequently taken to recovery in stable condition.,postoperative plan: , the patient will be maintain current pin, and long-arm cast for 4 weeks at which time he will return for cast removal. x-rays of the right forearm will be taken. the patient may need additional mobilization time. once the fracture has healed, we will take the pin out, usually at the earliest 3 to 4 months. intraoperative findings were relayed to the parents. all questions were answered.

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

preoperative diagnosis: , morbid obesity.,postoperative diagnosis: ,morbid obesity.,procedure: , laparoscopic antecolic antegastric roux-en-y gastric bypass with eea anastomosis.,anesthesia: , general with endotracheal intubation.,indication for procedure: , this is a 30-year-old female, who has been overweight for many years. she has tried many different diets, but is unsuccessful. she has been to our bariatric surgery seminar, received some handouts, and signed the consent. the risks and benefits of the procedure have been explained to the patient.,procedure in detail: ,the patient was taken to the operating room and placed supine on the operating room table. all pressure points were carefully padded. she was given general anesthesia with endotracheal intubation. scd stockings were placed on both legs. foley catheter was placed for bladder decompression. the abdomen was then prepped and draped in standard sterile surgical fashion. marcaine was then injected through umbilicus. a small incision was made. a veress needle was introduced into the abdomen. co2 insufflation was done to a maximum pressure of 15 mmhg. a 12-mm versastep port was placed through the umbilicus. i then placed a 5-mm port just anterior to the midaxillary line and just subcostal on the right side. i placed another 5-mm port in the midclavicular line just subcostal on the right side, a few centimeters below and medial to that, i placed a 12-mm versastep port. on the left side, just anterior to the midaxillary line and just subcostal, i placed a 5-mm port. a few centimeters below and medial to that, i placed a 15-mm port. i began by lifting up the omentum and identifying the transverse colon and lifting that up and thereby identifying my ligament of treitz. i ran the small bowel down approximately 40 cm and divided the small bowel with a white load gia stapler. i then divided the mesentery all the way down to the base of the mesentery with a ligasure device. i then ran the distal bowel down, approximately 100 cm, and at 100 cm, i made a hole at the antimesenteric portion of the roux limb and a hole in the antimesenteric portion of the duodenogastric limb, and i passed a 45 white load stapler and fired a stapler creating a side-to-side anastomosis. i reapproximated the edges of the defect. i lifted it up and stapled across it with another white load stapler. i then closed the mesenteric defect with interrupted surgidac sutures. i divided the omentum all the way down to the colon in order to create a passageway for my small bowel to go antecolic. i then put the patient in reverse trendelenburg. i placed a liver retractor, identified, and dissected the angle of his. i then dissected on the lesser curve, approximately 2.5 cm below the gastroesophageal junction, and got into a lesser space. i fired transversely across the stomach with a 45 blue load stapler. i then used two fires of the 60 blue load with seamguard to go up into my angle of his, thereby creating my gastric pouch. i then made a hole at the base of the gastric pouch and had anesthesia remove the bougie and place the og tube connected to the anvil. i pulled the anvil into place, and i then opened up my 15-mm port site and passed my eea stapler. i passed that in the end of my roux limb and had the spike come out antimesenteric. i joined the spike with the anvil and fired a stapler creating an end-to-side anastomosis, then divided across the redundant portion of my roux limb with a white load gi stapler, and removed it with an endocatch bag. i put some additional 2-0 vicryl sutures in the anastomosis for further security. i then placed a bowel clamp across the bowel. i went above and passed an egd scope into the mouth down to the esophagus and into the gastric pouch. i distended gastric pouch with air. there was no air leak seen. i could pass the scope easily through the anastomosis. there was no bleeding seen through the scope. we closed the 15-mm port site with interrupted 0 vicryl suture utilizing carter-thomason. i copiously irrigated out that incision with about 2 l of saline. i then closed the skin of all incisions with running monocryl. sponge, instrument, and needle counts were correct at the end of the case. the patient tolerated the procedure well without any complications.

preoperative diagnoses:,1. metatarsus primus varus with bunion deformity, right foot.,2. hallux abductovalgus with angulation deformity, right foot.,postoperative diagnoses:,1. metatarsus primus varus with bunion deformity, right foot.,2. hallux abductovalgus with angulation deformity, right foot.,procedures:,1. distal metaphyseal osteotomy and bunionectomy with internal screw fixation, right foot.,2. reposition osteotomy with internal screw fixation to correct angulation deformity of proximal phalanx, right foot.,anesthesia:,local infiltrate with iv sedation.,indication for surgery: , the patient has had a longstanding history of foot problems. the foot problem has been progressive in nature and has not been responsive to conservative treatment. the preoperative discussion with the patient included the alternative treatment options.,the procedure was explained in detail and risk factors such as infection, swelling, scarred tissue; numbness, continued pain, recurrence, and postoperative management were explained in detail. the patient has been advised, although no guaranty for success could be given, most patients have improved function and less pain. all questions were thoroughly answered. the patient requested surgical repair since the problem has reached a point that interferes with her normal daily activities. the purpose of the surgery is to alleviate the pain and discomfort.,details of procedure: ,the patient was brought to the operating room and placed in a supine position. no tourniquet was utilized. iv sedation was administered and during that time local anesthetic consisting of approximately 10 ml total in a 1:1 mixture of 0.25% marcaine and 1% lidocaine with epinephrine was locally infiltrated proximal to the operative site. the lower extremity was prepped and draped in the usual sterile manner. balanced anesthesia was obtained.,procedure #1: , distal metaphyseal osteotomy with internal screw fixation with bunionectomy, right foot. a dorsal curvilinear incision medial to the extensor hallucis longus tendon was made, extending from the distal third of the shaft of the first metatarsal to a point midway on the shaft of the proximal phalanx. care was taken to identify and retract the vital structures and when necessary, vessels were ligated via electrocautery. sharp and blunt dissection was carried down through the subcutaneous tissue, superficial fascia, and then down to the capsular and periosteal layer, which was visualized. a linear periosteal capsular incision was made in line with the skin incision. the capsular tissue and periosteal layer were underscored, free from its underlying osseous attachments, and they refracted to expose the osseous surface. inspection revealed increased first intermetatarsal angle and hypertrophic changes to the first metatarsal head. the head of the first metatarsal was dissected free from its attachment medially and dorsally, delivered dorsally and may be into the wound.,inspection revealed the first metatarsophalangeal joint surface appeared to be in satisfactory condition. the sesamoid was in satisfactory condition. an oscillating saw was utilized to resect the hypertrophic portion of the first metatarsal head to remove the normal and functional configuration. care was taken to preserve the sagittal groove. the rough edges were then smoothed with a rasp.,attention was then focused on the medial mid portion of the first metatarsal head where a k-wire access guide was positioned to define the apex and direction of displacement for the capital fragment. the access guide was noted to be in good position. a horizontally placed, through-and-through osteotomy with the apex distal and the base proximal was completed. the short plantar arm was from the access guide to proximal plantar and the long dorsal arm was from the access guide to proximal dorsal. the capital fragment was distracted off the first metatarsal, moved laterally to decrease the intermetatarsal angle to create a more anatomical and functional position of the first metatarsal head. the capital fragment was impacted upon the metatarsal.,inspection revealed satisfactory reduction of the intermetatarsal angle and good alignment of the capital fragment. it was then fixated with 1 screw. a guide pin was directed from the dorsal aspect of the capital fragment to the plantar aspect of the shaft and first metatarsal in a distal dorsal to proximal plantar direction. the length was measured, __________ mm cannulated cortical screw was placed over the guide pin and secured in position. compression and fixation were noted to be satisfactory. inspection revealed good fixation and alignment at the operative site. attention was then directed to the medial portion of the distal third of the shaft of the first metatarsal where an oscillating saw was used to resect the small portion of the bone that was created by shifting the capital fragment laterally. all rough edges were rasped smooth. examination revealed there was still lateral deviation of the hallux. a second procedure, the reposition osteotomy of the proximal phalanx with internal screw fixation to correct angulation deformity was indicated., ,procedure #2:, reposition osteotomy with internal screw fixation to correct angulation deformity, proximal phalanx, right hallux. the original skin incision was extended from the point just distal to the interphalangeal joint. all vital structures were identified and retracted. sharp and blunt dissection was carried down through the subcutaneous tissue, superficial fascia, and down to the periosteal layer, which was underscored, free from its underlying osseous attachments and reflected to expose the osseous surface. the focus of the deformity was noted to be more distal on the hallux. utilizing an oscillating saw, a more distal, wedge-shaped transverse oblique osteotomy was made with the apex being proximal and lateral and the base medial distal was affected. the proximal phalanx was then placed in appropriate alignment and stabilized with a guide pin, which was then measured, __________ 14 mm cannulated cortical screw was placed over the guide pin and secured into position.,inspection revealed good fixation and alignment at the osteotomy site. the alignment and contour of the first way was now satisfactorily improved. the entire surgical wound was flushed with copious amounts of sterile normal saline irrigation. the periosteal and capsular layer was closed with running sutures of #3-0 vicryl. the subcutaneous tissue was closed with #4-0 vicryl and the skin edges coapted well with #4-0 nylon with running simples, reinforced with steri-strips.,approximately 6 ml total in a 1:1 mixture of 0.25% marcaine and 1% lidocaine plain was locally infiltrated proximal to the operative site for postoperative anesthesia. a dressing consisting of adaptic and 4 x 4 was applied to the wound making sure the hallux was carefully splinted, followed by confirming bandages and an ace wrap to provide mild compression. the patient tolerated the procedure and anesthesia well and left the operating room to recovery room in good postoperative condition with vital signs stable and arterial perfusion intact as evident by the normal capillary fill time.,a walker boot was dispensed and applied. the patient should wear it when walking or standing., ,the next office visit will be in 4 days. the patient was given prescriptions for percocet 5 mg #40 one p.o. q.4-6h. p.r.n. pain, along with written and oral home instructions. the patient was discharged home with vital signs stable in no acute distress.

preoperative diagnosis: , chronic pelvic pain, probably secondary to endometriosis.,postoperative diagnosis:, mild pelvic endometriosis.,procedure:,1. attempted laparoscopy.,2. open laparoscopy.,3. fulguration of endometrial implant.,anesthesia: , general endotracheal.,blood loss: , minimal.,complications: , none.,indications: ,the patient is a 21-year-old single female with chronic recurrent pelvic pain unresponsive to both estrogen and progesterone-containing birth control pills, either cyclically or daily as well as progestational medication only, who had a negative gi workup recently including colonoscopy, and desired definitive operative evaluation and diagnosis prior to initiation of a 6-month course of depo-lupron.,procedure: , after an adequate plane of general anesthesia had been obtained, the patient was placed in a dorsal lithotomy position. she was prepped and draped in the usual sterile fashion for pelviolabdominal surgery. bimanual examination revealed a mid position normal-sized uterus with benign adnexal area.,in the high lithotomy position, a weighted speculum was placed into the posterior vaginal wall. the anterior lip of the cervix was grasped with a single-tooth tenaculum. a hulka tenaculum was placed transcervically. the other instruments were removed. a foley catheter was placed transurethrally to drain the bladder intraoperatively.,in the low lithotomy position and in steep trendelenburg, attention was turned to the infraumbilical region. here, a stab wound incision was made through which the 120 mm veress needle was placed and approximately 3 l of carbon dioxide used to create a pneumoperitoneum. the needle was removed, the incision minimally enlarged, and the #5 trocar and cannula were placed. the trocar was removed and the scope placed confirming a preperitoneal insufflation.,the space was drained off the insufflated gas and 2 more attempts were made, which failed due to the patient's adiposity. attention was turned back to the vaginal area where in the high lithotomy position, attempts were made at a posterior vaginal apical insertion. the hulka tenaculum was removed, the posterior lip of the cervix grasped with a single-tooth tenaculum, and the long allis clamp used to grasp the posterior fornix on which was placed traction. the first short and subsequently 15 cm veress needles were attempted to be placed, but after several passes, no good pneumoperitoneum could be established via this route also. it was elected not to do a transcervical intentional uterine perforation, but to return to the umbilical area. the 15 cm veress needle was inserted several times, but again a pneumo was preperitoneal.,finally, an open laparoscopic approach was undertaken. the skin incision was expanded with a knife blade. blunt dissection was used to carry the dissection down to the fascia. this was grasped with kocher clamps, entered sharply and opened transversely. four 0 vicryl sutures were placed as stay sutures and tagged with hemostats and needles were cutoff. dissection continued between the rectus muscle and finally the anterior peritoneum was reached, grasped, elevated, and entered.,at this juncture, the hasson cannula was placed and tied snugly with the above stay sutures while the pneumoperitoneum was being created, a #10 scope was placed confirming the intraperitoneal positioning.,under direct visualization, a suprapubic 5 mm cannula and manipulative probe were placed. clockwise inspection of the pelvis revealed a benign vesicouterine pouch, normal uterus and fundus, normal right tube and ovary. in the cul-de-sac, there were 3 clusters of 3 to 5 carbon charred type endometrial implants and those more distally in the greatest depth had created puckering and tenting. the left tube and ovary were normal. there were no adhesions. there was no evidence of acute pelvic inflammatory disease.,the endoshears and subsequently cautery on a hook were placed and the implants fulgurated. pictures were taken for confirmation both before and after the burn.,the carbon chars were irrigated and aspirated. the smoke plume was removed without difficulty. approximately 50 ml of irrigant was left in the pelvis. due to the difficulty in placing and maintaining the hasson cannula, no attempts were made to view the upper abdominal quadrant, specifically the liver and gallbladder.,the suprapubic cannula was removed under direct visualization, the pneumo released, the scope removed, the stay sutures cut, and the hasson cannula removed. the residual sutures were then tied together to completely occlude the fascial opening so that there will be no future hernia at this site. finally, the skin incisions were approximated with 3-0 dexon subcuticularly. they had been preincisionally injected with bupivacaine to which the patient said she had no known allergies. the vaginal instruments were removed. all counts were correct. the patient tolerated the procedure well and was taken to the recovery room in stable condition.

3-dimensional simulation,this patient is undergoing 3-dimensionally planned radiation therapy in order to adequately target structures at risk while diminishing the degree of exposure to uninvolved adjacent normal structures. this optimizes the chance of controlling tumor while diminishing the acute and long-term side effects. with conformal 3-dimensional simulation, there is extended physician, therapist, and dosimetrist effort and time expended. the patient is initially taken into a conventional simulator room where appropriate markers are placed and the patient is positioned and immobilized. preliminary filed sizes and arrangements, including gantry angles, collimator angles, and number of fields are conceived. radiographs are taken and these films are approved by the physician. appropriate marks are placed on the patient's skin or on the immobilization device.,the patient is transferred to the diagnostic facility and placed on a flat ct scan table. scans are performed through the targeted area. the scans are evaluated by the radiation oncologist and the tumor volume, target volume, and critical structures are outlined on the ct images. the dosimetrist then evaluates the slices in the treatment-planning computer with appropriately marked structures. this volume is reconstructed in a virtual 3-dimensional space utilizing the beam's-eye view features. appropriate blocks are designed. multiplane computerized dosimetry is performed throughout the volume. field arrangements and blocking are modified as necessary to provide coverage of the target volume while minimizing dose to normal structures.,once appropriate beam parameters and isodose distributions have been confirmed on the computer scan, the individual slices are then reviewed by the physician. the beam's-eye view, block design, and appropriate volumes are also printed and reviewed by the physician. once these are approved, physical blocks or multi-leaf collimator equivalents will be devised. if significant changes are made in the field arrangements from the original simulation, the patient is brought back to the simulator where computer designed fields are re-simulated.,in view of the extensive effort and time expenditure required, this procedure justifies the special procedure code, 77470.

2-d m-mode: , ,1. left atrial enlargement with left atrial diameter of 4.7 cm.,2. normal size right and left ventricle.,3. normal lv systolic function with left ventricular ejection fraction of 51%.,4. normal lv diastolic function.,5. no pericardial effusion.,6. normal morphology of aortic valve, mitral valve, tricuspid valve, and pulmonary valve.,7. pa systolic pressure is 36 mmhg.,doppler: , ,1. mild mitral and tricuspid regurgitation.,2. trace aortic and pulmonary regurgitation.

preoperative diagnosis:, prior history of neoplastic polyps.,postoperative diagnosis:, small rectal polyps/removed and fulgurated.,premedications:, prior to the colonoscopy, the patient complained of a sever headache and she was concerned that she might become ill. i asked the nurse to give her 25 mg of demerol iv.,following the iv demerol, she had a nausea reaction. she was then given 25 mg of phenergan iv. following this, her headache and nausea completely resolved. she was then given a total of 7.5 mg of versed with adequate sedation. rectal exam revealed no external lesions. digital exam revealed no mass.,reported procedure:, the p160 colonoscope was used. the scope was placed in the rectal ampulla and advanced to the cecum. navigation through the sigmoid colon was difficult. beginning at 30 cm was a very tight bend. with gentle maneuvering, the scope passed through and then entered the cecum. the cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, and descending colon were normal. the sigmoid colon was likewise normal. there were five very small (punctate) polyps in the rectum. one was resected using the electrocautery snare and the other four were ablated using the snare and cautery. there was no specimen because the polyps were so small. the scope was retroflexed in the rectum and no further abnormality was seen, so the scope was straightened, withdrawn, and the procedure terminated.,endoscopic impression:,1. five small polyps as described, all fulgurated.,2. otherwise unremarkable colonoscopy.

reason for consult: , i was asked to see this patient with metastatic non-small-cell lung cancer, on hospice with inferior st-elevation mi.,history of present illness: , the patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion. her daughter who accompanies her is very attentive whom i had met previously during drainage of a malignant hemorrhagic pericardial effusion last month. the patient has been feeling well for the last several weeks, per the daughter, but today per the personal aide, became agitated and uncomfortable at about 2:30 p.m. at about 7 p.m., the patient began vomiting, was noted to be short of breath by her daughter with garbled speech, arms flopping, and irregular head movements. her daughter called 911 and her symptoms seemed to improve. then, she began vomiting. when the patient's daughter asked her if she had chest pain, the patient said yes.,she came to the emergency room, an ekg showed inferior st-elevation mi. i was called immediately and knowing her history, especially, her hospice status with recent hemorrhagic pericardial effusion, i felt thrombolytic was contraindicated and she would not be a candidate for aggressive interventional therapy with pci/cabg. she was begun after discussion with the oncologist, on heparin drip and has received morphine, nitro, and beta-blocker, and currently states that she is pain free. repeat ekg shows normalization of her st elevation in the inferior leads as well as normalization of prior reciprocal changes.,past medical history: , significant for metastatic non-small-cell lung cancer. in early-to-mid december, she had an admission and was found to have a malignant pericardial effusion with tamponade requiring urgent drainage. we did repeat an echo several weeks later and that did not show any recurrence of the pericardial effusion. she is on hospice from the medical history, atrial fibrillation, hypertension, history of multiple cva.,medications: , medications as an outpatient:,1. amiodarone 200 mg once a day.,2. roxanol concentrate 5 mg three hours p.r.n. pain.,allergies: ,codeine. no shrimp, seafood, or dye allergy.,family history: , negative for cardiac disease.,social history: , she does not smoke cigarettes. she uses alcohol. no use of illicit drugs. she is divorced and lives with her daughter. she is a retired medical librarian from florida.,review of systems: ,unable to be obtained due to the patient's aphasia.,physical examination: , height 5 feet 3, weight of 106 pounds, temperature 97.1 degrees, blood pressure ranges from 138/82 to 111/87, pulse 61, respiratory rate 22. o2 saturation 100%. on general exam, she is an elderly woman with now marked aphasia, which per her daughter waxes and wanes, was more pronounced and she nods her head up and down when she says the word, no, and conversely, she nods her head side-to-side when she uses the word yes with some discordance in her head gestures with vocalization. heent shows the cranium is normocephalic and atraumatic. she has dry mucosal membrane. she now has a right facial droop, which per her daughter is new. neck veins are not distended. no carotid bruits visible. skin: warm, well perfused. lungs are clear to auscultation anteriorly. no wheezes. cardiac exam: s1, s2, regular rate. no significant murmurs. pmi is nondisplaced. abdomen: soft, nondistended. extremities: without edema, on limited exam. neurological exam seems to show only the right facial droop.,diagnostic/laboratory data: , ekgs as reviewed above. her last ecg shows normalization of prior st elevation in the inferior leads with q waves and first-degree av block, pr interval 280 milliseconds. further lab shows sodium 135, potassium 4.2, chloride 98, bicarbonate 26, bun 9, creatinine 0.8, glucose 162, troponin 0.17, inr 1.27, white blood cell count 1.3, hematocrit 31, platelet count of 179.,chest x-ray, no significant pericardial effusion.,impression: , the patient is a 69-year-old woman with metastatic non-small-cell lung cancer with a recent hemorrhagic pericardial effusion, now admitted with cerebrovascular accident and transient inferior myocardial infarction, which appears to be canalized. i will discuss this in detail with the patient and her daughter, and clearly, her situation is quite guarded with likely poor prognosis, which they are understanding of.,recommendations:,1. i think it is reasonable to continue heparin, but clearly she would be at risk for hemorrhagic pericardial effusion recurrence.,2. morphine is appropriate, especially for preload reduction and other comfort measures as appropriate.,3. would avoid other blood thinners including plavix, integrilin, and certainly, she is not a candidate for a thrombolytic with which the patient and her daughter are in agreement with after a long discussion.,other management as per the medical service. i have discussed the case with dr. x of the hospitalist service who will be admitting the patient.

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

history:, this 75-year-old man was transferred from the nursing home where he lived to the hospital late at night on 4/11 through the emergency department in complete urinary obstruction. after catheterization, the patient underwent cystoscopy on 4/13. on 4/14 the patient underwent a transurethral resection of the prostate and was discharged back to the nursing home later that day with voiding improved. final diagnosis was adenocarcinoma of the prostate. because of his mental status and general debility, the patient's family declined additional treatment.,laboratory:, none,procedures:,cystoscopy: blockage of the urethra by a markedly enlarged prostate.,transurethral resection of prostate: 45 grams of tissue were sent to the pathology department for analysis.,pathology: , well differentiated adenocarcinoma, microacinar type, in 1 of 25 chips of prostatic tissue.

please accept this letter of follow up on patient xxx xxx. he is now three months out from a left carotid angioplasty and stent placement. he was a part of a capsure trial. he has done quite well, with no neurologic or cardiac event in the three months of follow up. he had a follow-up ultrasound performed today that shows the stent to be patent, with no evidence of significant recurrence.,sincerely,,xyz, md,

exam:,mri/low ex not jnt rt w/o contrast,clinical:,pain and swelling in the right foot, peroneal tendon tear.,findings:, contours of marrow signal patterns of the regional bones are within normal range treating there is increased t2 signal within the soft tissues at the lateral margin of the cuboid bone. a small effusion is noted within the peroneal tendon sheath. there is a 3mm slight separation of the distal tip of the peroneus longus tendon from the lateral margin of the cuboid bone, consistent with an avulsion. there is no sign of cuboid fracture. the fifth metatarsal base appears intact. the calcaneus is also normal in appearance.,impression: ,findings consistent with an avulsion of the peroneus longus tendon from the insertion on the lateral aspect of cuboid bone.,

medical diagnosis:, strokes.,speech and language therapy diagnosis: ,global aphasia.,subjective: ,the patient is a 44-year-old female who is referred to medical center's outpatient rehabilitation department for skilled speech therapy, status post stroke. the patient's sister-in-law was present throughout this assessment and provided all the patient's previous medical history. based on the sister-in-law's report, the patient had a stroke on 09/19/08. the patient spent 6 weeks at xy medical center, where she was subsequently transferred to xyz for therapy for approximately 3 weeks. abcd brought the patient to home the monday before thanksgiving, because they were not satisfied with the care the patient was receiving at a skilled nursing facility in tucson. the patient's previous medical history includes a long history of illegal drug use to include cocaine, crystal methamphetamine, and marijuana. in march of 2008, the patient had some type of potassium issue and she was hospitalized at that time. prior to the stroke, the patient was not working and abcd reported that she believes the patient completed the ninth grade, but she did not graduate from high school. during the case history, i did pose several questions to the patient, but her response was often "no." she was very emotional during this evaluation and crying occurred multiple times.,objective: ,to evaluate the patient's overall communication ability, a western aphasia battery was completed. also tests were not done due to time constraint and the patient's severe difficulty and emotional state. speech automatic tests were also completed to determine if the patient had any functional speech.,assessment:, based on the results of the weston aphasia battery, the patient's deficits most closely resemble global aphasia. on the spontaneous speech subtest, the patient responded "no" to all questions asked except for how are you today where she gave a thumbs-up. she provided no responses to picture description task and it is unclear if the patient was unable to follow the direction or if she was unable to see the picture clearly. the patient's sister-in-law did state that the patient wore glasses, but she currently does not have them and she did not know the extent the patient's visual deficit.,on the auditory verbal comprehension portion of the western aphasia battery, the patient answered "no" to all "yes/no" questions. the auditory word recognition subtest, the patient had 5 out of 60 responses correct. with the sequential command, she had 10 out of 80 corrects. she was able to shut her eyes, point to the window, and point to the pen after directions. with repetition subtest, she repeated bed correctly, but no other stimuli. at this time, the patient became very emotional and repeatedly stated "i can't". during the naming subtest of the western aphasia battery, the patient's responses contained numerous paraphasias and her speech was often unintelligible due to jargon. the word fluency test was not administered and the patient scored 2 out of 10 on the sentence completion task and 0 out of 10 on the responsive speech. in regards to speech automatics, the patient is able to count from 1 to 9 accurately; however, stated 7 instead of 10 at the end of the task. she is not able to state the days of the week or months in the year or her name at this time. she cannot identify the day on calendar and was unable to verbally state the date or month.,diagnostic impression: ,the patient's communication deficits most closely resemble global aphasia where she has difficulty with both receptive as well as expressive communication. she does perseverate and is very emotional due to probable frustration. outpatient skilled speech therapy is recommended to improve the patient's functional communication skills.,patient goal: , her sister-in-law stated that they would like to improve upon the patient's speech to allow her to communicate more easily at home.,plan of care: , outpatient skilled speech therapy two times a week for the next 12 weeks. therapy to include aphasia treatment and home activities.,short-term goals (8 weeks):,1. the patient will answer simple "yes/no" questions with greater than 90% accuracy with minimal cueing.,2. the patient will be able to complete speech automatic tasks with greater than 80% accuracy without models or cueing.,3. the patient will be able to complete simple sentence completion and/or phrase completion with greater than 80% accuracy with minimal cueing.,4. the patient will be able to follow simple one-step commands with greater than 80% accuracy with minimal cueing.,5. the patient will be able to name 10 basic everyday objects with greater than 80% accuracy with minimal cueing.,short-term goals (12 weeks):, functional communication abilities to allow the patient to express her basic wants and needs.

cc: ,low back pain (lbp) with associated ble weakness.,hx:, this 75y/o rhm presented with a 10 day h/o progressively worsening lbp. the lbp started on 12/3/95; began radiating down the rle, on 12/6/95; then down the lle, on 12/9/95. by 12/10/95, he found it difficult to walk. on 12/11/95, he drove himself to his local physician, but no diagnosis was rendered. he was given some nsaid and drove home. by the time he got home he had great difficulty walking due to lbp and weakness in ble, but managed to feed his pets and himself. on 12/12/95 he went to see a local orthopedist, but on the way to his car he crumpled to the ground due to ble weakness and lbp pain. he also had had ble numbness since 12/11/95. he was evaluated locally and an l-s-spine ct scan and l-s spine x-rays were "negative." he was then referred to uihc.,meds: ,slntc, coumadin 4mg qd, propranolol, procardia xl, altace, zaroxolyn.,pmh: ,1) mi 11/9/78, 2) cholecystectomy, 3) turp for bph 1980's, 4) htn, 5) amaurosis fugax, od, 8/95 (mayo clinic evaluation--tee (-), but carotid doppler (+) but "non-surgical" so placed on coumadin).,fhx:, father died age 59 of valvular heart disease. mother died of dm. brother had cabg 8/95.,shx:, retired school teacher. 0.5-1.0 pack cigarettes per day for 60 years.,exam:, bp130.56, hr68, rr16, afebrile.,ms: a&o to person, place, time. speech fluent without dysarthria. lucid. appeared uncomfortable.,cn: unremarkable.,motor: 5/5 strength in bue. lower extremity strength: hip flexors & extensors 4-/4-, hip abductors 3+/3+, hip adductors 5/5, knee flexors & extensors 4/4-, ankle flexion 4-/4-, tibialis anterior 2/2-, peronei 3-/3-. mild atrophy in 4 extremities. questionable fasciculations in ble. spasms illicited on striking quadriceps with reflex hammer (? percussion myotonia). no rigidity and essential normal muscle tone on passive motion.,sensory: decreased vibratory sense in stocking distribution from toes to knees in ble (worse on right). no sensory level. pp/lt/temp testing unremarkable.,coord: normal fnf-ram. slowed hks due to weakness.,station: no pronator drift. romberg testing not done.,gait: unable to stand.,reflexes: 2/2 bue. 1/trace patellae, 0/0 achilles. plantar responses were flexor, bilaterally. abdominal reflex was present in all four quadrants. anal reflex was illicited from all four quadrants. no jaw jerk or palmomental reflexes illicited.,rectal: normal rectal tone, guaiac negative stool.,gen exam: bilateral carotid bruits, no lymphadenopathy, right inguinal hernia, rhonchi and inspiratory wheeze in both lung fields.,course: ,wbc 11.6, hgb 13.4, hct 38%, plt 295. esr 40 (normal 0-14), crp 1.4 (normal <0.4), inr 1.5, ptt 35 (normal), creatinine 2.1, ck 346. ekg normal. the differential diagnosis included amyotrophy, polymyositis, epidural hematoma, disc herniation and guillain-barre syndrome. an mri of the lumbar spine was obtained, 12/13/95. this revealed an l3-4 disc herniation extending inferiorly and behind the l4 vertebral body. this disc was located more on the right than on the left , compromised the right neural foramen, and narrowed the spinal canal. the patient underwent a l3-4 laminectomy and diskectomy and subsequently improved. he was never seen in follow-up at uihc.

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.,

scleral buckle opening,the patient was brought to the operating room and appropriately identified. general anesthesia was induced by the anesthesiologist. the patient was prepped and draped in the usual sterile fashion. a lid speculum was used to provide exposure to the right eye. a 360-degree limbal conjunctival peritomy was created with westcott scissors. curved tenotomy scissors were used to enter each of the intermuscular quadrants. the inferior rectus muscle was isolated with a muscle hook, freed of its tenon's attachment and tied with a 2-0 silk suture. the 3 other rectus muscles were isolated in a similar fashion. the 4 scleral quadrants were inspected and found to be free of scleral thinning or staphyloma.

chief complaint:, lump in the chest wall.,history of present illness: , this is a 56-year-old white male who has been complaining of having had a lump in the chest for the past year or so and it has been getting larger and tender according to the patient. it is tender on palpation and also he feels like, when he takes a deep breath also, it hurts.,chronic/inactive conditions,1. hypertension.,2. hyperlipidemia.,3. glucose intolerance.,4. chronic obstructive pulmonary disease?,5. tobacco abuse.,6. history of anal fistula.,illnesses:, see above.,previous operations: , anal fistulectomy, incision and drainage of perirectal abscess, hand surgery, colonoscopy, arm nerve surgery, and back surgery.,previous injuries: , he had a broken ankle in the past. they questioned the patient who is a truck driver whether he has had an auto accident in the past, he said that he has not had anything major. he said he bumped his head once, but not his chest, although he told the nurse that a car fell on his chest that is six years ago. he told me that he hit a moose once, but he does not remember hitting his chest.,allergies: , to bactrim, simvastatin, and cipro.,current medications,1. lisinopril.,2. metoprolol.,3. vitamin b12.,4. baby aspirin.,5. gemfibrozil.,6. felodipine.,7. levitra.,8. pravastatin.,family history: , positive for hypertension, diabetes, and cancer. negative for heart disease, obesity or stroke.,social history: ,the patient is married. he works as a truck driver and he drives in town. he smokes two packs a day and he has two beers a day he says, but not consuming illegal drugs.,review of systems,constitutional: denies weight loss/gain, fever or chills.,enmt: denies headaches, nosebleeds, voice changes, blurry vision or changes in/loss of vision.,cv: see history of present illness. denies chest pain, sob supine, palpitations, edema, varicose veins or leg pains.,respiratory: he has a chronic cough. denies shortness of breath, wheezing, sputum production or bloody sputum.,gi: denies heartburn, blood in stools, loss of appetite, abdominal pain or constipation.,gu: denies painful/burning urination, cloudy/dark urine, flank pain or groin pain.,ms: denies joint pain/stiffness, backaches, tendon/ligaments/muscle pains/strains, bone aches/pains or muscle weakness.,neuro: denies blackouts, seizures, loss of memory, hallucinations, weakness, numbness, tremors or paralysis.,psych: denies anxiety, irritability, apathy, depression, sleep disturbances, appetite disturbances or suicidal thoughts.,integumentary: denies unusual hair loss/breakage, skin lesions/discoloration or unusual nail breakage/discoloration.,physical examination,constitutional: blood pressure 140/84, pulse rate 100, respiratory rate 20, temperature 97.2, height 5 feet 10 inches, and weight 218 pounds. the patient is well developed, well nourished, and with fair attention to grooming. the patient is moderately overweight.,neck: the neck is symmetric, the trachea is in the midline, and there are no masses. no crepitus is palpated. the thyroid is palpable, not enlarged, smooth, moves with swallowing, and has no palpable masses.,respiration: normal respiratory effort. there is no intercostal retraction or action by the accessory muscles. normal breath sounds bilaterally with no rhonchi, wheezing or rubs. there is a localized 2-cm diameter hard mass in relationship to the costosternal cartilages in the lower most position in the left side, just adjacent to the sternum.,cardiovascular: the pmi is palpable at the 5ics in the mcl. no thrills on palpation. s1 and s2 are easily audible. no audible s3, s4, murmur, click, or rub. carotid pulses 2+ without bruits. abdominal aorta is not palpable. no audible abdominal bruits. femoral pulses are 2+ bilaterally, without audible bruits. extremities show no edema or varicosities.

operation:,

discharge diagnoses:,1. bilateral lower extremity cellulitis secondary to bilateral tinea pedis.,2. prostatic hypertrophy with bladder outlet obstruction.,3. cerebral palsy.,discharge instructions: , the patient would be discharged on his usual valium 10-20 mg at bedtime for spasticity, flomax 0.4 mg daily, cefazolin 500 mg q.i.d., and lotrimin cream between toes b.i.d. for an additional two weeks. he will be followed in the office.,history of present illness:, this is a pleasant 62-year-old male with cerebral palsy. the patient was recently admitted to hospital with lower extremity cellulitis. this resolved, however, recurred in both legs. examination at the time of this admission demonstrated peeling of the skin and excoriation between all of his toes on both feet consistent with tinea pedis.,past medical/family/social history:, as per the admission record.,review of systems: , as per the admission record.,physical examination: ,as per the admission record.,laboratory studies: , at the time of admission, his white blood cell count was 8200 with a normal differential, hemoglobin 13.6, hematocrit 40.6 with normal indices, and platelet count was 250,000. comprehensive metabolic profile was unremarkable, except for a nonfasting blood sugar of 137, lactic acid was 0.8. urine demonstrated 4-9 red blood cells per high-powered field with 2+ bacteria. blood culture and wound cultures were unremarkable. chest x-ray was unremarkable.,hospital course: , the patient was admitted to the general medical floor and treated with intravenous ceftriaxone and topical lotrimin. on this regimen, his lower extremity edema and erythema resolved quite rapidly.,because of urinary frequency, a bladder scan was done suggesting about 600 cc of residual urine. a foley catheter was inserted and was productive of approximately 500 cc of urine. the patient was prescribed flomax 0.4 mg daily. 24 hours later, the foley catheter was removed and a bladder scan demonstrated 60 cc of residual urine after approximately eight hours.,at the time of this dictation, the patient was ambulating minimally, however, not sufficiently to resume independent living.

preoperative diagnoses,1. neck pain with bilateral upper extremity radiculopathy, left more than the right.,2. cervical spondylosis with herniated nucleus pulposus, c5-c6.,postoperative diagnoses,1. neck pain with bilateral upper extremity radiculopathy, left more than the right.,2. cervical spondylosis with herniated nucleus pulposus, c5-c6.,operative procedures,1. anterior cervical discectomy with decompression, c5-c6.,2. arthrodesis with anterior interbody fusion, c5-c6.,3. spinal instrumentation, c5-c6 using pioneer 18-mm plate and four 14 x 4.0 mm screws (all titanium).,4. implant using peek 7 mm.,5. allograft using vitoss.,drains: , round french 10 jp drain.,fluids: ,1200 cc of crystalloids.,urine output: , no foley catheter.,specimens: , none.,complications: , none.,anesthesia: , general endotracheal anesthesia.,estimated blood loss: , less than 50 cc.,indications for the operation:, this is a case of a very pleasant 38-year-old caucasian female who has been complaining over the last eight years of neck pain and shoulder pain radiating down across the top of her left shoulder and also across her shoulder blades to the right side, but predominantly down the left upper extremity into the wrist. the patient has been diagnosed with fibromyalgia and subsequently, has been treated with pain medications, anti-inflammatories and muscle relaxants. the patient's symptoms continued to persist and subsequently, an mri of the c-spine was done, which showed disc desiccation, spondylosis and herniated disk at c5-c6, an emg and cv revealed a presence of mild-to-moderate carpal tunnel syndrome. the patient is now being recommended to undergo decompression and spinal instrumentation and fusion at c5-c6. the patient understood the risks and benefits of the surgery. risks include but not exclusive of bleeding and infection. bleeding can be in the form of soft tissue bleeding, which may compromise airway for which she can be brought emergently back to the operating room for emergent evacuation of the hematoma as this may cause weakness of all four extremities, numbness of all four extremities, as well as impairment of bowel and bladder function. this could also result in dural tear with its attendant symptoms of headache, nausea, vomiting, photophobia, and posterior neck pain as well as the development of pseudomeningocele. should the symptoms be severe or the pseudomeningocele be large, she can be brought back to the operating room for repair of the csf leak and evacuation of the pseudomeningocele. there is also the risk of pseudoarthrosis and nonfusion, for which she may require redo surgery at this level. there is also the possibility of nonimprovement of her symptoms in about 10% of cases. the patient understands this risk on top of the potential injury to the esophagus and trachea as well as the carotid artery. there is also the risk of stroke, should an undiagnosed plaque be propelled into the right cerebral circulation. the patient also understands that there could be hoarseness of the voice secondary to injury to the recurrent laryngeal nerve. she understood these risks on top of the risks of anesthesia and gave her consent for the procedure.,description of procedure: ,the patient was brought to the operating room, awake, alert and not in any form of distress. after smooth induction and intubation, the patient was positioned supine on the operating table with the neck placed on hyperextension and the head supported on a foam doughnut. a marker was placed. this verified the level to be at the c5-c6 level and incision was then marked in a transverse fashion starting from the midline extending about 5 mm beyond the anterior border of the sternocleidomastoid muscle. the area was then prepped with duraprep after the head was turned 45 degrees to the left.,after sterile drapes were laid out, an incision was made using a scalpel blade #10. wound edge bleeders were carefully controlled with bipolar coagulation and the platysma was cut using a hot knife in a transverse fashion. dissection was then carried underneath the platysma superiorly inferiorly. the anterior border of the sternocleidomastoid was identified and dissection was carried out lateral to the esophagus to trachea as well as medial to the carotid sheath in the sternocleidomastoid muscle. the prevertebral fascia was noted to be taken her case with a lot of fat deposition. bipolar coagulation of bleeders was done; however, branch of the superior thyroid artery was ligated with hemoclips x4. after this was completed, a localizing x-ray verified the marker to be at the c6-c7 level. we proceeded to strip the longus colli muscles off the vertebral body of the c5 and c6. self-retaining retractor was then laid down. an anterior osteophyte was carefully drilled using a midas 5-mm bur and the disk together with the inferior endplate of c5 and the superior endplate of c6 was also drilled down with the midas 5-mm bur. this was later followed with a 3-mm bur and the disk together with posterior longitudinal ligament was removed using kerrison's ranging from 1 to 4 mm. the herniation was noted on the right. however, there was significant neuroforaminal stenosis on the left. decompression on both sides was done and after this was completed, a valsalva maneuver showed no evidence of any csf leakage. the area was then irrigated with saline with bacitracin solution. a 7 mm implant with its inferior packed with vitoss was then laid down and secured in place with four 14 x 4.0 mm screws and plate 18 mm, all of which were titanium. x-ray after this placement showed excellent position of all these implants and screws and _____ and the patient's area was also irrigated with saline with bacitracin solution. a round french 10 jp drain was then laid down and exteriorized through a separate stab incision on the patient's right inferiorly. the catheter was then anchored to the skin with a nylon 3-0 stitch and connected to a sterile draining system. the wound was then closed in layers with vicryl 3-0 inverted interrupted sutures for the platysma, vicryl subcuticular 4-0 stitch for the dermis, and the wound was reinforced with dermabond. dressing was placed only at the exit site of the catheter. c-collar was placed. the patient was extubated and transferred to recovery.

admission diagnosis:, painful right knee status post total knee arthroplasty many years ago. the patient had gradual onset of worsening soreness and pain in this knee. x-ray showed that the poly seems to be worn out significantly in this area.,discharge diagnosis:, status post poly exchange, right knee, total knee arthroplasty.,condition on discharge:, stable.,procedures performed:, poly exchange total knee, right.,consultations: , anesthesia managed femoral nerve block on the patient.,hospital course: ,the patient was admitted with revision right total knee arthroplasty and replacement of patellar and tibial poly components. the patient recovered well after this. working with pt, she was able to ambulate with minimal assistance. nerve block was removed by anesthesia. the patient did well on oral pain medications. the patient was discharged home. she is actually going to home with her son who will be able to assist her and look after her for anything she might need. the patient is comfortable with this, understands the therapy regimen, and is very satisfied after the procedure.,discharge instructions and medications: , the patient is to be discharged home to the care of the son. diet is regular. activity, weight bear as tolerated right lower extremity. continue to do physical therapy exercises. the patient will be discharged home on coumadin 4 mg a day as the inr was 1.9 on discharge with twice weekly lab checks. vicodin 5/500 mg take one to two tablets p.o. q.4-6h. resume home medications. call the office or return to the emergency room for any concerns including increased redness, swelling, drainage, fever, or any concerns regarding operation or site of incision. the patient is to follow up with dr. abc in two weeks.

preoperative diagnosis:, ectopic left testis.,postoperative diagnosis: , ectopic left testis.,procedure performed: , left orchiopexy.,anesthesia: , general. the patient did receive ancef.,indications and consent: , this is a 16-year-old african-american male who had an ectopic left testis that severed approximately one-and-a-half years ago. the patient did have an mri, which confirmed ectopic testis located near the pubic tubercle. the risks, benefits, and alternatives of the proposed procedure were discussed with the patient. informed consent was on the chart at the time of procedure.,procedure details: ,the patient did receive ancef antibiotics prior to the procedure. he was then wheeled to the operative suite where a general anesthetic was administered. he was prepped and draped in the usual sterile fashion and shaved in the area of the intended procedure. next, with a #15 blade scalpel, an oblique skin incision was made over the spermatic cord region. the fascia was then dissected down both bluntly and sharply and hemostasis was maintained with bovie electrocautery. the fascia of the external oblique, creating the external ring was then encountered and that was grasped in two areas with hemostats and sized with metzenbaum scissors. this was then continued to open the external ring and was then carried cephalad to further open the external ring, exposing the spermatic cord. with this accomplished, the testis was then identified. it was located over the left pubic tubercle region and soft tissue was then meticulously dissected and cared to avoid all vascular and testicular structures.,the cord length was then achieved by applying some tension to the testis and further dissecting any of the fascial adhesions along the spermatic cord. once again, meticulous care was maintained not to involve any neurovascular or contents of the testis or vas deferens. weitlaner retractor was placed to provide further exposure. there was a small vein encountered posterior to the testis and this was then hemostated into place and cut with metzenbaum scissors and doubly ligated with #3-0 vicryl. again hemostasis was maintained with ligation and bovie electrocautery with adequate mobilization of the spermatic cord and testis. next, bluntly a tunnel was created through the subcutaneous tissue into the left empty scrotal compartment. this was taken down to approximately the two-thirds length of the left scrotal compartment. once this tunnel has been created, a #15 blade scalpel was then used to make transverse incision. a skin incision through the scrotal skin and once again the skin edges were grasped with allis forceps and the dartos was then entered with the bovie electrocautery exposing the scrotal compartment. once this was achieved, the apices of the dartos were then grasped with hemostats and supra-dartos pouch was then created using the iris scissors. a dartos pouch was created between the skin and the supra-dartos, both cephalad and caudad to the level of the scrotal incision. a hemostat was then placed from inferior to superior through the created tunnel and the testis was pulled through the created supra-dartos pouch ensuring that anatomic position was in place, maintaining the epididymis posterolateral without any rotation of the cord. with this accomplished, #3-0 prolene was then used to tack both the medial and lateral aspects of the testis to the remaining dartos into the tunica vaginalis. the sutures were then tied creating the orchiopexy. the remaining body of the testicle was then tucked into the supra-dartos pouch and the skin was then approximated with #4-0 undyed monocryl in a horizontal mattress fashion interrupted sutures. once again hemostasis was maintained with bovie electrocautery. finally the attention was made towards the inguinal incision and this was then copiously irrigated and any remaining bleeders were then fulgurated with bovie electrocautery to make sure to avoid any neurovascular spermatic structures. external ring was then recreated and grasped on each side with hemostats and approximated with #3-0 vicryl in a running fashion cephalad to caudad. once this was created, the created ring was inspected and there was adequate room for the cord. there appeared to be no evidence of compression. finally, subcutaneous layer with sutures of #4-0 interrupted chromic was placed and then the skin was then closed with #4-0 undyed vicryl in a running subcuticular fashion. the patient had been injected with bupivacaine prior to closing the skin. finally, the patient was cleansed.,the scrotal support was placed and plan will the for the patient to take keflex one tablet q.i.d. x7 days as well as tylenol #3 for severe pain and motrin for moderate pain as well as applying ice packs to scrotum. he will follow up with dr. x in 10 to 14 days. appointment will be made.

she has a past ocular history including cataract extraction with lens implants in both eyes in 2001 and 2003. she also has a history of glaucoma diagnosed in 1990 and macular degeneration. she has been followed in her home country and is here visiting family. she had the above-mentioned observation and was brought in on an urgent basis today.,her past medical history includes hypertension and hypercholesterolemia and hypothyroidism.,her medications include v-optic 0.5% eye drops to both eyes twice a day and pilocarpine 2% ou three times a day. she took both the drops this morning. she also takes eltroxin which is for hypothyroidism, plendil for blood pressure, and pravastatin.,she is allergic to cosopt.,she has a family history of blindness in her brother as well as glaucoma and hypertension.,her visual acuity today at distance without correction are 20/25 in the right and count fingers at 3 feet in the left eye. manifest refraction showed no improvement in either eye. the intraocular pressures by applanation were 7 on the right and 18 in the left eye. gonioscopy showed grade 4 open angles in both eyes. humphrey visual field testing done elsewhere showed diffuse reduction in sensitivity in both eyes. the lids were normal ou. she has mild dry eye ou. the corneas are clear ou. the anterior chamber is deep and quiet ou. irides appear normal. the lenses show well centered posterior chamber intraocular lenses ou.,dilated fundus exam shows clear vitreous ou. the optic nerves are normal in size. they both appear to have mild pallor. the optic cups in both eyes are shallow. the cup-to-disc ratio in the right eye is not overtly large, would estimated 0.5 to 0.6; however, she does have very thin rim tissue inferotemporally in the right eye. in the left eye, the glaucoma appears to be more advanced to the larger cup-to-disc ratio and a thinner rim tissue.,the macula on the right shows drusen with focal areas of rpe atrophy. i do not see any evidence of neovascularization such as subretinal fluid, lipid or hemorrhage. she does have a punctate area of rpe atrophy which is just adjacent to the fovea of the right eye. in the left eye, she has also several high-risk drusen, but no evidence of neovascularization. the rpe in the left eye does appear to be more diffusely abnormal although these changes do appear somewhat mild. i do not see any dense or focal areas of frank rpe atrophy or hypertrophy.,the peripheral retinas are attached in both eyes.,ms. abc has pseudophakia ou which is stable and she is doing well in this regard. she has glaucoma which likely is worse in the left eye and also likely explains her poor vision in the left eye. the intraocular pressure in the mid-to-high teens in the left eye is probably high for her. she has allergic reaction to cosopt. i will recommend starting xalatan os nightly. i think the intraocular pressure in the right eye is acceptable and is probably a stable pressure for her od. she will need followup in the next 1 or 2 months after returning home to israel later this week after starting the new medication which is xalatan.,regarding the macular degeneration, she has had high-risk changes in both eyes. the vision in the right eye is good, but she does have a very concerning area of rpe atrophy just adjacent to the fovea of the right eye. i strongly recommend that she see a retina specialist before returning to israel in order to fully discuss prophylactic measures to prevent worsening of her macular degeneration in the right eye.

subjective:, the patient is a 33-year-old black male who comes in to the office today main complaint of sexual dysfunction. patient reports that he would like to try cialis to see if it will improve his erectile performance. patient states that he did a quiz on-line at the cialis web site and did not score in the normal range, so he thought he should come in. patient states that perhaps his desire has been slightly decreased, but that has not been the primary problem. in discussing with me directly, patient primarily expresses that he would like to have his erections last longer. however, looking at the quiz as he filled it out, he reported that much less than half the time was he able to get erections during sexual activity and only about half of the time he was able to maintain his erection after penetration. however, he only reports that it is slightly difficult to maintain the erection until completion of intercourse. patient has no significant past medical history. he has never had any previous testicular infections. he denies any history of injuries to the groin and he has never been told that he has a hernia.,current medications:, none.,allergies: , no drug allergies.,social: , only occasionally drinks alcohol and he is a nonsmoker. he currently is working as a nurse aid, second shift, at a nursing home. he states that he did not enroll in wichita state this semester. stating he just was tired and wanted to take some time off. he states he is in a relationship with one partner and denies any specific stress in the relationship.,objective:,general: he appears in no distress.,vital signs: blood pressure: with large cuff is 120/90.,lungs: clear to auscultation.,cardiovascular: normal s1-s2 without murmur.,abdomen: soft, nontender. femoral pulses are 2+.,gu: testicles descended bilaterally. no evidence of masses. no evidence of inguinal hernias.,assessment:, sexual dysfunction.,plan:, we will check a free and total testosterone level as he does note some diminished desire. he was given a sample of cialis 10 mg with instructions on usage and a prescription for that if that is successful. he will follow up here p.r.n. lastly, i did give him a blood pressure recording card, as his blood pressure is borderline today. he will have that checked weekly at his workplace and follow up if they remain elevated.

nerve conduction testing and emg evaluation,1. right median sensory response 3.0, amplitude 2.5, distance 100.,2. right ulnar sensory response 2.1, amplitude 1, distance 90.,3. left median sensory response 3.0, amplitude 1.2, distance 100.,4. left median motor response distal 4.2, proximal 9, amplitude 2.2, distance 290, velocity 60.4 m/sec.,5. right median motor response distal 4.3, proximal 9.7, amplitude 2, and velocity 53.7 m/sec.,6. right ulnar motor response distal 2.5, proximal 7.5, amplitude 2, distance 300, velocity 60 m/sec.,needle emg testing,1. ,right biceps:, fibrillations 0, fasciculations occasional, positive waves 0. motor units, increased needle insertional activity and mild decreased number of motor units firing.,2. ,right triceps:, fibrillations 1+, fasciculations occasional to 1+, positive waves 1+. motor units, increased needle insertional activity and decreased number of motor units firing.,3. ,extensor digitorum:, fibrillations 0, fasciculations rare, positive waves 0, motor units probably normal.,4. ,first dorsal interosseous: , fibrillations 2+, fasciculations 1+, positive waves 2+. motor units, decreased number of motor units firing.,5. ,right abductor pollicis brevis:, fibrillations 1+, fasciculations 1+, positive waves 0. motor units, decreased number of motor units firing.,6. , flexor carpi ulnaris:, fibrillations 1+, occasionally entrained, fasciculations rare, positive waves 1+. motor units, decreased number of motor units firing.,7. ,left first dorsal interosseous:, fibrillations 1+, fasciculations 1+, positive waves occasional. motor units, decreased number of motor units firing.,8. ,left extensor digitorum:, fibrillations 1+, fasciculations 1+. motor units, decreased number of motor units firing.,9. ,right vastus medialis:, fibrillations 1+ to 2+, fasciculations 1+, positive waves 1+. motor units, decreased number of motor units firing.,10. ,anterior tibialis: , fibrillations 2+, occasionally entrained, fasciculations 1+, positive waves 1+. motor units, increased proportion of polyphasic units and decreased number of motor units firing. there is again increased needle insertional activity.,11. ,right gastrocnemius:, fibrillations 1+, fasciculations 1+, positive waves 1+. motor units, marked decreased number of motor units firing.,12. ,left gastrocnemius:, fibrillations 1+, fasciculations 1+, positive waves 2+. motor units, marked decreased number of motor units firing.,13. ,left vastus medialis: , fibrillations occasional, fasciculations occasional, positive waves 1+. motor units, decreased number of motor units firing.,impression:

name of procedure,1. selective coronary angiography.,2. placement of overlapping 3.0 x 18 and 3.0 x 8 mm xience stents in the proximal right coronary artery.,3. abdominal aortography.,indications: ,the patient is a 65-year-old gentleman with a history of exertional dyspnea and a cramping-like chest pain. thallium scan has been negative. he is undergoing angiography to determine if his symptoms are due to coronary artery disease.,narrative: ,the right groin was sterilely prepped and draped in the usual fashion and the area of the right coronary artery anesthetized with 2% lidocaine. constant sedation was obtained using versed 1 mg and fentanyl 50 mcg. received additional versed and fentanyl during the procedure. please refer to the nurses' notes for dosages and timing.,the right femoral artery was entered and a 4-french sheath was placed. advancement of the guidewire demonstrated some obstruction at the level of abdominal aorta. via the right judkins catheter, the guidewire was easily infiltrated to the thoracic aorta and over aortic arch. the right judkins catheter was advanced to the origin of the right coronary artery where selective angiograms were performed. this revealed a very high-grade lesion at the proximal right coronary artery. this catheter was exchanged for a left #4 judkins catheter which was advanced to the ostium of the left main coronary artery where selective angiograms were performed.,the patient was found to have the above mentioned high-grade lesion in the right coronary artery and a coronary intervention was performed. a 6-french sheath and a right judkins guide was placed. the patient was started on bivalarudin. a bmw wire was easily placed across the lesion and into the distal right coronary artery. a 3.0 x 15 mm voyager balloon was placed and deployed at 10 atmospheres. the intermediate result was improved with timi-3 flow to the terminus of the vessel. following this, a 3.0 x 18 mm xience stent was placed across the lesion and deployed at 17 atmospheres. this revealed excellent result however at the very distal of the stent there was an area of haziness but no definite dissection. this was stented with a 3.0 x 8 mm xience stent deployed again at 17 atmospheres. final angiograms revealed excellent result with timi-3 flow at the terminus of the right coronary artery and approximately 10% residual stenosis at the worst point of the narrowing. the guiding catheter was withdrawn over wire and a pigtail was placed. this was advanced to the abdominal aorta at the area of obstruction and small injection of contrast was given demonstrating that there was a small aneurysm versus a small retrograde dissection in that area with some dye hang up after injection. the catheter was removed. the bivalarudin was stopped at the termination of procedure. a small injection of contrast given through arterial sheath and angio-seal was placed without incident.,it should also be noted that an 8-french sheath was placed in the right femoral vein. this was placed initially as the patient was going to have a right heart catheterization as well because of the dyspnea.,total contrast media, 205 ml, total fluoroscopy time was 7.5 minutes, x-ray dose, 2666 milligray.,hemodynamics: , rhythm was sinus throughout the procedure. aortic pressure was 170/81 mmhg.,the right coronary artery is a dominant vessel. this vessel gives rise to conus branch and two small rv free wall branches and pda and a small left ventricular branch. it should be noted that there was competitive flow in the posterior left ventricular branch and that the distal right coronary artery fills via left sided collaterals. in the proximal right coronary artery, there is a large ulcerative plaque followed immediately by a severe stenosis that is subtotal in severity. after intervention, there is timi-3 flow to the terminus of the right coronary with better fill into the distal right coronary artery and loss of competitive flow. there was approximately 10% residual stenosis at the worst part of the previous stenosis.,the left main is without disease and trifurcates into a moderate-sized ramus intermedius, the lad and the circumflex. the ramus intermedius is free of disease. the lad terminates at the lv apex and has elongated area of mild stenosis at its mid segment. this measures 25% to 30% at its worst point. the circumflex is a large caliber vessel. there is a proximal 15% to 20% stenosis and an area of ectasia in the proximal circumflex. distally, this circumflex gives rise to a large bifurcating marginal artery and beyond that point, the circumflex is a small vessel within the av groove.,the aortogram demonstrates eccentric aneurysm formation. this may represent a small retrograde dissection as well. there was some dye hang up in the wall.,impression,1. successful stenting of subtotal stenosis of the proximal coronary artery.,2. non-obstructive coronary artery disease in the mid left anterior descending as described above and ectasia of the proximal circumflex coronary artery.,3. left to right collateral filling noted prior to coronary intervention.,4. small area of eccentric aneurysm formation in the abdominal aorta.

cc:, headache.,hx: ,the patient is an 8y/o rhm with a 2 year history of early morning headaches (3:00-6:00am) intermittently relieved by vomiting only. he had been evaluated 2 years ago and an eeg was "normal" then, but no brain imaging was performed. his headaches progressively worsened, especially in the past two months prior to this presentation. for 2 weeks prior to his 1/25/93 evaluation at uihc, he would awake screaming. his parent spoke with a local physician who thought this might be due to irritability secondary to pinworms and,vermox was prescribed and arrangements were made for a neurologic evaluation. on the evening of 1/24/93 the patient awoke screaming and began to vomit. this was followed by a 10 min period of tonic-clonic type movements and postictal lethargy. he was taken to a local er and a brain ct revealed an intracranial mass. he was given decadron and phenytoin and transferred to uihc for further evaluation.,meds:, noted above.,pmh: ,1)born at 37.5 weeks gestation by uncomplicated vaginal delivery to a g1p0 mother. pregnancy complicated by vaginal bleeding at 7 months. met developmental milestones without difficulty. 2) frequent otitis media, now resolved. 3) immunizations were "up to date.",fhx:, non-contributory.,shx:, lives with biologic father and mother. no siblings. in 3rd grade (mainstream) and maintaining good marks in schools.,exam:, bp121/57mmhg hr103 rr16 36.9c,ms: sleepy, but cooperative.,cn: eom full and smooth. advanced papilledema, ou. vfftc. pupils 4/4 decreasing to 2/2. right lower facial weakness. tongue midline upon protrusion. corneal reflexes intact bilaterally.,motor: 5/5 strength. slightly increased muscle on right side.,sensory. no deficit to pp/vib noted.,coord: normal fnf, hks and ram, bilaterally.,station: mild truncal ataxia. tends to fall backward.,reflexes: bue 2+/2+, patellar 3/3, ankles 3+/3+ with 6 beats of nonsustained clonus bilaterally.,gen exam: unremarkable.,course:, the patient was continued on dilantin 200mg qd and decadron 5mg iv q6hrs. brain mri, 1/26/93, revealed a large mass lesion in the region of the left caudate nucleus and thalamus which was hyperintense on t2 weighted images. there were areas of cystic formation at its periphery. the mass appeared to enhance on post gadolinium images. there was associated white matter edema and compression of the left lateral ventricle, and midline shift to the right. there was no sign of uncal herniation. he underwent bilateral vp shunting on 1/26/93; and then, subtotal resection (left frontal craniotomy with excision of the left caudate and thalamus with creation of an opening in the septum pellucidum) on 1/28/93. he then received 5040cgy of radiation therapy in 28 fractions completed on 3/25/93. a 3/20/95 neuropsychological evaluation revealed low average intellect on the wisc-iii. there were also signs of memory, attention, reading and spelling deficits; and mild right-sided motor incoordination and mood variability. he remained in mainstream classes at school, but his physical and cognitive performance began to deteriorate in 4/95. neurosurgical evaluation in 4/95 noted increased right hemiplegia and right homonymous hemianopia. mri revealed tumor progression and he was subsequently placed on carboplatin/vp-16 (cg 9933 protocol chemotherapy, regimen a). he was last seen on 4/96 and was having difficulty in the 6th grade; he was also undergoing physical therapy for his right hemiplegia.

subjective: ,this 68-year-old man presents to the emergency department for three days of cough, claims that he has brought up some green and grayish sputum. he says he does not feel short of breath. he denies any fever or chills.,review of systems:,heent: denies any severe headache or sore throat.,chest: no true pain.,gi: no nausea, vomiting, or diarrhea.,past history:, he states that he is on coumadin because he had a cardioversion done two months ago for atrial fibrillation. he also lists some other medications. i do have his medications list. he is on pacerone, zaroxolyn, albuterol inhaler, neurontin, lasix, and several other medicines. those are the predominant medicines. he is not a diabetic. the past history otherwise, he has had smoking history, but he quit several years ago and denies any copd or emphysema. no one else in the family is sick.,physical examination:,general: the patient appears comfortable. he did not appear to be in any respiratory distress. he was alert. i heard him cough once during the entire encounter. he did not bring up any sputum at that time.,vital signs: his temperature is 98, pulse 71, respiratory rate 18, blood pressure 122/57, and pulse ox is 95% on room air.,heent: throat was normal.,respiratory: he was breathing normally. there was clear and equal breath sounds. he was speaking in full sentences. there was no accessory muscle use.,heart: sounded regular.,skin: normal color, warm and dry.,neurologic: neurologically he was alert.,impression: , viral syndrome, which we have been seeing in many cases throughout the week. the patient asked me about antibiotics and i did not see a need to do this since he did not appear to have an infection other than viral given his normal temperature, normal pulse, normal respiratory rate, and near normal oxygen. the patient being on coumadin i explained to him that unless there was a solid reason to put him on antibiotics, he would be advised not to do so because antibiotics can alter the gut floor causing the inr to increase while on coumadin which may cause serious bleeding. the patient understands this. i then asked him if the cough was annoying him, he said it was. i offered him a cough syrup, which he agreed to take. the patient was then discharged with tussionex pennkinetic a hydrocodone time-release cough syrup. i told to check in three days, if the symptoms were not getting better. the patient appeared to be content with this treatment and was discharged in approximately 30 to 45 minutes later. his wife calls me very angry that i did not give him antibiotics. i explained her exactly what i explained to him that they were not indicative at this time, and she became very upset saying that they came there specifically for antibiotics and i explained again that antibiotics are not indicated for viral infection and that i did not think he had a bacterial infection.,diagnosis: , viral respiratory illness.

past medical history: , her medical conditions driving her toward surgery include hypercholesterolemia, hypertension, varicose veins, prior history of stroke. she denies any history of cancer. she does have a history of hepatitis which i will need to further investigate. she complains of multiple joint pains, and heavy snoring.,past surgical history: , includes hysterectomy in 1995 for fibroids and varicose vein removal. she had one ovary removed at the time of the hysterectomy as well.,social history:, she is a single mother of one adopted child.,family history: ,there is a strong family history of heart disease and hypertension, as well as diabetes on both sides of her family. her mother is alive. her father is deceased from alcohol. she has five siblings.,medications: , as you know she takes the following medications for her diabetes, insulin 70 units/6 units times four years, aspirin 81 mg a day, actos 15 mg, crestor 10 mg and cellcept 500 mg two times a day.,allergies: , she has no known drug allergies.,physical exam: , she is a 54-year-old obese female. she does not appear to have any significant residual deficits from her stroke. there may be slight left arm weakness.,assessment/plan:, we will have her undergo routine nutritional and psychosocial assessment. i suspect that we can significantly improve the situation with her insulin and oral hypoglycemia, as well as hypertension, with significant weight loss. she is otherwise at increased risk for future complications given her history, and weight loss will be a good option. we will see her back in the office once she completes her preliminary workup and submit her for approval to the insurance company.

reason for exam:,1. angina.,2. coronary artery disease.,interpretation: ,this is a technically acceptable study.,dimensions: ,anterior septal wall 1.2, posterior wall 1.2, left ventricular end diastolic 6.0, end systolic 4.7. the left atrium is 3.9.,findings: , left atrium was mildly to moderately dilated. no masses or thrombi were seen. the left ventricle was mildly dilated with mainly global hypokinesis, more prominent in the inferior septum and inferoposterior wall. the ef was moderately reduced with estimated ef of 40% with near normal thickening. the right atrium was mildly dilated. the right ventricle was normal in size.,mitral valve showed to be structurally normal with no prolapse or vegetation. there was mild mitral regurgitation on color flow interrogation. the mitral inflow pattern was consistent with pseudonormalization or grade 2 diastolic dysfunction. the aortic valve appeared to be structurally normal. normal peak velocity. no significant ai. pulmonic valve showed mild pi. tricuspid valve showed mild tricuspid regurgitation. based on which, the right ventricular systolic pressure was estimated to be mildly elevated at 40 to 45 mmhg. anterior septum appeared to be intact. no pericardial effusion was seen.,conclusion:,1. mild biatrial enlargement.,2. normal thickening of the left ventricle with mildly dilated ventricle and ef of 40%.,3. mild mitral regurgitation.,4. diastolic dysfunction grade 2.,5. mild pulmonary hypertension.

preoperative diagnosis: , right hemothorax.,postoperative diagnosis: , right hemothorax.,procedure performed: , insertion of a #32 french chest tube on the right hemithorax.,anesthesia: , 1% lidocaine and sedation.,indications for procedure:, this is a 54-year-old female with a newly diagnosed carcinoma of the cervix. the patient is to have an infuse-a-port insertion today. postoperatively from that, she started having a blood tinged pink frothy sputum. chest x-ray was obtained and showed evidence of a hemothorax on the right hand side, opposite side of the infuse-a-port and a wider mediastinum. the decision was made to place a chest tube in the right hemithorax to allow for the patient to be stable for transfer out of the operating room.,description of procedure: , the area was prepped and draped in the sterile fashion. the area was anesthetized with 1% lidocaine solution. the patient was given sedation. a #10 blade scalpel was used to make an incision approximately 1.5 cm long. then a curved scissor was used to dissect down to the level of the rib. a blunt peon was then used to again enter into the right hemithorax. immediately a blood tinged effusion was released. the chest tube was placed and directed in a posterior and superior direction. the chest tube was hooked up to the pleur-evac device which was ________ tip suction. the chest tube was tied in with a #0 silk suture in a u-stitch fashion. it was sutured in place with sterile dressing and silk tape. the patient tolerated this procedure well. we will obtain a chest x-ray in postop to ensure proper placement and continue to follow the patient very closely.

preoperative diagnosis: ,1. right cubital tunnel syndrome.,2. right carpal tunnel syndrome.,3. right olecranon bursitis.,postoperative diagnosis:, ,1. right cubital tunnel syndrome.,2. right carpal tunnel syndrome.,3. right olecranon bursitis.,procedures:, ,1. right ulnar nerve transposition.,2. right carpal tunnel release.,3. right excision of olecranon bursa.,anesthesia:, general.,blood loss:, minimal.,complications:, none.,findings: , thickened transverse carpal ligament and partially subluxed ulnar nerve.,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, his right arm was sterilely prepped and draped in normal fashion. after elevation and exsanguination with an esmarch, the tourniquet was inflated. the carpal tunnel was performed first with longitudinal incision in the palm carried down through the skin and subcutaneous tissues. the palmar fascia was divided exposing the transverse carpal ligament, which was incised longitudinally. a freer was then inserted beneath the ligament, and dissection was carried out proximally and distally.,after adequate release has been formed, the wound was irrigated and closed with nylon. the medial approach to the elbow was then performed and the skin was opened and subcutaneous tissues were dissected. a medial antebrachial cutaneous nerve was identified and protected throughout the case. the ulnar nerve was noted to be subluxing over the superior aspect of the medial epicondyle and flattened and inflamed. the ulnar nerve was freed proximally and distally. the medial intramuscular septum was excised and the flexor carpi ulnaris fascia was divided. the intraarticular branch and the first branch to the scu were transected; and then the nerve was transposed, it did not appear to have any significant tension or sharp turns. the fascial sling was made from the medial epicondyle and sewn to the subcutaneous tissues and the nerve had good translation with flexion and extension of the elbow and not too tight. the wound was irrigated. the tourniquet was deflated and the wound had excellent hemostasis. the subcutaneous tissues were closed with #2-0 vicryl and the skin was closed with staples. prior to the tourniquet being deflated, the subcutaneous dissection was carried out over to the olecranon bursa, where the loose fragments were excised with a rongeurs as well as abrading the ulnar cortex and excision of hypertrophic bursa. a posterior splint was applied. marcaine was injected into the incisions and the splint was reinforced with tape. he was awakened from the anesthesia and taken to recovery room in a stable condition. final needle, instrument, and sponge counts were correct.

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

history of present illness:, this 57-year-old black female was seen in my office on month dd, yyyy for further evaluation and management of hypertension. patient has severe backache secondary to disc herniation. patient has seen an orthopedic doctor and is scheduled for surgery. patient also came to my office for surgical clearance. patient had cardiac cath approximately four years ago, which was essentially normal. patient is documented to have morbid obesity and obstructive sleep apnea syndrome. patient does not use a cpap mask. her exercise tolerance is eight to ten feet for shortness of breath. patient also has two-pillow orthopnea. she has intermittent pedal edema.,physical examination: ,vital signs: blood pressure is 135/70. respirations 18 per minute. heart rate 70 beats per minute. weight 258 pounds.,heent: head normocephalic. eyes, no evidence of anemia or jaundice. oral hygiene is good. ,neck: supple. jvp is flat. carotid upstroke is good. ,lungs: clear. ,cardiovascular: there is no murmur or gallop heard over the precordium. ,abdomen: soft. there is no hepatosplenomegaly. ,extremities: the patient has no pedal edema. ,medications: ,1. buspar 50 mg daily.,2. diovan 320/12.5 daily.,3. lotrel 10/20 daily.,4. zetia 10 mg daily.,5. ambien 10 mg at bedtime.,6. fosamax 70 mg weekly.,diagnoses:,1. controlled hypertension.,2. morbid obesity.,3. osteoarthritis.,4. obstructive sleep apnea syndrome.,5. normal coronary arteriogram.,6. severe backache.,plan:,1. echocardiogram, stress test.,2 routine blood tests.,3. sleep apnea study.,4. patient will be seen again in my office in two weeks.

chief complaint:, stomach pain for 2 weeks.,history of present illness:, the patient is a 45yo mexican man without significant past medical history who presents to the emergency room with complaints of mid-epigastric and right upper quadrant abdominal pain for the last 14 days. the pain was initially crampy and burning in character and was relieved with food intake. he also reports that it initially was associated with a sour taste in his mouth. he went to his primary care physician who prescribed cimetidine 400mg qhs x 5 days; however, this did not relieve his symptoms. in fact, the pain has worsened such that the pain now radiates to the back but is waxing and waning in duration. it is relieved with standing and ambulation and exacerbated when lying in a supine position. he reports a decrease in appetite associated with a 4 lb. wt loss over the last 2 wks. he does have nausea with only one episode of non-bilious, non-bloody emesis on day of admission. he reports a 2 wk history of subjective fever and diaphoresis. he denies any diarrhea, constipation, dysuria, melena, or hematochezia. his last bowel movement was during the morning of admission and was normal. he denies any travel in the last 9 years and sick contacts.,past medical history:, right inguinal groin cyst removal 15 years ago. unknown etiology. no recurrence.,past surgical history:, left femoral neck fracture with prosthesis secondary to a fall 4 years ago.,family history:, mother with diabetes. no history of liver disease. no malignancies.,social history:, the patient was born in central mexico but moved to the united states 9 years ago. he is on disability due to his prior femoral fracture. he denies any tobacco or illicit drug use. he only drinks alcohol socially, no more than 1 drink every few weeks. he is married and has 3 healthy children. he denies any tattoos or risky sexual behavior.,allergies:, nkda.,medications:, tylenol prn (1-2 tabs every other day for the last 2 wks), cimetidine 400mg po qhs x 5 days.,review of systems:, no headache, vision changes. no shortness of breath. no chest pain or palpitations.,physical examination:,vitals: t 100.9-102.7 bp 136/86 pulse 117 rr 12 98% sat on room air,gen: well-developed, well-nourished, no apparent distress.,heent: pupils equal, round and reactive to light. anicteric. oropharynx clear and moist.,neck: supple. no lymphadenopathy or carotid bruits. no thyromegaly or masses.,chest: clear to auscultation bilaterally.,cv: tachycardic but regular rhythm, normal s1/s2, no murmurs/rubs/gallops.,abd: soft, active bowel sounds. tender in the epigastrium and right upper quadrant with palpation associated with slight guarding. no rebound tenderness. no hepatomegaly. no splenomegaly.,rectal: stool was brown and guaiac negative.,ext: no cyanosis/clubbing/edema.,neurological: he was alert and oriented x3. cn ii-xii intact. normal 2+ dtrs. no focal neurological deficit.,skin: no jaundice. no skin rashes or lesions.,imaging data:,ct abdomen with contrast ( 11/29/03 ): there is a 6x6 cm multilobular hypodense mass seen at the level of the hepatic hilum and caudate lobe which is resulting in mass effect with dilatation of the intrahepatic radicals of the left lobe of the liver. the rest of the liver parenchyma is homogeneous. the gallbladder, pancreas, spleen, adrenal glands and kidneys are within normal limits. the retroperitoneal vascular structures are within normal limits. there is no evidence of lymphadenopathy, free fluid or fluid collections.,hospital course:, the patient was admitted to the hospital for further evaluation. a diagnostic procedure was performed.

preoperative diagnoses,1. acquired absence of bilateral breast status post previous bilateral diep flap reconstruction.,2. bilateral breast asymmetry.,3. right breast macromastia.,4. right abdominal scar deformity.,5. left abdominal scar deformity.,6. a 1.3 cm lesion right inferior breast.,7. lesion measuring 0.5 cm right inferior breast lateral.,postoperative diagnoses,1. acquired absence of bilateral breast status post previous bilateral diep flap reconstruction.,2. bilateral breast asymmetry.,3. right breast macromastia.,4. right abdominal scar deformity.,5. left abdominal scar deformity.,6. a 1.3 cm lesion right inferior breast.,7. lesion measuring 0.5 cm right inferior breast lateral.,procedures,1. left breast flap revision.,2. right breast flap revision.,3. right breast reduction mammoplasty.,4. right nipple reconstruction.,5. left abdominal scar deformity.,6. right abdominal scar deformity.,7. excision of right breast medial lesion enclosure.,8. excision of right breast lateral lesion enclosure.,anesthesia:, general.,complications:, none.,drains:, none.,specimens:, right breast skin and lesions x2.,complications:, none.,indications:, this patient is a 54-year-old white female who presents for a revision of her previous bilateral breast reconstruction. the patient had asymmetry as well as right breast hypertrophy, and therefore, the procedures named above were indicated. the patient was informed about the possible risks and complications of the above procedures and gave an informed consent.,procedure:, the patient was brought to the operating room, placed supine on the operative table. after adequate endotracheal anesthesia was established and iv prophylactic antibiotics were given, the chest and abdomen were prepped and draped in standard surgical fashion.,attention was first turned to the left breast where liposuction was performed laterally to allow for better contour and minimize the outer quadrant. the incision was made for this and was then closed with 5-0 prolene interrupted suture.,attention was then turned to the right breast where liposuction was also performed to reduce the medial superior and lateral quadrants. once this was performed, the vertical reduction mammoplasty was outlined. prior to that, the nipple reconstruction was performed with a keyhole pattern flap. the flap was elevated with 15-blade and hemostasis was then obtained with the bovie. the flap was then sutured onto itself and secured with 5-0 prolene interrupted sutures. then the lateral and medial limbs were undermined to close the defect and this was performed with 3-0 monocryl interrupted sutures. subsequently, the reduction mastectomy skin was then excised sharply and passed up the table marked and sent to pathology. ,hemostasis was then obtained with the bovie and then undermining was performed in the medial, superior, and lateral skin to allow for closure of the reduction incisions. once this was performed, a 3-0 monocryl interrupted sutures were used to close the inferior limb. subsequently 2-0 pds continuous suture was then placed in the periareolar area to close the defect, with a diameter that equaled the new nipple areolar complex. once this was performed, the remaining incision was then closed with 3-0 monocryl followed by 4-0 monocryl subcuticular sutures. subsequently, the 2 lesions were excised, the larger one which was medial and the lateral one that was smaller that were excised sharply, passed up the table and sent to pathology. they were closed in 2 layers using 3-0 monocryl followed by 4-0 monocryl subcuticular suture.,attention was then turned to the abdominal scars where liposuction and tumescent solution of diluted epinephrine were used to minimize the amount of excision that was required. subsequently the extra skin was excised sharply in an elliptical fashion on the right side measuring approximately 10 x 3 cm, this was the superior and inferior skin, was when undermined and closure was performed after hemostasis was obtained with 3-0 monocryl followed by 4-0 monocryl subcuticular suture.,attention was then turned to the contralateral left side where there was a larger defect. there was a larger excision required measuring approximately 15 x 3 cm. the superior and inferior edges of skin were undermined and closed primarily using 3-0 monocryl followed by 4-0 monocryl subcuticular sutures. steri-strips were placed on all incisions followed by surgical bra.,the patient tolerated the procedure well and was extubated without complications and transferred to the recovery room in stable condition. all instruments, needle counts, and sponges were correct at the end of the case.

chief complaint (1/1):, this 59 year old female presents today complaining that her toenails are discolored, thickened, and painful. duration: condition has existed for 6 months. severity: severity of condition is worsening.,allergies: ,patient admits allergies to dairy products, penicillin.,medication history:, none.,past medical history:, past medical history is unremarkable.,past surgical history:, patient admits past surgical history of eye surgery in 1999.,social history:, patient denies alcohol use, patient denies illegal drug use, patient denies std history, patient denies tobacco use.,family history:, unremarkable.,review of systems:, psychiatric: (+) poor sleep pattern, respiratory: (+) breathing difficulties, respiratory symptoms.,physical exam:, patient is a 59 year old female who appears well developed, well nourished and with good attention to hygiene and body habitus. toenails 1-5 bilateral appear crumbly, discolored - yellow, friable and thickened.,cardiovascular: dp pulses palpable bilateral. pt pulses palpable bilateral. cft immediate. no edema observed. varicosities are not observed.,skin: skin temperature of the lower extremities is warm to cool, proximal to distal. no skin rash, subcutaneous nodules, lesions or ulcers observed.,neurological: touch, pin, vibratory and proprioception sensations are normal. deep tendon reflexes normal.,musculoskeletal: muscle strength is 5/5 for all groups tested. muscle tone is normal. inspection and palpation of bones, joints and muscles is unremarkable.,test results:, no tests to report at this time.,impression:, onychomycosis.,plan:, debrided 10 nails.,prescriptions:, penlac dosage: 8% topical solution sig:

name of procedure:, hypogastric plexus block.,anesthesia:, local.,procedure: , the patient was in the operating room in the prone position with the back prepped and draped in sterile fashion. local anesthesia was used to make a skin wheal 8-10 cm lateral to the l4 spinous process bilaterally from the midline. starting from the left side, a 20-gauge 6-inch needle was placed to the left l5-s1 facet level under ap fluoroscopic view. on lateral view, the tip of the needle was at the inferior one-third of the ls vertebral body, anterior aspect. next 5 cc of omnipaque dye was injection showing a linear spread along the anterior portion of l5 down the sacral promontory. after negative aspiration 18 cc of 0.25% marcaine plus 40 mg of depo-medrol was injection. there were no complications. the above sequence was repeated for the right side. there were no complications. the patient was discharged back to outpatient recovery in stable condition.

chief complaint: , this 5-year-old male presents to children's hospital emergency department by the mother with "have asthma." mother states he has been wheezing and coughing. they saw their primary medical doctor. he was evaluated at the clinic, given the breathing treatment and discharged home, was not having asthma, prescribed prednisone and an antibiotic. they told to go to the er if he got worse. he has had some vomiting and some abdominal pain. his peak flows on the morning are normal at 150, but in the morning, they were down to 100 and subsequently decreased to 75 over the course of the day.,past medical history:, asthma with his last admission in 07/2007. also inclusive of frequent pneumonia by report.,immunizations: , up-to-date.,allergies: , denied.,medications: ,advair, nasonex, xopenex, zicam, zithromax, prednisone, and albuterol.,past surgical history: , denied.,social history: , lives at home, here in the ed with the mother and there is no smoking in the home.,family history: , no noted exposures.,review of systems: ,documented on the template. systems reviewed on the template.,physical examination:,vital signs: temperature 98.7, pulse 105, respiration is 28, blood pressure 112/65, and weight of 16.5 kg. oxygen saturation low at 91% on room air.,general: this is a well-developed male who is cooperative, alert, active with oxygen by facemask.,heent: head is atraumatic and normocephalic. pupils are equal, round, and reactive to light. extraocular motions are intact and conjugate. clear tms, nose, and oropharynx.,neck: supple. full painless nontender range of motion.,chest: tight wheezing and retractions heard bilaterally.,heart: regular without rubs or murmurs.,abdomen: soft, nontender. no masses. no hepatosplenomegaly.,genitalia: male genitalia is present on a visual examination.,skin: no significant bruising, lesions or rash.,extremities: moves all extremities without difficulty, nontender. no deformity.,neurologic: symmetric face, cooperative, and age appropriate.,medical decision making:, the differential entertained on this patient includes reactive airways disease, viral syndrome, and foreign body pneumonia. he is evaluated in the emergency department with continuous high-dose albuterol, decadron by mouth, pulse oximetry, and close observation. chest x-ray reveals bronchial thickening, otherwise no definite infiltrate. she is further treated in the emergency department with continued breathing treatments. at 0048 hours, he has continued tight wheezes with saturations 99%, but ed sats are 92% with coughing spells. based on the above, the hospitalist was consulted and accepts this patient for admission to the hospital with the working diagnosis of respiratory distress and asthma.

chief complaint: , dental pain.,history of present illness: , this is a 45-year-old caucasian female who states that starting last night she has had very significant pain in her left lower jaw. the patient states that she can feel an area with her tongue and one of her teeth that appears to be fractured. the patient states that the pain in her left lower teeth kept her up last night. the patient did go to clinic but arrived there later than 7 a.m., so she was not able to be seen there will call line for dental care. the patient states that the pain continues to be very severe at 9/10. she states that this is like a throbbing heart beat in her left jaw. the patient denies fevers or chills. she denies purulent drainage from her gum line. the patient does believe that there may be an area of pus accumulating in her gum line however. the patient denies nausea or vomiting. she denies recent dental trauma to her knowledge.,past medical history:,1. coronary artery disease.,2. hypertension.,3. hypothyroidism.,past surgical history: ,coronary artery stent insertion.,social habits: , the patient denies alcohol or illicit drug usage. currently she does have a history of tobacco abuse.,medications:,1. plavix.,2. metoprolol.,3. synthroid.,4. potassium chloride.,allergies:,1. penicillin.,2. sulfa.,physical examination:,general: this is a caucasian female who appears of stated age of 45 years. she is well-nourished, well-developed, in no acute distress. the patient is pleasant but does appear to be uncomfortable.,vital signs: afebrile, blood pressure 145/91, pulse of 78, respiratory rate of 18, and pulse oximetry of 98% on room air.,heent: head is normocephalic. pupils are equal, round and reactive to light and accommodation. sclerae are anicteric and noninjected. nares are patent and free of mucoid discharge. mucous membranes are moist and free of exudate or lesion. bilateral tympanic membranes are visualized and free of infection or trauma. dentition shows significant decay throughout the dentition. the patient has had extraction of teeth 17, 18, and 19. the patient's tooth #20 does have a small fracture in the posterior section of the tooth and there does appear to be a very minor area of fluctuance and induration located at the alveolar margin at this site. there is no pus draining from the socket of the tooth. no other acute abnormality to the other dentition is visualized.,diagnostic studies: , none.,procedure note: ,the patient does receive an injection of 1.5 ml of 0.5% bupivacaine for inferior alveolar nerve block on the left mandibular teeth. the patient undergoes this all procedure without complication and does report some mild decrease of her pain with this and patient was also given two vicodin here in the emergency department and a dose of keflex for treatment of her dental infection.,assessment: ,dental pain with likely dental abscess. ,plan: , the patient was given a prescription for vicodin. she is also given prescription for keflex, as she is penicillin allergic. she has tolerated a dose of keflex here in the emergency department well without hypersensitivity. the patient is strongly encouraged to follow up with dental clinic on monday, and she states that she will do so. the patient verbalizes understanding of treatment plan and was discharged in satisfactory condition from the er.,

chief complaint: , possible exposure to ant bait.,history of present illness:, this is a 14-month-old child who apparently was near the sink, got into the childproof cabinet and pulled out ant bait that had borax in it. it had 11 ml of this fluid in it. she spilled it on her, had it on her hands. parents were not sure whether she ingested any of it. so, they brought her in for evaluation. they did not note any symptoms of any type.,past medical history: , negative. generally very healthy.,review of systems: , the child has not been having any coughing, gagging, vomiting, or other symptoms. acting perfectly normal. family mostly noted that she had spilled it on the ground around her, had it on her hands, and on her clothes. they did not witness that she ingested any, but did not see anything her mouth.,medications: , none.,allergies: , none.,physical examination: , vital signs: the patient was afebrile. stable vital signs and normal pulse oximetry. general: the child is very active, cheerful youngster, in no distress whatsoever. heent: unremarkable. oral mucosa is clear, moist, and well hydrated. i do not see any evidence of any sort of liquid on the face. her clothing did have the substance on the clothes, but i did not see any evidence of anything on her torso. apparently, she had some on her hands that has been wiped off.,emergency department course:, i discussed the case with poison control and apparently this is actually relatively small quantity and it is likely to be a nontoxic ingestion if she even ingested, which should does not appear likely to be the case.,impression: , exposure to ant bait.,plan: , at this point, it is fairly unlikely that this child ingested any significant amount, if at all, which seems unlikely. she is not exhibiting any symptoms and i explained to the parents that if she develops any vomiting, she should be brought back for reevaluation. so, the patient is discharged in stable condition.

procedure performed:, lumbar puncture.,the procedure, benefits, risks including possible risks of infection were explained to the patient and his father, who is signing the consent form. alternatives were explained. they agreed to proceed with the lumbar puncture. permit was signed and is on the chart. the indication was to rule out toxoplasmosis or any other cns infection. ,description: , the area was prepped and draped in a sterile fashion. lidocaine 1% of 5 ml was applied to the l3-l4 spinal space after the area had been prepped with betadine three times. a 20-gauge spinal needle was then inserted into the l3-l4 space. attempt was successful on the first try and several mls of clear, colorless csf were obtained. the spinal needle was then withdrawn and the area cleaned and dried and a band-aid applied to the clean, dry area.,complications:, none. the patient was resting comfortably and tolerated the procedure well.,estimated blood loss: , none.,disposition: , the patient was resting comfortably with nonlabored breathing and the incision was clean, dry, and intact. labs and cultures were sent for the usual in addition to some extra tests that had been ordered.,the opening pressure was 292, the closing pressure was 190.

cataract, is the loss of transparency of the lens of the eye. it often appears like a window that is fogged with steam.,what causes cataract formation?,* aging, the most common cause.,* family history.,* steroid use.,* injury to the eye.,* diabetes.,* previous eye surgery.,* long-term exposure to sunlight.,how do i know if i have a cataract?,* the best way for early detection is regular eye examinations by your medical eye doctor. there are many causes of visual loss in addition to the cataract such as problems involving the optic nerve and retina. if these other problems exist, cataract removal may not result in the return or improvement of vision. your eye doctor can tell you how much improvement in vision is likely.,does it take a long time for a cataract to form?,cataract development varies greatly between patients and is affected by the cause of the cataract. generally, cataracts progress gradually over many years. some people, especially diabetics and younger patients, may find that cataract formation progresses rapidly over a few months making it impossible to know exactly how long it will take for the cataract to develop. ,what is the treatment for cataracts?,the only way to remove a cataract is surgery. if the symptoms are not restricting your activity, a change of glasses may alleviate the symptoms at this time. no medications, exercise, optical devices or dietary supplements have been shown to stop the progression or prevent cataracts.,it is important to provide protection from excessive sunlight. making sure that the sunglasses you wear screen out ultraviolet (uv) light rays or your regular eyeglasses are coated with a clear, anti-uv coating will help prevent or slow the progression of cataracts.,how do i know if i need surgery?,surgery is considered when your vision is interfering with your daily activities. it is important to evaluate if you can see to do your job and drive safely. can you read and watch tv in comfort? are you able to cook, do your shopping and yard work or take your medications without difficulty? depending on how you feel your vision is affecting your daily life, you and your eye doctor will decide together when it is the appropriate time to do surgery.,what is involved with cataract surgery?,this surgery is generally performed under local anesthesia on an outpatient basis. with the assistance of a microscope, the cloudy lens is removed and replaced with a permanent intraocular lens implant.,right after the surgery you should be able to immediately perform all your normal activities except for the most strenuous ones. you will need to take eye drops as directed by your eye doctor. follow-up visits are necessary to make sure the surgical site is healing without problems.,this procedure is performed on over 1.4 million people each year in the united states alone, 95% without complications. with this highly successful procedure, 90% of the time vision improves unless a problem also exists with the cornea, retina or optic nerve. as with any surgery, a good result cannot be guaranteed.