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preoperative diagnosis:, left pleural effusion.,postoperative diagnosis:, left hemothorax.,procedure: , thoracentesis.,procedure in detail:, after obtaining informed consent and having explained the procedure to the patient, he was sat at the side of a stretcher in the emergency department. his left back was prepped and draped in the usual fashion. xylocaine 1% was used to infiltrate his chest wall and the chest entered upon the ninth intercostal space in the midscapular line and the thoracentesis catheter was used and placed, and then we proceed to draw by hand about 1200 ml blood. this blood was nonclotting and it was tested twice. halfway during the procedure, the patient felt that he was getting dizzy and his pressure at that time had dropped to the 80s. therefore, we laid him off his right side while keeping the chest catheter in place. at that time, i proceeded to continuously draw fluids slowly and then when the patient recovered we sat him up again and we proceed to complete the procedure.,overall besides the described episode, the patient tolerated the procedure well and afterwards, we took another chest x-ray that showed much improvement in the pleural effusion and at that particular time, with all the history we proceeded to admit the patient for observation and with an idea to obtain a ct in the morning to see whether the patient would need an pigtail intrapleural catheter or not.

operative procedure:, bronchoscopy brushings, washings and biopsies.,history: , this is a 41-year-old woman admitted to medical center with a bilateral pulmonary infiltrate, immunocompromise.,indications for the procedure:, bilateral infiltrates, immunocompromised host, and pneumonia.,prior to procedure, the patient was intubated with 8-french et tube orally by anesthesia due to her profound hypoxemia and respiratory distress.,description of procedure: , under mac and fluoroscopy, fiberoptic bronchoscope was passed through the et tube.,et tube was visualized approximately 2 cm above the carina. fiberoptic bronchoscope subsequently was passed through the right lower lobe area and transbronchial biopsies under fluoroscopy were done from the right lower lobe x3 as well as the brushings were obtained and the washings. the patient tolerated the procedure well. postprocedure, the patient is to be placed on a ventilator as well as postprocedure chest x-ray pending. specimens are sent for immunocompromise panel including pcp stains.,postprocedure diagnosis:, pneumonia, infiltrates.

preoperative diagnosis: , left buccal mucosal verrucous squamous cell carcinoma.,postoperative diagnosis: , left buccal mucosal verrucous squamous cell carcinoma.,procedure performed:,1. wide local excision of left buccal mucosal lesion with full thickness skin graft closure in the left supraclavicular region.,2. adjacent tissue transfer closure of the left supraclavicular grafting site.,estimated blood loss: , less than 30 cc.,complications:, none.,indications for procedure: , the patient is a 16-year-old caucasian female with a history of left verrucous squamous cell carcinoma of the buccal mucosa, present for a number of months that was diagnosed in the office after two biopsies. after risks, complications, consequences, and questions were addressed with the patient, medical clearance was obtained with the patient and a written consent was obtained.,procedure: , the patient was brought to operative suite by anesthesia. the patient was placed on the operative table in supine position. after this, the patient was then placed under general endotracheal intubation anesthesia. the operating bed was then turned 90 degrees away from anesthesia. a shoulder roll was then placed followed by the patient's oral lesion being localized with 1% lidocaine with epinephrine 1:1000 approximately 5 cc total. after this the patient was then prepped and draped in the usual sterile fashion including the left shoulder region.,after this sweetheart retractor along with a minnesota retractor were utilized to lift the upper and lower lips along with tongue to gain access to this oral cavity lesion. a #15 bard parker was then utilized to make an incision circumferentially around this lesion or mass with approximately a 1 cm margin. the lesion was then grasped with a debakey forceps and grasped through in order to dissect this from the buccal mucosal sites with a #15 blade along with a curved sharp joseph scissors. after this the 12, 6, and 3 o'clock positions were marked with marking suture and the specimen was finally passed off the field. it was sent to the frozen section's pathology. hemostasis was maintained with bipolar cauterization. pathology called back into the room and verified that the regions from 12 to 3 and from 6 to 12 were still involved. a second margin was obtained from the 6 o'clock position all the way to the 3 o'clock position with sutures again placed in the 12, 6, and 3 o'clock regions. this was cut utilizing the #15 bard-parker and grasped with the debakey forceps. it was passed off the field and sent to pathology. pathology then called back into the room and verified that margins were clear. after this the bipolar cauterization was then utilized to control a further bleeding. after this the superior and inferior aspects of the defect were reapproximated with approximately one #4-0 vicryl suture. after this the left shoulder that was prepped previously was unveiled. surgical gloves were all changed and a 3 x 4 cm elliptical skin graft was taken from the left supraclavicular region. first a #15 bard-parker was utilized to make an incision in the skin in elliptical fashion. after this the skin was then grasped and a full thickness graft was taken with undermining performed by the #15 bard-parker. after this the underlying subcutaneous tissue was then hemostatically controlled with bipolar cauterization. after this the tissue was then reapproximated in multiple interrupted #4-0 undyed vicryl followed by reapproximation of the skin with a #5-0 prolene. after this the skin graft was then defatted with a curved joseph scissors. it was then placed in the oral defect. circumferentially it was sutured down to the edge of the buccal mucosa with multiple interrupted #4-0 undyed vicryl sutures. it was then ________ with a #15 bard-parker and sutured in from the midportion of the multiple areas with multiple interrupted #4-0 undyed vicryl. after this the patient was then thoroughly cleaned and mastisol steri-strips were then placed on the left shoulder defect along with the sterile dressing. the patient was then turned back to the anesthesia, extubated in the operating room and transferred to recovery room in stable condition. the patient tolerated the procedure well and will be admitted to hospital for observation.

allowed conditions:, 726.31 right medial epicondylitis; 354.0 right carpal tunnel syndrome.,contested conditions:, 354.2 right cubital tunnel syndrome.,employer:, abcd, ,i examined xxxxx today for the allowed conditions and also the contested conditions listed above. i obtained her history from company medical records and performed an examination. she is a 38-year-old laborer who states that she was injured on april 26, 2006, which according to the froi (the injury occurred over a period of time from performing normal job processes such as putting bumpers on cars, gas caps and doors on cars). she denies having any symptoms prior to the accident april 26, 2006. she is right handed. she used a tennis elbow brace, hand exercises, physical therapy, and vicodin. she received treatment from dr. x and also dr. y,diagnostic studies:, june 27, 2006, emg and nerve conduction velocity right upper extremity showed a moderate right carpal tunnel syndrome. no evidence of a right cervical radiculopathy or ulnar neuropathy at the wrist or elbow. january 29, 2007, emg right upper extremity was normal and there was a normal nerve conduction velocity. at the time of the examination, she complained of a constant pain in the olecranon and distal triceps with tingling in the right long, ring and small fingers, and night pain. the pain was accentuated by gripping or opening the jar. she is taking four aleve a day and currently does not have any other treatment.,records reviewed: , injury and illness incident report, us healthworks records; z physician review; y office notes; x office notes who noted that on examination of the right elbow that the ulnar nerve subluxed with flexion and extension of the elbow.,examination: , examination of her right elbow revealed no measurable atrophy of the upper arm. she was markedly tender over the medial epicondyle, but also the olecranon and distal process and she was exquisitely tender over the ulnar nerve. i did not detect subluxation of the ulnar nerve with flexion and extension. with this, she was extremely tender in this area. there is no instability of the elbow. range of motion was 0 to 145 degrees, flexion 90 degrees of pronation and supination. the elbow flexion test was positive. there is normal motor power in the elbow and also on the right hand, specifically in the ulnar intrinsics. there was diminished sensation on the right ring and small fingers, specifically the ulnar side of the ring finger of the entire small finger. there was no wasting of the intrinsics. no clawing of the hand. examination of the right wrist revealed extension 45 degrees, flexion 45 degrees, radial deviation 15 degrees, and ulnar deviation 35 degrees. she was tender over the dorsum of the hand over the ulnar head and the volar aspect of the wrist. wrist flexion causes paresthesias on the right ring and small fingers. grasp was weak. there was no sign of causalgia, but no measurable atrophy of the forearm. no reflex changes.,question:, ms. xxxxx has filed an application of additional allowance of right cubital tunnel syndrome. based on the current objective findings, mechanism of injury, medical records or diagnostic studies, does the medical evidence support the existence of the requested condition?,answer:, yes. she has a positive elbow flexion test and she is markedly tender over the ulnar nerve at the elbow and also has diminished sensation in the ulnar nerve distribution, specifically in the entire right small finger and the ulnar half of the ring finger. i did not find the subluxation of the ulnar nerve with flexion and extension with dr. x did previously find on his examination.,question: , if you find these conditions exist, are they a direct and proximate result of april 26, 2006, injury?,answer: , yes. repeated flexion and extension would irritate the ulnar nerve particularly if it was subluxing which it could very well have which dr. x objectively identified on his examination. therefore, i believe it is a direct and proximate result of april 26, 2006, injury.,question: , do you find that ms. xxxxx's injury or disability is caused by natural deterioration of tissue, organ or part of the body?,answer: , no.,question:, in addition, if you find that the condition exists, are there non-occupational activities or intervening injuries that could have contributed to ms. xxxxx's condition?,answer: , it is possible that direct injury to the ulnar nerve at the elbow could cause this syndrome; however, there is no history of this and the records do not indicate an injury of this type.,question: ,

preoperative diagnosis: , right lower pole renal stone and possibly infected stent.,postoperative diagnosis: , right lower pole renal stone and possibly infected stent.,operation:, cysto stent removal.,anesthesia:, local mac.,estimated blood loss: , minimal.,fluids: , crystalloid.,medications: , the patient was on vancomycin and levaquin was given x1 dose. the patient was on vancomycin for the last 5 days.,brief history: ,the patient is a 53-year-old female who presented with enterococcus urosepsis. ct scan showed a lower pole stone with a stent in place. the stent was placed about 2 months ago, but when patient came in with a possibly upj stone with fevers of unknown etiology. the patient had a stent placed at that time due to the fevers, thinking that this was an urospetic stone. there was some pus that came out. the patient was cultured; actually it was negative at that time. the patient subsequently was found to have lower extremity dvt and then was started on coumadin. the patient cannot be taken off coumadin for the next 6 months due to the significant swelling and high risk for pe. the repeat films were taken which showed the stone had migrated into the pole.,the stent was intact. the patient subsequently developed recurrent utis and enterococcus in the urine with fevers. the patient was admitted for iv antibiotics since the patient could not really tolerate penicillin due to allergy and due to patient being on coumadin, cipro, and levaquin where treatment was little bit more complicated. due to drug interaction, the patient was admitted for iv antibiotic treatment. the thinking was that either the stone or the stent is infected, since the stone is pretty small in size, the stent is very likely possibility that it could have been infected and now it needs to be removed. since the stone is not obstructing, there is no reason to replace the stent at this time. we are unable to do the ureteroscopy or the shock-wave lithotripsy when the patient is fully anticoagulated. so, the best option at this time is to probably wait and perform the ureteroscopic laser lithotripsy when the patient is allowed to off her coumadin, which would be probably about 4 months down the road.,plan is to get rid of the stent and improve patient's urinary symptoms and to get rid of the infection and we will worry about the stone at later point.,details of the or: , consent had been obtained from the patient. risks, benefits, and options were discussed. risk of anesthesia, bleeding, infection, pain, mi, dvt, and pe were discussed. the patient understood all the risks and benefits of removing the stent and wanted to proceed. the patient was brought to the or. the patient was placed in dorsal lithotomy position. the patient was given some iv pain meds. the patient had received vancomycin and levaquin preop. cystoscopy was performed using graspers. the stent was removed without difficulty. plan was for repeat cultures and continuation of the iv antibiotics.

history of present illness: ,this is the initial clinic visit for a 29-year-old man who is seen for new onset of right shoulder pain. he states that this began approximately one week ago when he was lifting stacks of cardboard. the motion that he describes is essentially picking up a stack of cardboard at his waist level, twisting to the right and delivering it at approximately waist level. sometimes he has to throw the stacks a little bit as well. he states he felt a popping sensation on 06/30/04. since that time, he has had persistent shoulder pain with lifting activities. he localizes the pain to the posterior and to a lesser extent the lateral aspect of the shoulder. he has no upper extremity . , ,review of systems: ,focal lateral and posterior shoulder pain without a suggestion of any cervical radiculopathies. he denies any chronic cardiac, pulmonary, gi, gu, neurologic, musculoskeletal, endocrine abnormalities. , ,medications: , claritin for allergic rhinitis. , ,allergies: , none. , ,physical examination:, blood pressure 120/90, respirations 10, pulse 72, temperature 97.2. he is sitting upright, alert and oriented, and in no acute distress. skin is warm and dry. gross neurologic examination is normal. ent examination reveals normal oropharynx, nasopharynx, and tympanic membranes. neck: full range of motion with no adenopathy or thyromegaly. cardiovascular: regular rate and rhythm. lungs: clear. abdomen: soft.

identifying data: ,the patient is a 35-year-old caucasian female who speaks english.,chief complaint: ,the patient has a manic disorder, is presently psychotic with flight of ideas, believes, "i can fly," tangential speech, rapid pressured speech and behavior, impulsive behavior. last night, she tried to turn on the garbage disposal and put her hand in it, in the apartment shared by her husband. she then turned on the oven and put her head in the oven and then tried to climb over the second storied balcony. all of these behaviors were interrupted by her husband who called 911. he reports that she has not slept in 3 to 5 days and has not taken her meds in at least that time period.,history of present illness: ,the patient was treated most recently at abcd hospital and decompensated during that admission resulting in her 90-day lr being revoked. after leaving abcd approximately 01/25/2010, she stopped taking her abilify and lithium. her husband states that he restrained her from jumping, "so she would not kill herself," and this was taken as a statement in his affidavit. the patient was taken to x hospital, medically cleared, given ativan 2 mg p.o. and transferred on an involuntary status to xyz hospital. she arrives here and is today pacing on the unit and in and out of the large tv room area. she is friendly towards the patients although sometimes raises her voice and comes too close to other patients in a rapid manner. she is highly tangential, delusional, and disorganized. she refused to sign all admit papers and a considerable part of her immediate history is unknown.,past psychiatric history: ,the patient was last admitted to xyz hospital on january 14, 2009, and discharged on january 23, 2009. please see the excellent discharge summary of dr. x regarding this admission for information, which the patient is unable to give at the present. she is currently treated by dr. y. she has been involuntarily detained at least 7 times and revoked at least 6 times. she was on xyz inpatient in 2001 and in 01/2009. she states that she "feels invincible" when she becomes manic and this is also the description given by her husband.,medical history: ,the patient has a history of a herniated disc in 1999.,medications: , current meds, which are her outpatient meds, which she is not taking at the moment are lithium 300 mg p.o. am and 600 mg p.o. q.p.m., abilify 15 mg p.o. per day, lyrica 100 mg p.o. per day, it is not clear if she is taking geodon as the record is conflicting in this regard. she is being given vicodin, is not sure who the prescriber for that medication is and it is presumably due to her history of herniated disc. of note, she also has a history of abusing vicodin.,allergies: ,said to be penicillin, lamictal, and zyprexa.,social and developmental history: , the patient lives with her husband. there are no children. she reportedly has a college education and has 2 brothers.,substance and alcohol history: , per abcd information, the patient has a history of abusing opiates, benzodiazepines, and vicodin. the x hospital tox screen of last night was positive for opiates. her lithium level per last night at x hospital was 0.42 meq/l. she smokes nicotine, the amount is not known although she has asked and received nicorette gum.,legal history: , she had a 90-day lr, which was revoked at abcd hospital, 12/ 25/2009, when she quickly deteriorated.,mental status exam:,attitude: ,the patient's attitude is agitated when asked questions, loud and evasive.,appearance:, disheveled and moderately well nourished.,psychomotor: , restless with erratic sudden movements.,eps:, none.,affect: , hyperactive, hostile, and labile.,mood: , her mood is agitated, suspicious, and angry.,speech: ,circumstantial and sometimes intelligible when asked simple direct questions and at other points becomes completely tangential describing issues which are not real.,thought content: , delusional, disorganized, psychotic, and paranoid. suicidal ideation, the patient refuses to answer the questions, but the record shows a past history of suicide attempt.,cognitive assessment: ,the patient was said on her nursing admit to be oriented to place and person, but could not answer that question for me, and appeared to think that she may still be at abcd hospital. her recent, intermediate, and remote memory are impaired although there is a lack of cooperation in this testing.,judgment and insight:, nil. when asked, are there situations when you lose control, she refuses to answer. when asked, are meds helpful, she refuses to answer. she refuses to give her family information nor release of information to contact them.,assets:, the patient has an outpatient psychiatrist and she does better or is more stable when taking her medications.,limitations:, the patient goes off her medications routinely, behaves unsafely and in a potentially suicidal manner.,formulation,: the patient has bipolar affective disorder in a manic state at present. she also may be depressed and is struggling with marital issues.,diagnoses:

procedure performed: , tonsillectomy and adenoidectomy.,anesthesia:, general endotracheal.,description of procedure: , the patient was taken to the operating room and prepped and draped in the usual fashion after induction of general endotracheal anesthesia. the mcivor mouth gag was placed in the oral cavity, and a tongue depressor applied. two #12-french red rubber robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll placed on the upper lip to provide soft palate retraction.,the nasopharynx was inspected with a laryngeal mirror. the adenoid tissue was fulgurated with the suction bovie set at 35. the catheters and the dental gauze roll were then removed. the anterior tonsillar pillars were infiltrated with 0.5% marcaine and epinephrine. using the radiofrequency wand, the tonsils were ablated bilaterally. if bleeding occurred, it was treated with the wand on coag mode using a coag mode of 3 and an ablation mode of 9. the tonsillectomy was completed.,the nasopharynx and nasal passages were suctioned free of debris, and the procedure was terminated.,the patient tolerated the procedure well and left the operating room in good condition.

procedure: , esophagogastroduodenoscopy with gastric biopsies.,indication:, abdominal pain.,findings:, antral erythema; 2 cm polypoid pyloric channel tissue, questionable inflammatory polyp which was biopsied; duodenal erythema and erosion.,medications: , fentanyl 200 mcg and versed 6 mg.,scope: , gif-q180.,procedure detail: , following the preprocedure patient assessment the procedure, goals, risks including bleeding, perforation and side effects of medications and alternatives were reviewed. questions were answered. pause preprocedure was performed.,following titrated intravenous sedation the flexible video endoscope was introduced into the esophagus and advanced to the second portion of the duodenum without difficulty. the esophagus appeared to have normal motility and mucosa. regular z line was located at 44 cm from incisors. no erosion or ulceration. no esophagitis.,upon entering the stomach gastric mucosa was examined in detail including retroflexed views of cardia and fundus. there was pyloric channel and antral erythema, but no visible erosion or ulceration. there was a 2 cm polypoid pyloric channel tissue which was suspicious for inflammatory polyp. this was biopsied and was placed separately in bottle #2. random gastric biopsies from antrum, incisura and body were obtained and placed in separate jar, bottle #1. no active ulceration was found.,upon entering the duodenal bulb there was extensive erythema and mild erosions, less than 3 mm in length, in first portion of duodenum, duodenal bulb and junction of first and second part of the duodenum. postbulbar duodenum looked normal.,the patient was assessed upon completion of the procedure. okay to discharge once criteria met.,follow up with primary care physician.,i met with patient afterward and discussed with him avoiding any nonsteroidal anti-inflammatory medication. await biopsy results.

preoperative diagnosis: , painful ingrown toenail, left big toe.,postoperative diagnosis: , painful ingrown toenail, left big toe.,operation: , removal of an ingrown part of the left big toenail with excision of the nail matrix.,description of procedure: ,after obtaining informed consent, the patient was taken to the minor or room and intravenous sedation with morphine and versed was performed and the toe was blocked with 1% xylocaine after having been prepped and draped in the usual fashion. the ingrown part of the toenail was freed from its bed and removed, then a flap of skin had been made in the area of the matrix supplying the particular part of the toenail. the matrix was excised down to the bone and then the skin flap was placed over it. hemostasis had been achieved with a cautery. a tubular dressing was performed to provide a bulky dressing.,the patient tolerated the procedure well. estimated blood loss was negligible. the patient was sent back to same day surgery for recovery.

preoperative diagnoses:,1. hyperpyrexia/leukocytosis.,2. ventilator-dependent respiratory failure.,3. acute pancreatitis.,postoperative diagnoses:,1. hyperpyrexia/leukocytosis.,2. ventilator-dependent respiratory failure.,3. acute pancreatitis.,procedure performed:,1. insertion of a right brachial artery arterial catheter.,2. insertion of a right subclavian vein triple lumen catheter.,anesthesia: , local, 1% lidocaine.,blood loss:, less than 5 cc.,complications: , none.,indications: , the patient is a 46-year-old caucasian female admitted with severe pancreatitis. she was severely dehydrated and necessitated some fluid boluses. the patient became hypotensive, required many fluid boluses, became very anasarcic and had difficulty with breathing and became hypoxic. she required intubation and has been ventilator-dependent in the intensive care since that time. the patient developed very high temperatures as well as leukocytosis. her lines required being changed.,procedure:,1. right brachial arterial line: ,the patient's right arm was prepped and draped in the usual sterile fashion. there was a good brachial pulse palpated. the artery was cannulated with the provided needle and the kit. there was good arterial blood return noted immediately. on the first stick, the seldinger wire was inserted through the needle to cannulate the right brachial artery without difficulty. the needle was removed and a catheter was inserted over the seldinger wire to cannulate the brachial artery. the femoral catheter was used in this case secondary to the patient's severe edema and anasarca. we did not feel that the shorter catheter would provide enough length. the catheter was connected to the system and flushed without difficulty. a good waveform was noted. the catheter was sutured into place with #3-0 silk suture and opsite dressing was placed over this.,2. right subclavian triple lumen catheter: ,the patient was prepped and draped in the usual sterile fashion. 1% xylocaine was used to anesthetize an area just inferior and lateral to the angle of the clavicle. using the anesthetic needle, we checked down to the soft tissues anesthetizing, as we proceeded to the angle of the clavicle, this was also anesthetized. next, a #18 gauge thin walled needle was used following the same track to the angle of clavicle. we roughed the needle down off the clavicle and directed it towards the sternal notch. there was good venous return noted immediately. the syringe was removed and a seldinger guidewire was inserted through the needle to cannulate the vein. the needle was then removed. a small skin nick was made with a #11 blade scalpel and the provided dilator was used to dilate the skin, soft tissue and vein. next, the triple lumen catheter was inserted over the guidewire without difficulty. the guidewire was removed. all the ports aspirated and flushed without difficulty. the catheter was sutured into place with #3-0 silk suture and a sterile opsite dressing was also applied. the patient tolerated the above procedures well. a chest x-ray has been ordered, however, it has not been completed at this time, this will be checked and documented in the progress notes.

preoperative diagnoses: ,1. chronic eustachian tube dysfunction.,2. retained right pressure equalization tube.,3. retracted left tympanic membrane.,4. dizziness.,postoperative diagnoses:,1. chronic eustachian tube dysfunction.,2. retained right pressure equalization tube.,3. retracted left tympanic membrane.,4. dizziness.,procedure:,1. removal of the old right pressure equalizing tube with placement of a tube. tube used was santa barbara.,2. myringotomy with placement of a left pressure equalizing tube. the tube used was santa barbara.,anesthesia:, general.,indication: , this is a 98-year-old female whom i have known for several years. she has a marginal hearing. with the additional conductive loss secondary to the retraction of the tympanic membrane, her hearing aid and function deteriorated significantly. so, we have kept sets of tubes in her ears at all times. the major problem is that she has got small ear canals and a very sensitive external auditory canal; therefore it cannot tolerate even the wax cleaning in the clinic awake.,the patient was seen in the or and tubes were placed. there were no significant findings.,procedure in detail: , after obtaining informed consent from the patient, she was brought to the neurosensory or, placed under general anesthesia. mask airway was used. iv had already been started.,on the right side, we removed the old tube and then cleaned the cerumen and found that it was larger than the side of the tube in perfection or perforation in tympanic membrane in the anterior inferior quadrant. in the same area, a small santa barbara tube was placed. this t-tube was cut to 80% of its original length for comfort and then positioned to point straight out and treated. three drops of ciprofloxacin eyedrops was placed in the ear canal.,on the left side, the tympanic membrane adhered and it was retracted and has some myringosclerosis. anterior, inferior incision was made. tympanic membrane bounced back to neutral position. a santa barbara tube was cut to the 80% of the original length and placed in the hole. ciprofloxacin drops were placed in the ear. procedure completed.,estimated blood loss: , none.,complication: , none.,specimen:, none.,disposition:, to pacu in a stable condition.

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

preoperative diagnosis: , history of polyps.,postoperative diagnoses:,1. normal colonoscopy, left colonic diverticular disease.,2. 3+ benign prostatic hypertrophy.,procedure performed: , total colonoscopy and photography.,gross findings: , this is a 74-year-old white male here for recheck colonoscopy for a history of polyps. after signed informed consent, blood pressure monitoring, ekg monitoring, and pulse oximetry monitoring, he was brought to the endoscopic suite. he was given 100 mg of demerol, 3 mg of versed iv push slowly. digital examination revealed a large prostate for which he is following up with his urologist. no nodules. 3+ bph. anorectal canal was within normal limits. no stricture tumor or ulcer. the olympus cf 20l video endoscope was inserted per anus. the anorectal canal was visualized, was normal. the sigmoid, descending, splenic, and transverse showed scattered diverticula. the hepatic, ascending, cecum, and ileocecal valve was visualized and was normal. the colonoscope was removed. the air was aspirated. the patient was discharged with high-fiber, diverticular diet. recheck colonoscopy three years.

reason for admission: , fever of unknown origin.,history of present illness: , the patient is a 39-year-old woman with polymyositis/dermatomyositis on methotrexate once a week. the patient has also been on high-dose prednisone for an urticarial rash. the patient was admitted because of persistent high fevers without a clear-cut source of infection. she had been having temperatures of up to 103 for 8-10 days. she had been seen at alta view emergency department a week prior to admission. a workup there including chest x-ray, blood cultures, and a transthoracic echocardiogram had all remained nondiagnostic, and were normal. her chest x-ray on that occasion was normal. after the patient was seen in the office on august 10, she persisted with high fevers and was admitted on august 11 to cottonwood hospital. studies done at cottonwood: ct scan of the chest, abdomen, and pelvis. results: ct chest showed mild bibasilar pleural-based interstitial changes. these were localized to mid and lower lung zones. the process was not diffuse. there was no ground glass change. ct abdomen and pelvis was normal. infectious disease consultation was obtained. dr. xyz saw the patient. he ordered serologies for cmv including a cmv blood pcr. next serologies for ebv, legionella, chlamydia, mycoplasma, coccidioides, and cryptococcal antigen, and a ppd. the cmv serology came back positive for igm. the igg was negative. the cmv blood pcr was positive, as well. other serologies and her ppd stayed negative. blood cultures stayed negative.,in view of the positive cmv, pcr, and the changes in her cat scan, the patient was taken for a bronchoscopy. bal and transbronchial biopsies were performed. the transbronchial biopsies did not show any evidence of pneumocystis, fungal infection, afb. there was some nonspecific interstitial fibrosis, which was minimal. i spoke with the pathologist, dr. xyz and immunopathology was done to look for cmv. the patient had 3 nucleoli on the biopsy specimens that stained positive and were consistent with cmv infection. the patient was started on ganciclovir once her cmv serologies had come back positive. no other antibiotic therapy was prescribed. next, the patient's methotrexate was held.,a chest x-ray prior to discharge showed some bibasilar disease, showing interstitial infiltrates. the patient was given ibuprofen and acetaminophen during her hospitalization, and her fever resolved with these measures.,on the bal fluid cell count, the patient only had 5 wbcs and 5 rbcs on the differential. it showed 43% neutrophils, 45% lymphocytes.,discussions were held with dr. xyz, dr. xyz, her rheumatologist, and with pathology.,discharge diagnoses:,1. disseminated cmv infection with possible cmv pneumonitis.,2. polymyositis on immunosuppressive therapy (methotrexate and prednisone).,discharge medications:,1. the patient is going to go on ganciclovir 275 mg iv q.12 h. for approximately 3 weeks.,2. advair 100/50, 1 puff b.i.d.,3. ibuprofen p.r.n. and tylenol p.r.n. for fever, and will continue her folic acid.,4. the patient will not restart for methotrexate for now.,she is supposed to follow up with me on august 22, 2007 at 1:45 p.m. she is also supposed to see dr. xyz in 2 weeks, and dr. xyz in 2-3 weeks. she also has an appointment to see an ophthalmologist in about 10 days' time. this was a prolonged discharge, more than 30 minutes were spent on discharging this patient.

preoperative diagnosis: , ganglion of the left wrist.,postoperative diagnosis: , ganglion of the left wrist.,operation: , excision of ganglion.,anesthesia: , general.,estimated blood loss: , less than 5 ml.,operation: , after a successful anesthetic, the patient was positioned on the operating table. a tourniquet applied to the upper arm. the extremity was prepped in a usual manner for a surgical procedure and draped off. the superficial vessels were exsanguinated with an elastic wrap and the tourniquet was then inflated to the usual arm pressure. a curved incision was made over the presenting ganglion over the dorsal aspect of the wrist. by blunt and sharp dissection, it was dissected out from underneath the extensor tendons and the stalk appeared to arise from the distal radiocapitellar joint and the dorsal capsule was excised along with the ganglion and the specimen was removed and submitted. the small superficial vessels were electrocoagulated and instilled after closing the skin with 4-0 prolene, into the area was approximately 6 to 7 ml of 0.25 marcaine with epinephrine. a jackson-pratt drain was inserted and then after the tourniquet was released, it was kept deflated until at least 5 to 10 minutes had passed and then it was activated and then removed in the recovery room. the dressings applied to the hand were that of xeroform, 4x4s, abd, kerlix, and elastic wrap over a volar fiberglass splint. the tourniquet was released. circulation returned to the fingers. the patient then was allowed to awaken and left the operating room in good condition.

preoperative diagnoses:,1. enlarged fibroid uterus.,2. hypermenorrhea.,postoperative diagnoses:,1. enlarged fibroid uterus.,2. hypermenorrhea.,3. secondary anemia.,procedure performed:,1. dilatation and curettage.,2. hysteroscopy.,gross findings: , uterus was anteverted, greatly enlarged, irregular and firm. the cervix is patulous and nulliparous without lesions. adnexal examination was negative for masses.,procedure: ,the patient was taken to the operating room where she was properly prepped and draped in sterile manner under general anesthesia. after bimanual examination, the cervix was exposed with a weighted vaginal speculum and the anterior lip of the cervix grasped with a vulsellum tenaculum. the uterus was sounded to a depth of 11 cm. the endocervical canal was then progressively dilated with hanks and hegar dilators to a #10 hegar. the acmi hysteroscope was then introduced into the uterine cavity using sterile saline solution as a distending media and with attached video camera. the endometrial cavity was distended with fluids and the cavity visualized. multiple irregular areas of fibroid degeneration were noted throughout the cavity. the coronal areas were visualized bilaterally with corresponding tubal ostia. a moderate amount of proliferative appearing endometrium was noted. there were no direct intraluminal lesions seen. the patient tolerated the procedure well. several pictures were taken of the endometrial cavity and the hysteroscope removed from the cavity.,a large sharp curet was then used to obtain a moderate amount of tissue, which was the sent to pathologist for analysis. the instrument was removed from the vaginal vault. the patient was sent to recovery area in satisfactory postoperative condition.

cc: ,difficulty with speech.,hx:, this 84 y/o rhf presented with sudden onset word finding and word phonation difficulties. she had an episode of transient aphasia in 2/92 during which she had difficulty with writing, written and verbal comprehension, and exhibited numerous semantic and phonemic paraphasic errors of speech. these problems resolved within 24 hours of onset and she had no subsequent speech problems prior to this presentation. workup at that time revealed a right to left shunt on trans-thoracic echocardiogram. carotid doppler studies showed 0-15% bica stenosis and a lica aneurysm (mentioned above). brain ct was unremarkable. she was placed on asa after the 2/92 event.,in 5/92 she was involved in a motor vehicle accident and suffered a fractured left humerus and left occipital scalp laceration. hct at that time showed a small area of slightly increased attenuation at the posterior right claustrum only. this was not felt to be a contusion; nevertheless, she was placed on dilantin seizure prophylaxis. her left arm was casted and she returned home.,5 hours prior to presentation today, the patient began having difficulty finding words and putting them into speech. she was able to comprehend speech. this continued for an hour; then partially resolved for one hour; then returned; then waxed and waned. there was no reported weakness, numbness, incontinence, seizure-like activity, incoordination, ha, nausea, vomiting, or lightheadedness,meds:, asa , dph, tenormin, premarin, hctz,pmh:, 1)transient fluent aphasia 2/92 (which resolved), 2)bilateral carotid endarterectomies 1986, 3)htn, 4)distal left internal carotid artery aneurysm.,exam:, bp 168/70, pulse 82, rr 16, 35.8f,ms:a & o x 3, difficulty following commands, speech fluent, and without dysarthria. there were occasional phonemic paraphasic errors.,cn: unremarkable.,motor: 5/5 throughout except for 4+ right wrist extension and right knee flexion.,sensory: unremarkable.,coordination: mild left finger-nose-finger dysynergia and dysmetria.,gait: mildly unsteady tandem walk.,station: no romberg sign.,reflexes: slightly more brisk at the left patella than on the right. plantar responses were flexor bilaterally.,the remainder of the neurologic exam and the general physical exam were unremarkable.,labs:, cbc wnl, gen screen wnl, , pt/ptt wnl, dph 26.2mcg/ml, cxr wnl, ekg: lbbb, hct revealed a left subdural hematoma.,course:, patient was taken to surgery and the subdural hematoma was evacuated. her mental status, language skills, improved dramatically. the dph dosage was adjusted appropriately.

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

procedure: , phacoemulsification with posterior chamber intraocular lens insertion.,intraocular lens: , allergan medical optics model s140mb xxx diopter chamber lens.,phaco time:, not known.,anesthesia: , retrobulbar block with local minimal anesthesia care.,complications: ,none.,estimated blood loss:, none.,description of procedure: , while the patient was in the holding area, the operative eye was dilated with four sets of drops. the drops consisted of cyclogyl 1%, acular, and neo-synephrine 2.5 %. additionally, a peripheral iv was established by the anesthesia team. once the eye was dilated, the patient was wheeled to the operating suite.,inside the operating suite, central monitoring lines were established. through the peripheral iv, the patient received intravenous sedation consisting of propofol and once somnolent from this, retrobulbar block was administered consisting of 2 cc's of 2% xylocaine plain with 150 units of wydase. the block was administered in a retrobulbar fashion using an atkinson needle and a good block was obtained. digital pressure was applied for approximately five minutes.,the patient was then prepped and draped in the usual sterile fashion for ophthalmological surgery. a betadine prep was carried out of the face, lids, and eye. during the draping process, care was taken to isolate the lashes. a wire lid speculum was inserted to maintain patency of the lids. with benefit of the operating microscope, a diamond blade was used to place a groove temporally. a paracentesis wound was also placed temporally using the same blade. viscoelastic was then instilled into the anterior chamber through the paracentesis site and a 2.8 mm. diamond keratome was used to enter the anterior chamber through the previously placed groove. the cystotome was then inserted into the eye and circular capsulorhexis was performed without difficulty. the capsular remnant was withdrawn from the eye using long angled mcpherson forceps. balanced salt solution with a blunt cannula was then inserted into the eye and hydrodissection was performed. the lens was noted to rotate freely within the capsular bag. the phaco instrument was then inserted into the eye using the kelman tip. the lens nucleus was grooved and broken into two halves. one of the halves was in turn broken into quarters. each of the quarters was removed from the eye using the memory 2 settings and phacoemulsification. attention was then turned toward the remaining half of the nucleus and this, in turn, was removed as well, with the splitting maneuver. once the nucleus had been removed from the eye, the irrigating and aspirating tip was inserted and the cortical material was stripped out in sections. once the cortical material had been completely removed, a diamond dusted cannula was inserted into the eye and the posterior capsule was polished. viscoelastic was again instilled into the capsular bag as well as the anterior chamber. the wound was enlarged slightly using the diamond keratome. the above described intraocular lens was folded outside the eye using a mustache fold and inserted using folding forceps. once inside the eye, the lens was unfolded into the capsular bag in a single maneuver. it was noted to be centered nicely. the viscoelastic was then withdrawn from the eye using the irrigating and aspirating tip of the phaco machine.,next, miostat was instilled into the operative eye and the wound was checked for water tightness. it was found to be such. after removing the drapes and speculum, tobradex drops were instilled into the operative eye and a gauze patch and fox protective shield were placed over the eye.,the patient tolerated the procedure extremely well and was taken to the recovery area in good condition. the patient is scheduled to be seen in follow-up in the office tomorrow, but should any complications arise this evening, the patient is to contact me immediately.

subjective:, patient presents with mom and dad for her 5-year 3-month well-child check. family has not concerns stating patient has been doing well overall since last visit. taking in a well-balanced diet consisting of milk and dairy products, fruits, vegetables, proteins and grains with minimal junk food and snack food. no behavioral concerns. gets along well with peers as well as adults. is excited to start kindergarten this upcoming school year. does attend daycare. normal voiding and stooling pattern. no concerns with hearing or vision. sees the dentist regularly. growth and development: denver ii normal passing all developmental milestones per age in areas of fine motor, gross motor, personal and social interaction and speech and language development. see denver ii form in the chart.,allergies:, none.,medications: , none.,family social history:, unchanged since last checkup. lives at home with mother, father and sibling. no smoking in the home.,review of systems:, as per hpi; otherwise negative.,objective:,vital signs: weight 43 pounds. height 42-1/4 inches. temperature 97.7. blood pressure 90/64.,general: well-developed, well-nourished, cooperative, alert and interactive 5-year -3month-old white female in no acute distress.,heent: atraumatic, normocephalic. pupils equal, round and reactive. sclerae clear. red reflex present bilaterally. extraocular muscles intact. tms clear bilaterally. oropharynx: mucous membranes moist and pink. good dentition.,neck: supple, no lymphadenopathy.,chest: clear to auscultation bilaterally. no wheeze or crackles. good air exchange.,cardiovascular: regular rate and rhythm. no murmur. good pulses bilaterally.,abdomen: soft, nontender. nondistended. positive bowel sounds. no masses or organomegaly.,gu: tanner i female genitalia. femoral pulses equal bilaterally. no rash.,extremities: full range of motion. no cyanosis, clubbing or edema.,back: straight. no scoliosis.,integument: warm, dry and pink without lesions.,neurological: alert. good muscle tone and strength. cranial nerves ii-xii grossly intact. dtrs 2+/4+ bilaterally.,assessment/plan:,1. well 5-year 3-month-old white female.,2. anticipatory guidance for growth and diet development and safety issues as well as immunizations. will receive mmr, dtap and ipv today. discussed risks and benefits as well as possible side effects and symptomatic treatment. gave 5-year well-child check handout to mom. completed school pre-participation physical. copy in the chart. completed vision and hearing screening. reviewed results with family.,3. follow up in one year for next well-child check or as needed for acute care.

procedure performed: ,dddr permanent pacemaker.,indication: , tachybrady syndrome.,procedure:, after all risks, benefits, and alternatives of the procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing. the patient was taken to the cardiac catheterization suite where the right subclavian region was prepped and draped in the usual sterile fashion. 1% lidocaine solution was used to infiltrate the skin overlying the left subclavian vein. once adequate anesthesia had been obtained, a thin-walled #18-gauze argon needle was used to cannulate the left subclavian vein. a steel guidewire was inserted through the needle into the vascular lumen without resistance. the needle was then removed over the guidewire and the guidewire was secured to the field. a second #18 gauze argon needle was used to cannulate the left subclavian vein and once again a steel guidewire was inserted through the needle into the vascular lumen. likewise, the needle was removed over the guidewire and the guidewire was then secured to the field. next, a #15-knife blade was used to make a 1 to 1.5 inch linear incision over the area. a #11-knife blade was used to make a deeper incision. hemostasis was made complete. the edges of the incision were grasped and retracted. using metzenbaum scissors, dissection was carried down to the pectoralis muscle fascial plane. digital blunt dissection was used to make a pacemaker pocket large enough to accommodate the pacemaker generator. metzenbaum scissors were then used to dissect cephalad to expose the guide wires. the guidewires were then pulled through the pacemaker pocket. one guidewire was secured to the field.,a bloodless introducer sheath was then advanced over a guidewire into the vascular lumen under fluoroscopic guidance. the guidewire and dilator were then removed. next, a ventricular pacemaker lead was advanced through the sheath and into the vascular lumen and under fluoroscopic guidance guided down into the right atrium. the pacemaker lead was then placed in the appropriate position in the right ventricle. pacing and sensing thresholds were obtained. the lead was sewn at the pectoralis muscle plane using #2-0 silk suture in an interrupted stitch fashion around the ________. pacing and sensing threshold were then reconfirmed. next, a second bloodless introducer sheath was advanced over the second guidewire into the vascular lumen. the guidewire and dilator were then removed. under fluoroscopic guidance, the atrial lead was passed into the right atrium. the sheath was then turned away in standard fashion. using fluoroscopic guidance, the atrial lead was then placed in the appropriate position. pacing and sensing thresholds were obtained. the lead was sewn to the pectoralis muscle facial plane utilizing #2-0 silk suture around the ________. sensing and pacing thresholds were then reconfirmed. the leads were wiped free of blood and placed into the pacemaker generator. the pacemaker generator leads were then placed into pocket with the leads posteriorly. the deep tissues were closed utilizing #2-0 chromic suture in an interrupted stitch fashion. a #4-0 undyed vicryl was then used to close the subcutaneous tissue in a continuous subcuticular stitch. steri-strips overlaid. a sterile gauge dressing was placed over the site. the patient tolerated the procedure well and was transferred to the cardiac catheterization room in stable and satisfactory condition.,pacemaker data (generator data):,manufacturer: medtronics.,model: sigma.,model #: 1234.,serial #: 123456789.,lead information:,right atrial lead:,manufacturer: medtronics.,model #: 1234.,serial #: 123456789.,ventricular lead:,manufacturer: medtronics.,model #: 1234.,serial #: 123456789.,pacing and sensing thresholds:,right atrial bipolar lead: pulse width 0.50 milliseconds, impedance 518 ohms, p-wave sensing 2.2 millivolts, polarity is bipolar.,ventricular bipolar lead: pulse width 0.50 milliseconds, voltage 0.7 volts, current 1.5 milliamps, impedance 655 ohms, r-wave sensing 9.7 millivolts, polarity is bipolar.,parameter settings:, pacing mode dddr: mode switch is on, low rate 60, upper 120, ________ is 33.0 milliseconds.,impression:, successful implantation of dddr permanent pacemaker.,plan:,1. the patient will be monitored on telemetry for 24 hours to ensure adequate pacemaker function.,2. the patient will be placed on antibiotics for five days to avoid pacemaker infection.

preoperative diagnosis: , tonsillitis.,postoperative diagnosis: ,tonsillitis.,procedure performed: ,tonsillectomy.,anesthesia: , general endotracheal.,description of procedure: ,the patient was taken to the operating room and prepped and draped in the usual fashion. after induction of general endotracheal anesthesia, the mcivor mouth gag was placed in the oral cavity and a tongue depressor applied. two #12-french red rubber robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll on the upper lip to provide soft palate retraction. the nasopharynx was inspected with the laryngeal mirror.,attention was then directed to the right tonsil. the anterior tonsillar pillar was infiltrated with 1.5 cc of 1% xylocaine with 1:100,000 epinephrine, as was the left tonsillar pillar. the right tonsil was grasped with the tenaculum and retracted out of its fossa. the anterior tonsillar pillar was incised with the #12 knife blade. the plica semilunaris was incised with the metzenbaum scissors. using the metzenbaum scissors and the fisher knife, the tonsil was dissected free of its fossa onto an inferior pedicle around which the tonsillar snare was placed and applied. the tonsil was removed from the fossa and the fossa packed with a cherry gauze sponge as previously described. by a similar procedure, the opposite tonsillectomy was performed and the fossa was packed.,attention was re-directed to the right tonsil. the pack was removed and bleeding was controlled with the suction bovie unit. bleeding was then similarly controlled in the left tonsillar fossa and the nasopharynx after removal of the packs. the catheters were then removed. the nasal passages and oropharynx were suctioned free of debris. the procedure was terminated.,the patient tolerated the procedure well and left the operating room in good condition.

problem list:,1. refractory hypertension, much improved.,2. history of cardiac arrhythmia and history of pacemaker secondary to av block.,3. history of gi bleed in 1995.,4. history of depression.,history of present illness:, this is a return visit to the renal clinic for this patient. she is an 85-year-old woman with history as noted above. her last visit was approximately four months ago. since that time, the patient has been considerably more compliant with her antihypertensive medications and actually had a better blood pressure reading today than she had had for many visits previously. she is not reporting any untoward side effect. she is not having weakness, dizziness, lightheadedness, nausea, vomiting, constipation, diarrhea, abdominal pain, chest pain, shortness of breath or difficulty breathing. she has no orthopnea. her exercise capacity is about the same. the only problem she has is musculoskeletal and that pain in the right buttock, she thinks originating from her spine. no history of extremity pain.,current medications:,1. triamterene/hydrochlorothiazide 37.5/25 mg.,2. norvasc 10 mg daily.,3. atenolol 50 mg a day.,4. atacand 32 mg a day.,5. cardura 4 mg a day.,physical examination:,vital signs: temperature 36.2, pulse 47, respirations 16, and blood pressure 157/56. thorax: revealed lungs that are clear, pa and lateral without adventitious sounds. cardiovascular: demonstrated regular rate and rhythm. s1 and s2 without murmur. no s3. i could not hear murmur today. abdomen: above plane, but nontender. extremities: revealed no edema.,assessment:, this is a return visit for this patient who has refractory hypertension. this seems to be doing very well given her current blood pressure reading, at least much improved from what she had been previously. we had discussed with her in the past beginning to see an internist at the senior center. she apparently had an appointment scheduled and it was missed. we are going to reschedule that today given her overall state of well-being and the fact that she has no evidence of gfr that is greater than 60%.,plan: , the plan will be for her to follow up at the senior center for her routine health care, and should the need arise for further management of blood pressure, a referral back to us. in the meantime, we will discharge her from our practice. should there be confusion or difficulty getting in the senior center, we can always see her back in followup

reason for visit: ,the patient is a 38-year-old woman with pseudotumor cerebri without papilledema who comes in because of new onset of headaches. she comes to clinic by herself.,history of present illness: , dr. x has cared for her since 2002. she has a codman-hakim shunt set at 90 mmh2o. she last saw us in clinic in january 2008 and at that time we recommended that she followup with dr. y for medical management of her chronic headaches. we also recommended that the patient see a psychiatrist regarding her depression, which she stated that she would followup with that herself. today, the patient returns to clinic because of acute onset of headaches that she has had since her shunt was adjusted after an mri on 04/18/08. she states that since that time her headaches have been bad. they woke her up at night. she has not been able to sleep. she has not had a good sleep cycle since that time. she states that the pain is constant and is worse with coughing, straining, and sneezing as well as on standing up. she states that they feel a little bit better when lying down. medication shave not helped her. she has tried taking imitrex as well as motrin 800 mg twice a day, but she states it has not provided much relief. the pain is generalized, but also noted to be quite intense in the frontal region of her head. she also reports ringing in the ears and states that she just does not feel well. she reports no nausea at this time. she also states that she has been experiencing intermittent blurry vision and dimming lights as well. she tells me that she has an appointment with dr. y tomorrow. she reports no other complaints at this time.,major findings:, on examination today, this is a pleasant 38-year-old woman who comes back from the clinic waiting area without difficulty. she is well developed, well nourished, and kempt.,vital signs: blood pressure 153/86, pulse 63, and respiratory rate 16.,cranial nerves: intact for extraocular movements. facial movement, hearing, head turning, tongue, and palate movements are all intact. i did not know any papilledema on exam bilaterally.,i examined her shut site, which is clean, dry, and intact. she did have a small 3 mm to 4 mm round scab, which was noted farther down from her shunt reservoir. it looks like there is a little bit of dry blood there.,assessment:, the patient appears to have had worsening headaches since shunt adjustment back after an mri.,problems/diagnoses:,1. pseudotumor cerebri without papilledema.,2. migraine headaches.,procedures:, i programmed her shunt to 90 mmh2o.,plan:, it was noted that the patient began to have an acute onset of headache pain after her shunt adjustment approximately a week and a half ago. i had programmed her shunt back to 90 mmh2o at that time and confirmed it with an x-ray. however, the picture of the x-ray was not the most desirable picture. thus, i decided to reprogram the shunt back to 90 mmh2o today and have the patient return to sinai for a skull x-ray to confirm the setting at 90. in addition, she told me that she is scheduled to see dr. y tomorrow, so she should followup with him and also plan on contacting the wilmer eye institute to setup an appointment. she should followup with the wilmer eye institute as she is complaining of blurry vision and dimming of the lights occasionally.,total visit time was approximately 60 minutes and about 10 minutes of that time was spent in counseling the patient.

preoperative diagnoses:,1. hallux abductovalgus deformity, right foot.,2. tailor bunion deformity, right foot.,postoperative diagnoses:,1. hallux abductovalgus deformity, right foot.,2. tailor bunion deformity, right foot.,procedures performed: ,tailor bunionectomy, right foot, weil-type with screw fixation.,anesthesia: , local with mac, local consisting of 20 ml of 0.5% marcaine plain.,hemostasis:, pneumatic ankle tourniquet at 200 mmhg.,injectables:, a 10 ml of 0.5% marcaine plain and 1 ml of dexamethasone phosphate.,material: , a 2.4 x 14 mm, 2.4 x 16 mm, and 2.0 x 10 mm osteomed noncannulated screw. a 2-0 vicryl, 3-0 vicryl, 4-0 vicryl, and 5-0 nylon.,complications: , none.,specimens: , none.,estimated blood loss:, minimal.,procedure in detail: , the patient was brought to the operating room and placed on the operating table in the usual supine position. at this time, a pneumatic ankle tourniquet was placed on the patient's right ankle for the purpose of maintaining hemostasis. number of the anesthesias was obtained and then induced mild sedation and local anesthetic as described above was infiltrated about the surgical site. the right foot was then scrubbed, prepped, and draped in the usual aseptic manner. an esmarch bandage was then used to exsanguinate the patient's right foot, and the pneumatic ankle tourniquet inflated to 200 mmhg. attention was then directed to dorsal aspect of the first metatarsophalangeal joint where a linear longitudinal incision measuring approximately a 3.5 cm in length was made. the incision was carried deep utilizing both sharp and blunt dissections. all major neurovascular structures were avoided. at this time, through the original skin incision, attention was directed to the first intermetatarsal space where utilizing both sharp and blunt dissection the deep transverse intermetatarsal ligament was identified. this was then incised fully exposing the tendon and the abductor hallucis muscle. this was then resected from his osseous attachments and a small tenotomy was performed. at this time, a small lateral capsulotomy was also performed. lateral contractures were once again reevaluated and noted to be grossly reduced.,attention was then directed to the dorsal aspect of the first metatarsal phalangeal joint where linear longitudinal and periosteal and capsular incisions were made following the first metatarsal joint and following the original shape of the skin incision. the periosteal capsular layers were then reflected both medially and laterally from the head of the first metatarsal and a utilizing an oscillating bone saw, the head of the first metatarsal and medial eminence was resected and passed from the operative field. a 0.045 inch k-wire was then driven across the first metatarsal head in order to act as an access dye. the patient was then placed in the frog-leg position, and two osteotomy cuts were made, one from the access guide to the plantar proximal position and one from the access guide to the dorsal proximal position. the dorsal arm was made longer than the plantar arm to accommodate for fixation. at this time, the capital fragment was resected and shifted laterally into a more corrected position. at this time, three portions of the 0.045-inch k-wire were placed across the osteotomy site in order to access temporary forms of fixation. two of the three of these k-wires were removed in sequence and following the standard ao technique two 3.4 x 15 mm and one 2.4 x 14 mm osteomed noncannulated screws were placed across the osteotomy site. compression was noted to be excellent. all guide wires and 0.045-inch k-wires were then removed. utilizing an oscillating bone saw, the overhanging wedge of the bone on the medial side of the first metatarsal was resected and passed from the operating field. the wound was then once again flushed with copious amounts of sterile normal saline. at this time, utilizing both 2-0 and 3-0 vicryl, the periosteal and capsular layers were then reapproximated. at this time, the skin was then closed in layers utilizing 4-0 vicryl and 4-0 nylon. at this time, attention was directed to the dorsal aspect of the right fifth metatarsal where a linear longitudinal incision was made over the metatarsophalangeal joint just lateral to the extensor digitorum longus tension. incision was carried deep utilizing both sharp and blunt dissections and all major neurovascular structures were avoided.,a periosteal and capsular incision was then made on the lateral aspect of the extensor digitorum longus tendon and periosteum and capsular layers were then reflected medially and laterally from the head of the fifth metatarsal. utilizing an oscillating bone saw, the lateral eminence was resected and passed from the operative field. utilizing the sagittal saw, a weil-type osteotomy was made at the fifth metatarsal head. the head was then shifted medially into a more corrected position. a 0.045-inch k-wire was then used as a temporary fixation, and a 2.0 x 10 mm osteomed noncannulated screw was placed across the osteotomy site. this was noted to be in correct position and compression was noted to be excellent. utilizing a small bone rongeur, the overhanging wedge of the bone on the dorsal aspect of the fifth metatarsal was resected and passed from the operative field. the wound was once again flushed with copious amounts of sterile normal saline. the periosteal and capsular layers were reapproximated utilizing 3-0 vicryl, and the skin was then closed utilizing 4-0 vicryl and 4-0 nylon. at this time, 10 ml of 0.5% marcaine plain and 1 ml of dexamethasone phosphate were infiltrated about the surgical site. the right foot was then dressed with xeroform gauze, fluffs, kling, and ace wrap, all applied in mild compressive fashion. the pneumatic ankle tourniquet was then deflated and a prompt hyperemic response was noted to all digits of the right foot. the patient was then transported from the operating room to the recovery room with vital sings stable and neurovascular status grossly intact to the right foot. after a brief period of postoperative monitoring, the patient was discharged to home with proper written and verbal discharge instructions, which included to keep dressing clean, dry, and intact and to follow up with dr. a. the patient is to be nonweightbearing to the right foot. the patient was given a prescription for pain medications on nonsteroidal anti-inflammatory drugs and was educated on these. the patient tolerated the procedure and anesthesia well. dr. a was present throughout the entire case.

chief complaint: , the patient is here for followup visit and chemotherapy.,diagnoses:,1. posttransplant lymphoproliferative disorder.,2. chronic renal insufficiency.,3. squamous cell carcinoma of the skin.,4. anemia secondary to chronic renal insufficiency and chemotherapy.,5. hypertension.,history of present illness: , a 51-year-old white male diagnosed with ptld in latter half of 2007. he presented with symptoms of increasing adenopathy, abdominal pain, weight loss, and anorexia. he did not seek medical attention immediately. he was finally hospitalized by the renal transplant service and underwent a lymph node biopsy in the groin, which showed diagnosis of large cell lymphoma. he was discussed at the hematopathology conference. chemotherapy with rituximab plus cyclophosphamide, daunorubicin, vincristine, and prednisone was started. first cycle of chemotherapy was complicated by sepsis despite growth factor support. he also appeared to have become disoriented either secondary to sepsis or steroid therapy.,the patient has received 5 cycles of chemotherapy to date. he did not keep his appointment for a pet scan after 3 cycles because he was not feeling well. his therapy has been interrupted for infection related to squamous cell cancer, skin surgery as well as complaints of chest infection.,the patient is here for the sixth and final cycle of chemotherapy. he states he feels well. he denies any nausea, vomiting, cough, shortness of breath, chest pain or fatigue. he denies any tingling or numbness in his fingers. review of systems is otherwise entirely negative.,performance status on the ecog scale is 1.,physical examination:,vital signs: he is afebrile. blood pressure 161/80, pulse 65, weight 71.5 kg, which is essentially unchanged from his prior visit. there is mild pallor noted. there is no icterus, adenopathy or petechiae noted. chest: clear to auscultation. cardiovascular: s1 and s2 normal with regular rate and rhythm. systolic flow murmur is best heard in the pulmonary area. abdomen: soft and nontender with no organomegaly. renal transplant is noted in the right lower quadrant with a scar present. extremities: reveal no edema.,laboratory data: , cbc from today shows white count of 9.6 with a normal differential, anc of 7400, hemoglobin 8.9, hematocrit 26.5 with an mcv of 109, and platelet count of 220,000.,assessment and plan:,1. diffuse large b-cell lymphoma following transplantation. the patient is to receive his sixth and final cycle of chemotherapy today. pet scan has been ordered to be done within 2 weeks. he will see me back for the visit in 3 weeks with cbc, cmp, and ldh.,2. chronic renal insufficiency.,3. anemia secondary to chronic renal failure and chemotherapy. he is to continue on his regimen of growth factor support.,4. hypertension. this is elevated today because he held his meds because he is getting rituximab other than that this is well controlled. his cmp is pending from today.,5. squamous cell carcinoma of the skin. the scalp is well healed. he still has an open wound on the right posterior aspect of his trunk. this has no active drainage, but it is yet to heal. this probably will heal by secondary intention once chemotherapy is finished. prescription for prednisone as part of his chemotherapy has been given to him.

history of present illness:, the patient is a 63-year-old white male who was admitted to the hospital with chf and lymphedema. he also has a history of obesity, hypertension, sleep apnea, chronic low back pain, cataracts, and past history of ca of the lung. this consultation was made for better control of his blood sugars. on questioning, the patient says that he does not have diabetes. he says that he has never been told about diabetes except during his last admission at jefferson hospital. apparently, he was started on glipizide at that time. his blood sugars since then have been good and he says when he went back to jefferson three weeks later, he was told that he does not have a sugar problem. he is not sure. he is not following any specific diet. he says "my doctor wants me to lose 30-40 pounds in weight" and he would not mind going on a diet. he has a long history of numbness of his toes. he denies any visual problems.,past medical history: , as above that includes ca of the lung, copd, bilateral cataracts. he has had chronic back pain. there is also a history of bilateral hip surgeries, penile implant and removal, umbilical hernia repair, and back pain with two surgeries with details of which are unknown.,social history: , the patient has been a smoker since the age of 10. so, he was smoking 2-3 packs per day. since being started on chantix, he says he has cut it down to half a pack per day. he does not abuse alcohol.,medications: ,1. glipizide 5 mg p.o. daily.,2. theophylline.,3. z-pak.,4. chantix.,5. januvia 100 mg daily.,6. k-lor.,7. oxycontin.,8. flomax.,9. lasix.,10. advair.,11. avapro.,12. albuterol sulfate.,13. vitamin b tablet.,14. oxycontin and oxycodone for pain.,family history: , positive for diabetes mellitus in the maternal grandmother.,review of systems: , as above. he says he has had numbness of toes for a long time. he denies any visual problems. his legs have been swelling up from time to time for a long time. he also has history of copd and gets short of breath with minimal activity. he is also not able to walk due to his weight. he has had ulcers on his legs, which he gets discharge from. he has chronic back pain and takes oxycontin. he denies any constipation, diarrhea, abdominal pain, nausea or vomiting. there is no chest pain. he does get short of breath on walking.,physical examination:,the patient is a well-built, obese, white male in no acute distress.,vital signs: pulse rate of 89 per minute and regular. blood pressure of 113/69, temperature is 98.4 degrees fahrenheit, and respirations are 18.,heent: head is normocephalic and atraumatic. eyes, perrla. eoms intact. fundi were not examined.,neck: supple. jvp is low. trachea central. thyroid small in size. no carotid bruits.,heart: shows normal sinus rhythm with s1 and s2.,lungs: show bilateral wheezes with decreased breath sounds at the bases.,abdomen: soft and obese. no masses. bowel sounds are present.,extremities: show bilateral edema with changes of chronic venostasis. he does have some open weeping sores. pulses could not be palpated due to leg swelling.,impression/plan:,1. diabetes mellitus, type 2, new onset. at this time, the patient is on januvia as well as glipizide. his blood sugar right after eating his supper was 101. so, i am going to discontinue glipizide, continue on januvia, and add no-concentrated sweets to the diet. we will continue to follow his blood sugars closely and make adjustments as needed.,2. neuropathy, peripheral, query etiology. we will check tsh and b12 levels.,3. lymphedema.,4. recurrent cellulitis.,5. obesity, morbid.,6. tobacco abuse. he was encouraged to cut his cigarettes down to 5 cigarettes a day. he says he feels like smoking after meals. so, we will let him have it after meals first thing in the morning and last thing at night.,7. chronic venostasis.,8. lymphedema. we would check his lipid profile also.,9. hypertension.,10. backbone pain, status post back surgery.,11. status post hernia repair.,12. status post penile implant and removal.,13. umbilical hernia repair.

problems list:,1. nonischemic cardiomyopathy.,2. branch vessel coronary artery disease.,3. congestive heart failure, nyha class iii.,4. history of nonsustained ventricular tachycardia.,5. hypertension.,6. hepatitis c.,interval history: , the patient was recently hospitalized for chf exacerbation and was discharged with increased medications. however, he did not fill his prescriptions and came back with persistent shortness of breath on exertion and on rest. he has history of orthopnea and pnd. he has gained a few pounds of weight but denied to have any palpitation, presyncope, or syncope.,review of systems: , positive for right upper quadrant pain. he has occasional nausea, but no vomiting. his appetite has decreased. no joint pain, tia, seizure or syncope. other review of systems is unremarkable.,i reviewed his past medical history, past surgical history, and family history.,social history: , he has quit smoking, but unfortunately was positive for cocaine during last hospital stay in 01/08.,allergies: , he has no known drug allergies.,medications:, i reviewed his medication list in the chart. he states he is compliant, but he was not taking the revised dose of medications as per discharge orders and prescription.,physical examination:,vital signs: pulse 91 per minute and regular, blood pressure 151/102 in the right arm and 152/104 in the left arm, weight 172 pounds, which is about 6 pounds more than last visit in 11/07. heent: atraumatic and normocephalic. no pallor, icterus or cyanosis. neck: supple. jugular venous distention 5 cm above the clavicle present. no thyromegaly. lungs: clear to auscultation. no rales or rhonchi. pulse ox was 98% on room air. cvs: s1 and s2 present. s3 and s4 present. abdomen: soft and nontender. liver is palpable 5 cm below the right subcostal margin. extremities: no clubbing or cyanosis. a 1+ edema present.,assessment and plan:, the patient has hypertension, nonischemic cardiomyopathy, and branch vessel coronary artery disease. clinically, he is in nyha class iii. he has some volume overload and was not unfortunately taking lasix as prescribed. i have advised him to take lasix 40 mg p.o. b.i.d. i also increased the dose of hydralazine from 75 mg t.i.d. to 100 mg t.i.d. i advised him to continue to take toprol and lisinopril. i have also added aldactone 25 mg p.o. daily for survival advantage. i reinforced the idea of not using cocaine. he states that it was a mistake, may be somebody mixed in his drink, but he has not intentionally taken any cocaine. i encouraged him to find a primary care provider. he will come for a bmp check in one week. i asked him to check his blood pressure and weight. i discussed medication changes and gave him an updated list. i have asked him to see a gastroenterologist for hepatitis c. at this point, his medicaid is pending. he has no insurance and finds hard to find a primary care provider. i will see him in one month. he will have his fasting lipid profile, ast, and alt checked in one week.

preoperative diagnoses:,1. chronic adenotonsillitis.,2. ankyloglossia,postoperative diagnoses:,1. chronic adenotonsillitis.,2. ankyloglossia,procedure performed:,1. adenoidectomy and tonsillectomy.,2. lingual frenulectomy.,anesthesia: , general endotracheal.,findings/specimen:, tonsil and adenoid tissue.,complications: , none.,condition: ,the patient is stable and tolerated the procedure well, and sent to pacu.,history of present illness: , this is a 3-year-old child with a history of adenotonsillitis.,procedure: , the patient was prepped and draped in the usual sterile fashion. a curved hemostat was used to grasp the lingual frenulum. the stat was removed and metzenbaum scissors were used to free the lingual frenulum. cautery was used to allow hemostasis. the patient was then turned. mcivor mouth gag was inserted. tonsils and adenoids were exposed. the patient's right tonsil was first grasped with a curved hemostat. needle tip cautery was used to free the superior pole of tonsil. the tonsil was then grasped in medial superior aspect with a straight hemostat. the tonsil fascia planes were identified with bovie dissection along the plane. the tonsil was freed from anterior pillar and posterior pillar. amputation occurred along the same plane as the patient's tongue. suction cautery was then used to allow for hemostasis. the patient's adenoids were then viewed with an adenoid mirror. an adenoid curet was used to remove the patient's adenoid tissue. specimen sent. suction cautery was used to allow for hemostasis. superior pole of left tonsil was then grasped with a curved hemostat. superior pole was freed using needle tip bovie dissection. beginning with 15 desiccate, after superior pole was free, bovie was switched to 15 fulgurate, and the tonsil was stripped from anterior and posterior pillars. the tonsil was then amputated at the same plane as tongue base. hemostasis was achieved with using suction cautery. mouth gag was removed. dual position and occlusion were tested. the patient was extubated and tolerated the procedure well and sent back to pacu.

chief complaint:, right ankle sprain.,history of present illness: , this is a 56-year-old female who fell on november 26, 2007 at 11:30 a.m. while at work. she did not recall the specifics of her injury but she thinks that her right foot inverted and subsequently noticed pain in the right ankle. she describes no other injury at this time.,past medical history: , hypertension and anxiety.,past surgical history: , none.,medications: , she takes lexapro and a blood pressure pill, but does not know anything more about the names and the doses.,allergies:, no known drug allergies.,social history: , the patient lives here locally. she does not report any significant alcohol or illicit drug use. she works full time.,family history:, noncontributory.,review of systems:,pulm: no cough, no wheezing, no shortness of breath,cv: no chest pain or palpitations,gi: no abdominal pain. no nausea, vomiting, or diarrhea.,physical exam:,general appearance: no acute distress,vital signs: temperature 97.8, blood pressure 122/74, heart rate 76, respirations 24, weight 250 lbs, o2 sat 95% on r.a.,neck: supple. no lymphadenopathy. no thyromegaly.,chest: clear to auscultation bilaterally.,heart: regular rate and rhythm. no murmurs.,abdomen: non-distended, nontender, normal active bowel sounds.,extremities: no clubbing, no cyanosis, no edema.,musculoskeletal: the spine is straight and there is no significant muscle spasm or tenderness there. both knees appear to be non-traumatic with no deformity or significant tenderness. the right ankle has some swelling just below the right lateral malleolus and the dorsum of the foot is tender. there is decreased range of motion and some mild ecchymosis noted around the ankle.,diagnostic data: , x-ray of the right ankle reveals no acute fracture by my observation. radiologic interpretation is pending., ,impression:, right ankle sprain.,plan:,1. motrin 800 mg t.i.d.,2. tylenol 1 gm q.i.d. as needed.,3. walking cast is prescribed.,4. i told the patient to call back if any problems. the next morning she called back complaining of worsening pain and i called in some vicodin es 1-2 p.o. q. 8 hours p.r.n. pain #60 with no refills.

preoperative diagnosis:, rule out temporal arteritis.,postoperative diagnosis: ,rule out temporal arteritis.,procedure:, bilateral temporal artery biopsy.,anesthesia:, local anesthesia 1% xylocaine with epinephrine.,indications:, i was consulted by dr. x for this patient with bilateral temporal headaches to rule out temporal arteritis. i explained fully the procedure to the patient.,procedure: , both sides were done exactly the same way. after 1% xylocaine infiltration, a 2 to 3-cm incision was made over the temporal artery. the temporal artery was identified and was grossly normal on both sides. proximal and distal were ligated with both of 3-0 silk suture and hemoccult. the specimen of temporal artery was taken from both sides measuring at least 2 to 3 cm. they were sent as separate specimens, right and left labeled. the wound was then closed with interrupted 3-0 monocryl subcuticular sutures and dermabond. she tolerated the procedure well.

history of present illness: , the patient is a 62-year old male with a gleason score 8 adenocarcinoma of the prostate involving the left and right lobes. he has a psa of 3.1, with a prostate gland size of 41 grams. this was initially found on rectal examination with a nodule on the right side of the prostate, showing enlargement relative to the left. he has undergone evaluation with a bone scan that showed a right parietal lesion uptake and was seen by dr. xxx and ultimately underwent an open biopsy that was not malignant. prior to this, he has also had a prostascint scan that was negative for any metastatic disease. again, he is being admitted to undergo a radical prostatectomy, the risks, benefits, and alternatives of which have been discussed, including that of bleeding, and a blood transfusion.,past medical history: , coronary stenting. history of high blood pressure, as well. he has erectile dysfunction and has been treated with viagra.,medications: , lisinopril, aspirin, zocor, and prilosec.,allergies:, penicillin.,social history:, he is not a smoker. he does drink six beers a day.,review of systems: , remarkable for his high blood pressure and drug allergies, but otherwise unremarkable, except for some obstructive urinary symptoms, with an aua score of 19.,physical examination:,heent: examination unremarkable.,breasts: examination deferred.,chest: clear to auscultation.,cardiac: regular rate and rhythm.,abdomen: soft and nontender. he has no hernias.,genitourinary: there is a normal-appearing phallus, prominence of the right side of prostate.,extremities: examination unremarkable.,neurologic: examination nonfocal.,impression:,1. adenocarcinoma of the prostate.,2. erectile dysfunction.,plan: ,the patient will undergo a bilateral pelvic lymphadenectomy and radical retropubic prostatectomy. the risks, benefits, and alternatives of this have been discussed. he understands and asks that i proceed ahead. we also discussed bleeding and blood transfusions, and the risks, benefits and alternatives thereof.

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

procedure performed: , ultrasound-guided placement of multilumen central venous line, left femoral vein.,indications:, need for venous access in a patient on a ventilator and on multiple iv drugs.,consent: , consent obtained from patient's sister.,preoperative medications: , local anesthesia with 1% plain lidocaine.,procedure in detail: , the ultrasound was used to localize the left femoral vein and to confirm it's patency and course. the left inguinal area was then prepped and draped in a sterile manner. the overlying soft tissues were anesthetized with 1% plain lidocaine. under direct ultrasound visualization, the femoral vein was cannulated without difficulty, and a guidewire advanced. this was followed by a stab incision and the vein dilator in order to form a tract for the catheter itself. finally, the multilumen catheter itself was inserted over the guidewire. once the catheter was fully inserted, the guidewire was completely withdrawn. placement was confirmed by the withdrawal of dark venous blood from all ports; all ports were then flushed, the catheter sewn into place, and the dressing applied. he tolerated the procedure very well, without complications.

preoperative diagnosis: , hallux abductovalgus deformity with bunion of the left foot.,postoperative diagnosis: , hallux abductovalgus deformity with bunion of the left foot.,procedure performed: , scarf bunionectomy procedure of the first metatarsal of the left foot.,anesthesia:, iv sedation with local.,history: , this patient is a 55-year-old female who presents to abcd preoperative holding area after keeping herself n.p.o., since mid night for surgery for her painful left bunion. the patient has had increasing pain over time and is having difficulty ambulating and wearing shoes. the patient has failed to conservative treatment and desires surgical correction at this time. risks versus benefits of the procedure have been explained in detail by dr. x, and consent is available on the chart for review.,procedure in detail:, after an iv established by the department of anesthesia, the patient was given preoperatively 600 mg of clindamycin intravenously. the patient was then taken to the operating suite via cart and was placed on the operating table in a supine position and a safety strap was placed across her waist for protection. next, a pneumatic ankle tourniquet was applied over her left ankle with copious amounts of webril for the patient's protection. after adequate iv sedation was applied, the patient was given a local injection consisting of 17 cc of 4.5 cc 1% lidocaine plain, 4.5 cc of 0.5% marcaine plain, and 1.0 cc of solu-medrol mixture in the standard mayo block to the left foot. the foot was then prepped and draped in the usual sterile orthopedic fashion. the foot was then elevated, the esmarch was applied and the tourniquet was inflated to 250 mmhg. the foot was then lowered to the operating field.,a sterile stockinet was reflected and the attention was directed to the first metatarsophalangeal joint of the left foot. after sufficient anesthesia, using a #10 blade a linear incision was made approximately 5 to 6 cm in length over the first metatarsophalangeal joint dorsally, just near to the extensor hallucis longus tendon. then using a fresh #15 blade, this incision was deepened through the skin into the subcutaneous layer after all small traversing veins were ligated and cauterized with electrocautery. a neurovascular bundle was identified and reflected medially. laterally the extensor hallucis longus tendon was identified and protected with retraction as well. care was then taken to undermine the medial and lateral margins of the first metatarsophalangeal joint carefully. the first metatarsophalangeal joint capsule was then identified and using a #15 blade, a linear incision made down to the bone through the joint capsule. the periosteum was reflected and elevated off of its bone and the metatarsal head as well as the base of the proximal phalanx to a small degree. noted was a large hypertrophic bone spur on the dorsal medial aspect of the first metatarsal head as well as some small osteophytes along the medial portion of the proximal phalanx. care was then taken to reflect and dissect the periosteum off of the shaft of the first metatarsal proximally into the proximal portion of the metatarsal close to the first metatarsocuneiform joint. the bone cortex was noted to be intact and in good condition. following this, using a sagittal saw with a #138 blade, the attention was directed to the medial hypertrophic bone of the first metatarsal head. in the sagittal plane with the blade angulated from dorsolateral to proximal medial, the medial eminence of bone was resected. plantarly it was noted that the tibial sesamoid groove was intact and the sesamoid apparatus was intact as well. following this bone cut, 0.45 k-wire was inserted from medial to lateral through the medial portion of the first metatarsal head directed in the dorsal third of the metatarsal head. then using the reese osteotomy guide, the guide was directed from the distal portion of the metatarsal head proximally to the proximal portion of the first metatarsal. a second 0.45 k-wire was inserted proximally as well. following this, using the sagittal saw with the #138 blade a transverse linear osteotomy cut was made through the first metatarsal from medial to lateral. after reaching the distal as well as the proximal portions of the bone and ensuring that cortex was cut on both the medial as well as lateral side, the reese osteotomy guide was removed and the dorsal and plantar incision cuts were made. this began with the dorsal distal cut, which extended from medial to lateral with the dorsal portion of the blade angled proximally about five degrees through the dorsal third of the distal first metatarsal. following this, attention was directed proximally and an incision osteotomy cut through the bone was made, directed medially to laterally with the inferior portion of the blade angled distally to transect the cortex of the bone. following this, the distal portion of the osteotomy cut was freely movable and was able to be translocated medially. the head was then slit medially several millimeters until it was noted to be in good position and no chopping was present in the medullary canal of the bone. following this, the bone was stabilized using a 0.45 k-wire distally as well as proximally directed from dorsal to planar direction. next using the normal ao manner, the distal cortex was drilled from dorsal to plantar with a 2.0 mm drill bit and then over drilled proximally with the cortex using a 2.7 mm drill bit. the proximal cortex was then _________ and then the drill hole was measured and it was determined to be 18 mm in length from dorsal to plantar cortex. then using 2.7 mm tap, the thread holes were placed and using an 18 x 2.7 mm screw ___________ was achieved and good apposition of the bone and tightness were achieved. intramedullary sludge was noted to exit from the osteotomy cut. following this, attention was directed proximally and the 0.45 k-wire was removed and the holes were predrilled using a 2.0 mm screw then over-drilled using 2.7 mm screw and counter sucked. following this, the holes were measured, found to 20 mm in length and the drill hole was tapped using a 2.7 mm tap. following this, a 20 mm full threaded screw was inserted and tightened. good intramedullary sludge was noted and compression was achieved. attention was then directed to the distal screw where it was once again tightened and found to be in good position with good bite. following this, range of motion was performed on the first metatarsophalangeal joint and some lateral deviation of the hallux was noted. based on this, a lateral release was performed. the extensor hallucis longus tendon was identified and was transected medially and a linear incision was placed down using a #15 blade into the first interspace. the incision was then deepened with sharp and blunt dissection and using a curved hemostat, the transverse as well as the oblique fibers of the abductor hallucis tendon were identified and transected. care was taken to perform lateral release around the fibular sesamoid through these suspensory ligaments as well as the transverse metatarsal ligament and the collateral ligament. upon completion of this, the hallux was noted to be in a rectus position with good alignment. the area was then flushed and irrigated with copious amounts of sterile saline. after this, attention was directed back to the medial capsule and a medial capsulorrhaphy was performed and the capsule was closed using #3-0 vicryl suture. subcutaneous tissues were closed using #3-0 and #4-0 vicryl sutures to close in layers. the skin was then reapproximated and closed using #5-0 monocryl suture. following this, the incisions were dressed and bandaged in the normal manner using owen silk, 4x4s, kling, and kerlix as well as coban dressing. the tourniquet was then dropped with a total tourniquet time of 99 minutes at 250 mmhg. the patient followed the procedure and the anesthesia well and vascular status was intact as noted by immediate hyperemia to digits one through five of the left foot. the patient was then transferred back to the cart and escorted on the cart to the postanesthesia care unit. following this, the patient was given prescription for vicoprofen total #20 to be taken one every six hours as necessary for moderate to severe pain. the patient was also given prescription for clindamycin to be taken 300 mg four times a day. the patient was given surgical shoe and was placed in a posterior sling. the patient was given crutches and instructed to use them for ambulation. the patient was instructed to keep her foot iced and elevated and to remain nonweightbearing over the weekend. the patient will follow up with dr. x on tuesday morning at 11'o clock in his livonia office. the patient was concerned about any possible allergic reaction to medication and was placed on codeine and antibiotics due to that. the patient has dr. x's pager and will contact him over this weekend if she has any problems or complaints or return to emergency department if any difficulty should arise. x-rays were taken and the patient was discharged home upon completion of this.

preoperative diagnosis: , biliary colic and biliary dyskinesia.,postoperative diagnosis:, biliary colic and biliary dyskinesia.,procedure performed:, laparoscopic cholecystectomy.,anesthesia: , general endotracheal.,complications:, none.,disposition: ,the patient tolerated the procedure well and was transferred to recovery in stable condition.,brief history: ,this patient is a 42-year-old female who presented to dr. x's office with complaints of upper abdominal and back pain, which was sudden onset for couple of weeks. the patient is also diabetic. the patient had a workup for her gallbladder, which showed evidence of biliary dyskinesia. the patient was then scheduled for laparoscopic cholecystectomy for biliary colic and biliary dyskinesia.,intraoperative findings: , the patient's abdomen was explored. there was no evidence of any peritoneal studding or masses. the abdomen was otherwise within normal limits. the gallbladder was easily visualized. there was an intrahepatic gallbladder. there was no evidence of any inflammatory change.,procedure:, after informed written consent, the risks and benefits of the procedure were explained to the patient. the patient was brought into the operating suite.,after general endotracheal intubation, the patient was prepped and draped in normal sterile fashion. next, an infraumbilical incision was made with a #10 scalpel. the skin was elevated with towel clips and a veress needle was inserted. the abdomen was then insufflated to 15 mmhg of pressure. the veress needle was removed and a #10 blade trocar was inserted without difficulty. the laparoscope was then inserted through this #10 port and the abdomen was explored. there was no evidence of any peritoneal studding. the peritoneum was smooth. the gallbladder was intrahepatic somewhat. no evidence of any inflammatory change. there were no other abnormalities noted in the abdomen. next, attention was made to placing the epigastric #10 port, which again was placed under direct visualization without difficulty. the two #5 ports were placed, one in the midclavicular and one in the anterior axillary line again in similar fashion under direct visualization. the gallbladder was then grasped out at its fundus, elevated to patient's left shoulder. using a curved dissector, the cystic duct was identified and freed up circumferentially. next, an endoclip was used to distal and proximal to the gallbladder, endoshears were used in between to transect the cystic duct. the cystic artery was transected in similar fashion. attention was next made in removing the gallbladder from the liver bed using electrobovie cautery and spatulated tip. it was done without difficulty. the gallbladder was then grasped via the epigastric port and removed without difficulty and sent to pathology. hemostasis was maintained using electrobovie cautery. the liver bed was then copiously irrigated and aspirated. all the fluid and air was then aspirated and then all ports were removed under direct visualization. the two #10 ports were then closed in the fascia with #0 vicryl and a ur6 needle. the skin was closed with a running subcuticular #4-0 undyed vicryl. 0.25% marcaine was injected and steri-strips and sterile dressings were applied. the patient tolerated the procedure well and was transferred to recovery in stable condition.

preoperative diagnosis: , right distal both-bone forearm fracture.,postoperative diagnosis: , right distal both-bone forearm fracture.,indications:, mr. abc is a 10-year-old boy who suffered a fall resulting in a right distal both-bone forearm fracture. upon evaluation by orthopedic surgery team in the emergency department, it was determined that a closed reduction under conscious sedation and application of a splint was warranted. this was discussed with the parents who expressed verbal and written consent.,procedure:, conscious sedation was achieved via propofol via the emergency department staff. afterwards, traction with re-creation of the injury pattern was utilized to achieve reduction of the patient's fracture. this was confirmed with image intensifier. subsequently, the patient was placed into a splint. the patient was aroused from conscious sedation and at this time it was noted that he had full sensation throughout radial, median, and ulnar nerve distributions and positive extensor pollicis longus, flexor pollicis longus, dorsal and palmar interossei.,disposition: ,post-reduction x-rays revealed good alignment in the ap x-rays. the lateral x-rays also revealed adequate reduction. at this time, we will allow the patient to be discharged home and have him follow up with dr. xyz in one week.

preoperative diagnosis: , rotator cuff tear, right shoulder.,postoperative diagnosis: , superior labrum anterior and posterior lesion (peel-back), right shoulder.,procedure performed:,1. arthroscopy with arthroscopic slap lesion.,2. repair of soft tissue subacromial decompression rotator cuff repair, right shoulder.,specifications: , the entire operative procedure was done in inpatient operating suite, room #1 at abcd general hospital. this was done under a interscalene block anesthetic and subsequent general anesthetic in the modified beachchair position.,history and gross findings: ,this is a 54-year-old white female suffering an increasing right shoulder pain for a few months prior to surgical intervention. she had an injury to her right shoulder when she fell off a bike. she was diagnosed preoperatively with a rotated cuff tear.,intra-articularly besides we noted a large slap lesion, superior and posterior to the attachment of the glenoid labrum from approximately 12:30 back to 10:30. this acted as a peel-back type of mechanism and was displaced into the joint beyond the superior rim of the glenoid. this was an obvious avulsion into subchondral bone with bone exposed. the anterior aspect had degenerative changes, but did not have evidence of avulsion. the subscapular was noted to be intact. on the joint side of the supraspinatus, there was noted to be a laminated type of tearing to the rotated cuff to the anterior and mid-aspect of the supraspinatus attachment.,this was confirmed subacromially. the patient had a type-i plus acromion in outlet view and thus it was elected to not perform a subacromial decompression, but soft tissue release of the ca ligament in a releasing resection type fashion.,operative procedure: , the patient was placed supine upon the operative table after she was given interscalene and then general anesthesia by the anesthesia department. she was safely placed in a modified beachchair position. she was prepped and draped in the usual sterile manner. the portals were created from outside the ends, posterior to the scope and anteriorly for an intraoperative portal and then laterally. she had at least two other portals appropriate for both repair mechanisms described above.,attention was then turned to the slap lesion. the edges were debrided both on the bony side as well as soft tissue side. we used the anterior portal to lift up the mechanism and created a superolateral portal through the rotator cuff and into the edge of the labrum. further debridement was carried out here. a drill hole was made just on the articular surface superiorly for a knotless anchor. a pull-through suture of #2 fiber wire was utilized with the ________. this was pulled through. it was tied to the leader suture of the knotless anchor. this was pulled through and one limb of the anchor loop was grabbed and the anchor impacted with a mallet. there was excellent fixation of the superior labrum. it was noted to be solid and intact. the anchor was placed safely in the bone. there was no room for further knotless or other anchors. after probing was carried out, hard copy polaroid was obtained.,attention was then turned to the articular side for the rotator cuff. it was debrided. subchondral debridement was carried out to the tuberosity also. care was taken to go to the subchondral region but not beyond. the bone was satisfactory.,scope was then placed in the subacromial region. gross bursectomy was carried out with in the lateral portal. this was done throughout as well as in the gutters anterolaterally and posteriorly. debridement was carried out further to the rotator cuff. two types of fixation were carried out, one with a superolateral portal a drill hole was made and anchor of the _knotless suture placed after pds leader suture placed with a caspari punch. there was an excellent reduction of the tear posteriorly and then anteriorly. tendon to tendon repair was accomplished by placing a fiber wire across the tendon and tying sutured down through the anterolateral portal. this was done with a sliding stitch and then two half stitches. there was excellent reduction of the tear.,attention was then turned to the ca ligament. it was released along with periosteum and the undersurface of the anterior acromion. the ca ligament was not only released but resected. there was noted to be no evidence of significant spurring with only a mostly type-i acromion. thus, it was not elected to perform subacromial decompression for bone with soft tissue only. a pain buster catheter was placed separately. it was cut to length. an interrupted #4-0 nylon was utilized for portal closure. a 0.5% marcaine was instilled subacromially. adaptic, 4x4s, abds, and elastoplast tape placed for dressing. the patient's arm was placed in a arm sling. she was transferred to pacu in apparent satisfactory condition. expected surgical prognosis on this patient is fair.

pitocin was started quickly to allow for delivery as quickly as possible and the patient rapidly became complete, and then as she began to push, there were additional decelerations of the baby's heart rate, which were suspicions of cord around the neck. these were variable decelerations occurring late in the contraction phase. the baby was in a +2 at a 3 station in an occiput anterior position, and so a low-forceps delivery was performed with tucker forceps using gentle traction, and the baby was delivered with a single maternal pushing effort with retraction by the forceps. the baby was a little bit depressed at birth because of the cord around the neck, and the cord had to be cut before the baby was delivered because of the tension, but she responded quickly to stimulus and was given an apgar of 8 at 1 minute and 9 at 5 minutes. the female infant seemed to weigh about 7.5 pounds, but has not been officially weighed yet. cord gases were sent and the placenta was sent to pathology. the cervix, the placenta, and the rectum all seemed to be intact. the second-degree episiotomy was repaired with 2-o and 3-0 vicryl. blood loss was about 400 ml.,because of the hole in the dura, plan is to keep the patient horizontal through the day and a foley catheter is left in place. she is continuing to be attended to by the anesthesiologist who will manage the epidural catheter. the baby's father was present for the delivery, as was one of the patient's sisters. all are relieved and pleased with the good outcome.

preoperative diagnosis: , bilateral progressive conductive hearing losses with probable otosclerosis.,postoperative diagnosis: , bilateral conductive hearing losses with right stapedial fixation secondary to otosclerosis.,operation performed: , right argon laser assisted stapedectomy.,description of operation: ,the patient was brought to the operating room. endotracheal intubation carried out by dr. x. the patient's right ear was carefully prepped and then draped in the usual sterile fashion. slow infiltration of the external canal accomplished with 1% xylocaine with epinephrine. the earlobe was also infiltrated with the same solution. a limited incision was made in the earlobe harvesting a small bit of fat from the earlobe that was diced and the donor site closed with interrupted sutures of 5-0 nylon. this could later be removed in bishop. a reinspection of the ear canal was accomplished. a 65 beaver blade was used to make incision both at 12 o'clock and at 6 o'clock. jordan round knife was used to incise the tympanomeatal flap with an adequate cuff for later reapproximation. elevation was carried down to the fibrous annulus. an annulus elevator was used to complete the elevation beneath the annular ligament. the tympanic membrane and the associated flap rotated anteriorly exposing the ossicular chain. palpation of the malleus revealed good mobility of both it and incus, but no movement of the stapes was identified. palpation with a fine curved needle on the stapes itself revealed no movement. a house curette was used to takedown portions of the scutum with extreme care to avoid any inadvertent trauma to the chorda tympani. the nerve was later hydrated with a small curved needle and an additional fluid to try to avoid inadvertent desiccation of it as well. the self-retaining speculum holder was used to get secure visibility and argon laser then used to create rosette on the posterior cruse. the stapes superstructure anteriorly was mobilized with a right angle hook at the incostapedial joint and the superstructure could then be downfractured. the fenestration created in the footplate was nearly perfect for placement of the piston and therefore additional laser vaporization was not required in this particular situation. a small bit of additional footplate was removed with a right angle hook to accommodate the 0.6 mm piston. the measuring device was used and a 4.25 mm slim shaft wire teflon piston chosen. it was placed in the middle ear atraumatically with a small alligator forceps and was directed towards the fenestration in the footplate. the hook was placed over the incus and measurement appeared to be appropriate. a downbiting crimper was then used to complete the attachment of the prosthesis to the incus. prosthesis is once again checked for location and centering and appeared to be in ideal position. small pledgets of fat were placed around the perimeter of the piston in an attempt to avoid any postoperative drainage of perilymph. a small pledget of fat was also placed on the top of the incudo-prosthesis junction. the mobility appeared excellent. the flap was placed back in its normal anatomic position. the external canal packed with small pledgets of gelfoam and antibiotic ointment. she was then awakened and taken to the recovery room in a stable condition with discharge anticipated later this day to bishop. sutures will be out in a week and a recheck in reno in four to five weeks from now.

history of present illness:, the patient is a 71-year-old caucasian female with a history of diabetes, osteoarthritis, atrial fibrillation, hypertension, asthma, obstructive sleep apnea on cpap, diabetic foot ulcer, anemia and left lower extremity cellulitis. she was brought in by the ems service to erlanger emergency department with pulseless electrical activity. her husband states that he was at home with his wife, when she presented to him complaining of fever and chills. she became acutely unresponsive. she was noted to have worsening of her breathing. she took several of her mdis and then was placed on her cpap. he went to notify ems and when he returned, she was found to not be breathing. he stated that she was noted to have no breathing in excess of 10 minutes. he states that the ems system arrived at the home and she was found not breathing. the patient was intubated at the scene and upon arrival to erlanger medical center, she was found to have pupils fixed and dilated. she was seen by me in the emergency department and was on neo-synephrine, dopamine with a blood pressure of 97/22 with a rapid heart rate and again, in an unresponsive state.,review of systems:, review of systems was not obtainable.,past medical history:, diabetes, osteoarthritis, hypertension, asthma, atrial fibrillation, diabetic foot ulcer and anemia.,past surgical history:, noncontributory to above.,family history:, mother with history of coronary artery disease.,social history:, the patient is married. she uses no ethanol, no tobacco and no illicits. she has a very support family unit.,medications:, augmentin; detrol la; lisinopril.,immunizations:, immunizations were up to date for influenza, negative for pneumovax.,allergies:, penicillin.,laboratory at presentation:, white blood cell count 11, hemoglobin 10.5, hematocrit 32.2, platelets 175,000. sodium 148, potassium 5.2, bun 30, creatinine 2.2 and glucose 216. pt was 22.4.,radiologic data:, chest x-ray revealed a diffuse pulmonary edema.,physical examination:,vital signs: blood pressure 97/52, pulse of 79, respirations 16, o2 sat 100%.,heent: the patient's pupils were again, fixed and dilated and intubated on the monitor.,chest: poor air movement bilateral with bilateral rales.,cardiovascular: regular rate and rhythm.,abdomen: the abdomen was obese, nondistended and nontender.,extremities: left diabetic foot had oozing pus drainage from the foot.,gu: foley catheter was in place.,impression and plan:,1. acute cardiac arrest with pulseless electrical activity with hypotensive shock and respiratory failure: will continue ventilator support. will rule out pulmonary embolus, rule out myocardial infarction. continue pressors. the patient is currently on dopamine, neo-synephrine and levophed.,2. acute respiratory distress syndrome: will continue ventilatory support.,3. questionable sepsis: will obtain blood cultures, intravenous vancomycin and rocephin given.,4. hypotensive shock: will continue pressors. will check random cortisol. hydrocortisone was added.,further inpatient management for this patient will be provided by dr. r. the patient's status was discussed with her daughter and her husband. the husband states that his wife has been very ill in the past with multiple admissions, but he had never seen her as severely ill as with this event. he states that she completely was not breathing at all and he is aware of the severity of her illness and the gravity of her current prognosis. will obtain the assistance with cardiology with this admission and will continue pressors and supportive therapy. the family will make an assessment and final decision concerning her long-term management after a 24 hour period.

identifying data: , this is a 26-year-old caucasian male of unknown employment, who has been living with his father.,chief complaint and/or reaction to hospitalization: , the patient is unresponsive.,history of present illness: , the patient was found by outpatient case manager to be unresponsive and incontinent of urine and feces at his father's home. it is unknown how long the patient has been decompensated after a stay at hospital.,past psychiatric history: , inpatient ita stay at hospital one year ago, outpatient at valley cities, but currently not engaged in treatment.,medical history: , due to the patient being unresponsive and very little information available in the chart, the only medical history that we can identify is to observe that the patient is quite thin for height. he is likely dehydrated, as it appears that he has not had food or fluids for quite some time.,current medications:, prior to admission, we do not have that information. he has been started on ativan 2 mg p.o. or im if he refuses the p.o. and this would be t.i.d. to treat the catatonia.,social and developmental history: ,the patient has been living in his father's home and this is all the information that we have available from the chart.,substance and alcohol history: ,it is unknown with the exception of nicotine use.,legal history: , unknown.,genetic psychiatric history: , unknown.,mental status exam:,attitude: the patient is unresponsive.,appearance: he is lying in bed in the fetal position with a blanket over his head.,psychomotor: catatonic.,eps/td: unable to assess though his limbs are quite contracted.,affect: unresponsive.,mood: unresponsive.,speech: unresponsive.,thought process and thought content: unresponsive.,psychosis: unable to elicit information to make this assessment.,suicidal/homicidal: also unable to elicit this information.,cognitive assessment: unable to elicit.,judgment and insight: unable to elicit.,assets: the patient is young.,limitations: severe decompensation.,formulation: ,this is a 26-year-old caucasian male with a diagnosis of psychosis, nos, admitted with catatonia.,diagnoses:,axis i: psychosis, nos.,axis ii: deferred.,axis iii: dehydration.,axis iv: severe.,axis v: 10.,estimated length of stay: , 10 to 14 days.,recommendations and plan:,1. stabilize medically from the dehydration per internal medicine.,2. medications, milieu therapy to assist with re-compensation.

right:,1. mild heterogeneous plaque seen in common carotid artery.,2. moderate heterogeneous plaque seen in the bulb and internal carotid artery.,3. severe heterogeneous plaque seen in external carotid artery with degree of stenosis around 70%. ,4. peak systolic velocity is normal in common carotid, bulb, and internal carotid artery.,5. peak systolic velocity is 280 cm/sec in external carotid artery with moderate spectral broadening.,left: , ,1. mild heterogeneous plaque seen in common carotid artery and external carotid artery.,2. moderate heterogeneous plaque seen in the bulb and internal carotid artery with degree of stenosis less than 50%.,3. peak systolic velocity is normal in common carotid artery and in the bulb.,4. peak systolic velocity is 128 cm/sec in internal carotid artery and 156 cm/sec in external carotid artery.,vertebrals:, antegrade flow seen bilaterally.

cc:, transient visual field loss.,hx: ,this 58 y/o rhf had a 2 yr h/o increasing gait difficulty which she attributed to generalized weakness and occasional visual obscurations. she was evaluated by a local physician several days prior to this presentation (1/7/91), for clumsiness of her right hand and falling. hct and mri brain revealed bilateral posterior clinoid masses.,meds:, colace, quinidine, synthroid, lasix, lanoxin, kcl, elavil, tenormin.,pmh: ,1) obesity. 2) vbg, 1990. 3) a-fib. 4) htn. 5) hypothyroidism. 6) hypercholesterolemia. 7) briquet's syndrome: h/o of hysterical paralysis. 8) cll, dx 1989; in 1992 presented with left neck lymphadenopathy and received 5 cycles of chlorambucil/prednisone chemotherapy; 10/95 parotid gland biopsy was consistent with cll and she received 5 more cycles of chlorambucil/prednisone; 1/10/96, she received 3000cgy to right parotid mass. 9) snhl,fhx:, father died, mi age 61.,shx:, denied tobacco/etoh/illicit drug use.,exam:, vitals were unremarkable.,the neurologic exam was unremarkable except for obesity and mild decreased pp about the right upper and lower face, diffusely about the left upper and lower face, per neurosurgery notes. the neuro-ophthalmologic exam was unremarkable, per neuro-ophthalmology.,course:, she underwent cerebral angiography on 1/8/91. this revealed a 15x17x20mm lica paraclinoid/ophthalmic artery aneurysm and a 5x7mm rica paraclinoid/ophthalmic artery aneurysm. on 1/16/91 she underwent a left frontotemporal craniotomy and exploration of the left aneurysm. the aneurysm neck went into the cavernous sinus and was unclippable so it was wrapped. she has complained of headaches since.

preoperative diagnosis: , left patellar chondromalacia.,postoperative diagnosis:, left patellar chondromalacia with tight lateral structures.,procedure:, left knee arthroscopy with lateral capsular release.,anesthesia: , surgery performed under general anesthesia.,tourniquet time: ,47 minutes.,medication: ,the patient received 0.5% marcaine local anesthetic 32 ml.,complications: , no intraoperative complications.,drains and specimens: , none.,history and physical: ,the patient is a 14-year-old girl who started having left knee pain in the fall of 2007. she was not seen in orthopedic clinic until november 2007. the patient had an outside mri performed that demonstrated left patellar chondromalacia only. the patient was referred to physical therapy for patellar tracking exercises. she was also given a brace. the patient reported increasing pain with physical therapy and mother strongly desired other treatment. it was explained to the mother in detail that this is a difficult problem to treat although majority of the patients get better with physical therapy. her failure with nonoperative treatment is below the standard 6-month trial; however, given her symptoms and severe pain, lateral capsular release was offered. risk and benefits of surgery were discussed. risks of surgery including risk of anesthesia, infection, bleeding, changes in sensation and motion extremity, failure of procedure to relieve pain, need for postoperative rehab, and significant postoperative swelling. all questions were answered, and mother and daughter agreed to the above plans.,procedure note: , the patient was taken to the operating room and placed on the operating table. general anesthesia was then administered. the patient received ancef preoperatively. a nonsterile tourniquet was placed on the upper aspect of left thigh. the extremity was then prepped and draped in the standard surgical fashion. a medial suprapatellar portal was marked on the skin as well as anteromedial and anterolateral joint line. the extremity was wrapped in esmarch prior to inflation of tourniquet to 250 mmhg. esmarch was then removed. incisions were then made. camera was initially inserted into the lateral joint line. visualization of patellofemoral joint revealed type 2 chondromalacia with slight lateral subluxation. the patient did have congruent articulation about 30 degrees of knee flexion. visualization of the medial joint line revealed no loose bodies. there was a small plica. visualization of the medial joint line revealed no significant chondromalacia. menisci was probed and tested with no signs of tears and instability. acl was noted to be intact. the intercondylar notch and lateral joint line also revealed no significant chondromalacia or meniscal pathology. lateral gutter also demonstrated no loose bodies or plica. the camera was then removed and inserted into the anteromedial portal using two 18-gauge needles. the extent of lateral capsular release was marked using a monopolar coblator, lateral capsular release was performed. the patient had significant improvement in anteromedial translation from 25% to 50%. at the end of the case, all instruments were removed. the knee was injected with 32 ml of 0.5% marcaine with additional epinephrine. please note, the patient received 30 ml of 1:500,000 dilution epinephrine at the beginning of the case. the portals were then closed using 4-0 monocryl. the wound was clean and dry, and dressed with steri-strips, xeroform, and 4 x 4s. the kneecap was translated medially under pressure and a bias placed. the tourniquet was released at 47 minutes. the patient was then placed in the knee immobilizer. the patient tolerated the procedure well and was subsequently extubated and taken to the recovery in stable condition.,postoperative plan: , the patient will weightbear as tolerated in the knee immobilizer. she will start physical therapy within 1 to 2 weeks to work on patella mobilization as well as reconditioning and strengthening. intraoperative findings were relayed to the mother. all questions were answered.

reason for consultation: , this 92-year-old female states that last night she had a transient episode of slurred speech and numbness of her left cheek for a few hours. however, the chart indicates that she had recurrent tias x3 yesterday, each lasting about 5 minutes with facial drooping and some mental confusion. she had also complained of blurred vision for several days. she was brought to the emergency room last night, where she was noted to have a left carotid bruit and was felt to have recurrent tias.,current medications: , the patient is on lanoxin, amoxicillin, hydergine, cardizem, lasix, micro-k and a salt-free diet. ,social history: , she does not smoke or drink alcohol.,findings: ,admission ct scan of the head showed a densely calcified mass lesion of the sphenoid bone, probably representing the benign osteochondroma seen on previous studies. cbc was normal, aside from a hemoglobin of 11.2. ecg showed atrial fibrillation. bun was 22, creatinine normal, cpk normal, glucose normal, electrolytes normal.,physical examination: , on examination, the patient is noted to be alert and fully oriented. she has some impairment of recent memory. she is not dysphasic, or apraxic. speech is normal and clear. the head is noted to be normocephalic. neck is supple. carotid pulses are full bilaterally, with left carotid bruit. neurologic exam shows cranial nerve function ii through xii to be intact, save for some slight flattening of the left nasolabial fold. motor examination shows no drift of the outstretched arms. there is no tremor or past-pointing. finger-to-nose and heel-to-shin performed well bilaterally. motor showed intact neuromuscular tone, strength, and coordination in all limbs. reflexes 1+ and symmetrical, with bilateral plantar flexion, absent jaw jerk, no snout. sensory exam is intact to pinprick touch, vibration, position, temperature, and graphesthesia.,impression: , neurological examination is normal, aside from mild impairment of recent memory, slight flattening of the left nasolabial fold, and left carotid bruit. she also has atrial fibrillation, apparently chronic. in view of her age and the fact that she is in chronic atrial fibrillation, i would suspect that she most likely has had an embolic phenomenon as the cause of her tias.,recommendations:, i would recommend conservative management with antiplatelet agents unless a near occlusion of the carotid arteries is demonstrated, in which case you might consider it best to do an angiography and consider endarterectomy. in view of her age, i would be reluctant to recommend coumadin anticoagulation. i will be happy to follow the patient with you.

procedure: , colonoscopy.,preoperative diagnoses:, the patient is a 56-year-old female. she was referred for a screening colonoscopy. the patient has bowel movements every other day. there is no blood in the stool, no abdominal pain. she has hypertension, dyslipidemia, and gastroesophageal reflux disease. she has had cesarean section twice in the past. physical examination is unremarkable. there is no family history of colon cancer.,postoperative diagnosis: , diverticulosis.,procedure in detail: , procedure and possible complications were explained to the patient. ample opportunity was provided to her to ask questions. informed consent was obtained. she was placed in left lateral position. inspection of perianal area was normal. digital exam of the rectum was normal.,video olympus colonoscope was introduced into the rectum. the sigmoid colon is very tortuous. the instrument was advanced to the cecum after placing the patient in a supine position. the patient was well prepared and a good examination was possible. the cecum was identified by the ileocecal valve and the appendiceal orifice. images were taken. the instrument was then gradually withdrawn while examining the colon again in a circumferential manner. few diverticula were encountered in the sigmoid and descending colon. retroflex view of the rectum was unremarkable. no polyps or malignancy was identified.,after obtaining images, the air was suctioned. instrument was withdrawn from the patient. the patient tolerated the procedure well. there were no complications.,summary of findings: ,colonoscopy was performed to cecum and demonstrates the following:,1. mild-to-moderate diverticulosis.,2. ,recommendation:,1. the patient was provided information on diverticulosis including dietary advice.,2. she was advised repeat colonoscopy after 10 years.

operation performed: , cervical epidural steroid injection c7-t1.,anesthesia:, local and versed 2 mg iv.,complications: ,none.,description of procedure: ,the patient was placed in the seated position with the neck flexed the forehead was placed on a cervical rest. the head and cervical spine were restrained. the patient was monitored with a blood pressure cuff, ekg and pulse oximetry. the skin was prepped and draped in sterile classical fashion. excess cleansing solution was removed from the skin. local anesthesia was injected at c7-t1. an 18-gauge tuohy needle was then placed in the epidural space with loss of resistance technique and a saline-filled syringe utilizing a midline intralaminar approach.,once the epidural space was identified, a negative aspiration for heme or csf was done. this was followed by the injection of 6 cc of saline mixed with methyl prednisolone acetate 120 mg in aliquots of 2 cc. negative aspirations were done prior to each injection. the needle was cleared with saline prior to its withdrawal. the patient tolerated the procedure well without any apparent difficulties or complications.

preoperative diagnosis: , herniated nucleus pulposus, l5-s1 on the left with severe weakness and intractable pain.,postoperative diagnosis:, herniated nucleus pulposus, l5-s1 on the left with severe weakness and intractable pain.,procedure performed:,1. injection for myelogram.,2. microscopic-assisted lumbar laminectomy with discectomy at l5-s1 on the left on 08/28/03.,blood loss: , approximately 25 cc.,anesthesia: , general.,position:, prone on the jackson table.,intraoperative findings:, extruded nucleus pulposus at the level of l5-s1.,history: , this is a 34-year-old male with history of back pain with radiation into the left leg in the s1 nerve root distribution. the patient was lifting at work on 08/27/03 and felt immediate sharp pain from his back down to the left lower extremity. he denied any previous history of back pain or back surgeries. because of his intractable pain as well as severe weakness in the s1 nerve root distribution, the patient was aware of all risks as well as possible complications of this type of surgery and he has agreed to pursue on. after an informed consent was obtained, all risks as well as complications were discussed with the patient. ,procedure detail: ,he was wheeled back to operating room #5 at abcd general hospital on 08/28/03. after a general anesthetic was administered, a foley catheter was inserted.,the patient was then turned prone on the jackson table. all of his bony prominences were well-padded. at this time, a myelogram was then performed. after the lumbar spine was prepped, a #20 gauge needle was then used to perform a myelogram. the needle was localized to the level of l3-l4 region. once inserted into the thecal sac, we immediately got cerebrospinal fluid through the spinal needle. at this time, approximately 10 cc of conray injected into the thecal sac. the patient was then placed in the reversed trendelenburg position in order to assist with distal migration of the contrast. the myelogram did reveal that there was some space occupying lesion, most likely disc at the level of l5-s1 on the left. there was a lack of space filling defect on the left evident on both the ap and the lateral projections using c-arm fluoroscopy. at this point, the patient was then fully prepped and draped in the usual sterile fashion for this procedure for a microdiscectomy. a long spinal needle was then inserted into region of surgery on the right. the surgery was going to be on the left. once the spinal needle was inserted, a localizing fluoroscopy was then used to assure appropriate location and this did confirm that we were at the l5-s1 nerve root region. at this time, an approximately 2 cm skin incision was made over the lumbar region, dissected down to the deep lumbar fascia. at this time, a weitlaner was inserted. bovie cautery was used to obtain hemostasis. we further continued through the deep lumbar fascia and dissected off the short lumbar muscles off of the spinous process and the lamina. a cobb elevator was then used to elevate subperiosteally off of all the inserting short lumbar muscles off of the spinous process as well as the lamina on the left-hand side. at this time, a taylor retractor was then inserted and held there for retraction. suction as well as bovie cautery was used to obtain hemostasis. at this time, a small kerrison rongeur was used to make a small lumbar laminotomy to expose our window for the nerve root decompression. once the laminotomy was performed, a small _______ curette was used to elevate the ligamentum flavum off of the thecal sac as well as the adjoining nerve roots. once the ligamentum flavum was removed, we immediately identified a piece of disc material floating around outside of the disc space over the s1 nerve root, which was compressive. we removed the extruded disc with further freeing up of the s1 nerve root. a nerve root retractor was then placed. identification of disc space was then performed. a #15 blade was then inserted and small a key hole into the disc space was then performed with a #15 blade. a small pituitary was then inserted within the disc space and more disc material was freed and removed. the part of the annulus fibrosis were also removed in addition to the loose intranuclear pieces of disc. once this was performed, we removed the retraction off the nerve root and the nerve root appeared to be free with pulsatile visualization of the vasculature indicating that the nerve root was essentially free.,at this time, copious irrigation was used to irrigate the wound. we then performed another look to see if any loose pieces of disc were extruding from the disc space and only small pieces were evident and they were then removed with the pituitary rongeur. at this time, a small piece of gelfoam was then used to cover the exposed nerve root. we did not have any dural leaks during this case. #1-0 vicryl was then used to approximate the deep lumbar fascia, #2-0 vicryl was used to approximate the superficial lumbar fascia, and #4-0 running vicryl for the subcutaneous skin. sterile dressings were then applied. the patient was then carefully slipped over into the supine position, extubated and transferred to recovery in stable condition. at this time, we are still waiting to assess the patient postoperatively to assure no neurological sequela postsurgically are found and also to assess his pain level.

reason for visit: , the patient is an 84-year-old man who returns for revaluation of possible idiopathic normal pressure hydrocephalus. he is accompanied by his wife and daughter.,history of present illness:, i first saw him nearly a year ago on december 20, 2007. at that time, he had had a traumatic deterioration over the course of approximately eight months. this included severe cognitive impairment, gait impairment, and incontinence. he had actually been evaluated at hospital with csf drainage via a temporary spinal catheter, but there was no response that was noted. when i saw him, there were findings consistent with cervical stenosis and i ordered an mri scan of the cervical spine. i subsequently referred him to dr. x, who performed a cervical laminectomy and instrumented fusion on july 16, 2008. according to his notes this went well.,according to the family, there has not been any improvement.,with regard to the gait and balance, they actually think that he is worse now than he was a year ago. he is virtually unable to walk at all. he needs both a walker and support from an assistant to be able to stand or walk. therefore, he is always in the wheelchair.,he is completely incontinent. he never indicates his need to the go to the bathroom. on the other hand when asked, he will indicate that he needs to go. he wears a depends undergarment all the time.,he has no headaches.,his thinking and memory are worse. for the most part, he is apathetic. he does not talk very much. he lives in a skilled nursing facility in the alzheimer's section. he does have some daytime activities. he takes a nap once a day. he does not read very much. on the other hand, he did recently exercise the right to vote in the presidential election. he needs full assistance at the nursing home.,medications:, from the list by the nursing home are aricept 10 mg in the evening, carbidopa/levodopa 25/100 mg three times a day, citalopram (celexa) 40 mg daily, colace 100 mg twice a day, finasteride (proscar) 5 mg once a day, flomax (tamsulosin) 0.4 mg once a day, multivitamin with iron once a day, omeprazole (prilosec) 20 mg once a day, senna 8.6 mg twice a day, tylenol 650 mg as needed, and promethazine 25 mg as needed.,physical exam: , on examination today, this is a pleasant 81-year-old man who is brought back from the clinic waiting area in a wheelchair. he is well developed, well nourished, and kempt.,vital signs: temperature 96.7, pulse 62, respirations 16, and blood pressure 123/71.,head: the head is normocephalic and atraumatic.,mental status: assessed for orientation, recent and remote memory, attention span, concentration, language, and fund of knowledge. the mini-mental state exam score was 14/30. he was not at all oriented. he did know we were at sinai hospital on the second floor. he could spell 'world' forward, but was mute when asked to spell backwards. he was mute when asked to recall 3/3 objects for delayed recall. he could not copy a diagram of intersecting pentagons. for comparison, the mini-mental state exam score last december was 20/30 when attention was tested by having him spell 'world' backwards and 28/30 when tested with serial 7 subtractions. additionally, there are times when he stutters or stammers. i do not see any paraphasic errors. there is some evidence of ideomotor apraxia. he is also stimulus bound. there is a tendency to mimic.,cranial nerve exam: there is no upgaze that i can elicit today. the horizontal gaze and down gaze are intact. this is a change from a year ago. the muscles of facial expiration are intact as are hearing, head turning, cough, tongue, and palate movement.,motor exam: normal bulk and strength. the tone is characterized by paratonia. there is no atrophy, fasciculations, drift, or tremor.,sensory exam: intact to light touch.,cerebellar exam: intact for finger-to-nose testing that he can perform only by mimicking, but not by following verbal commands.,gait: severely impaired. when in the wheelchair, he leans to one side. he cannot getup on his own. he needs assistance. once up, he can bear weight, but cannot maintain his balance. this would amount to a tinetti score of zero.,review of x-rays: , i personally reviewed the ct scan of the brain from november 1, 2008 and compared it to the mri scan from a year ago. the ventricles appear larger to me now in comparison to a year ago. the frontal horn span is now 6 cm, whereas previously it was about 5.5 cm. the 3rd ventricular span is about 15 mm. there is no obvious atrophy, although there may be some subtle bilateral perisylvian atrophy. the scan from a year ago showed that there was a patent sylvian aqueduct.,assessment:, the patient has had worsening of his gait, his dementia, and his incontinence. the new finding for me today is the limited upgaze. this would be consistent either with progressive supranuclear palsy, which was one of the differential diagnoses a year ago, or it could be consistent with progressive enlargement of the ventricles.,problems/diagnoses:,1. question of idiopathic normal pressure hydrocephalus (331.5).,2. possible supranuclear palsy.,3. severe gait impairment.,4. urinary urgency and incontinence.,5. dementia.,plan: , i had a long talk with him and his family. even though he has already had a trial of csf drainage via spinal catheter at hospital over a year ago, i offered this test to them again. i do so on the basis that there is further enlargement of the ventricles on the scan. his family and i discussed the facts that it is not likely to be only hydrocephalus. instead we are trying to answer the question of whether hydrocephalus is contributing sufficiently to his symptoms that progressing with shunt surgery would make a difference. i have advised them to think it over for a day and contact my office to see whether they would wish to proceed. i gave them a printed prescription of the protocol including its rationale, risks, benefits, and alternatives. i specifically mentioned the 3% chance of infection, which mean a 97% chance of no infection.

postoperative diagnosis: , type 4 thoracoabdominal aneurysm.,operation/procedure: , a 26-mm dacron graft replacement of type 4 thoracoabdominal aneurysm from t10 to the bifurcation of the aorta, re-implanting the celiac, superior mesenteric artery and right renal as an island and the left renal as a 8-mm interposition dacron graft, utilizing left heart bypass and cerebrospinal fluid drainage.,description of procedure in detail: , patient was brought to the operating room and put in supine position, and general endotracheal anesthesia was induced through a double-lumen endotracheal tube. patient was placed in the thoracoabdominal position with the left chest up and the hips back to a 30-degree angle. the left groin, abdominal and chest were prepped and draped in a sterile fashion. a thoracoabdominal incision was made. the 8th interspace was entered. the costal margin was divided. the retroperitoneal space was entered and bluntly dissected free to the psoas, bringing all the peritoneal contents to the midline, exposing the aorta. the inferior pulmonary ligament was then taken down so the aorta could be dissected free at the t10 level just above the diaphragm. it was dissected free circumferentially. the aortic bifurcation was dissected free, dissecting free both iliac arteries. the left inferior pulmonary vein was then dissected free, and a pursestring of 4-0 prolene was placed on this. the patient was heparinized. through a stab wound in the center of this, a right-angle venous cannula was then placed at the left atrium and secured to a rumel tourniquet. this was hooked to a venous inflow of left heart bypass machine. a pursestring of 4-0 prolene was placed on the aneurysm and through a stab wound in the center of this, an arterial cannula was placed and hooked to outflow. bypass was instituted. the aneurysm was cross clamped just above t10 and also, cross clamped just below the diaphragm. the area was divided at this point. a 26-mm graft was then sutured in place with running 3-0 prolene suture. the graft was brought into the diaphragm. clamps were then placed on the iliacs, and the pump was shut off. the aorta was opened longitudinally, going posterior between the left and right renal arteries, and it was completely transected at its bifurcation. the sma, celiac and right renal artery were then dissected free as a complete island, and the left renal was dissected free as a complete carrell patch. the island was laid in the graft for the visceral liner, and it was sutured in place with running 4-0 prolene suture with pledgetted 4-0 prolene sutures around the circumference. the clamp was then moved below the visceral vessels, and the clamp on the chest was removed, re-establishing flow to the visceral vessels. the graft was cut to fit the bifurcation and sutured in place with running 3-0 prolene suture. all clamps were removed, and flow was re-established. an 8-mm graft was sutured end-to-end to the carrell patch and to the left renal. a partial-occlusion clamp was placed. an area of graft was removed. the end of the graft was cut to fit this and sutured in place with running prolene suture. the partial-occlusion clamp was removed. protamine was given. good hemostasis was noted. the arterial cannula, of course, had been removed when that part of the aneurysm was removed. the venous cannula was removed and oversewn with a 4-0 prolene suture. good hemostasis was noted. a 36 french posterior and a 32 french anterior chest tube were placed. the ribs were closed with figure-of-eight #2 vicryl. the fascial layer was closed with running #1 prolene, subcu with running 2-0 dexon and the skin with running 4-0 dexon subcuticular stitch. patient tolerated the procedure well.

multisystem exam,constitutional: ,the vital signs showed that the patient was afebrile; blood pressure and heart rate were within normal limits. the patient appeared alert.,eyes: ,the conjunctiva was clear. the pupil was equal and reactive. there was no ptosis. the irides appeared normal.,ears, nose and throat: ,the ears and the nose appeared normal in appearance. hearing was grossly intact. the oropharynx showed that the mucosa was moist. there was no lesion that i could see in the palate, tongue. tonsil or posterior pharynx.,neck: ,the neck was supple. the thyroid gland was not enlarged by palpation.,respiratory: ,the patient's respiratory effort was normal. auscultation of the lung showed it to be clear with good air movement.,cardiovascular: ,auscultation of the heart revealed s1 and s2 with regular rate with no murmur noted. the extremities showed no edema.,gastrointestinal: , the abdomen was soft, nontender with no rebound, no guarding, no enlarged liver or spleen. bowel sounds were present.,gu: , the scrotal elements were normal. the testes were without discrete mass. the penis showed no lesion, no discharge.,lymphatic: ,there was no appreciated node that i could feel in the groin or neck area.,musculoskeletal: ,the head and neck by inspection showed no obvious deformity. again, the extremities showed no obvious deformity. range of motion appeared to be normal for the upper and lower extremities.,skin: , inspection of the skin and subcutaneous tissues appeared to be normal. the skin was pink, warm and dry to touch.,neurologic: ,deep tendon reflexes were symmetrical at the patellar area. sensation was grossly intact by touch.,psychiatric: , the patient was oriented to time, place and person. the patient's judgment and insight appeared to be normal.

diagnoses:,1. cervical dystonia.,2. post cervical laminectomy pain syndrome.,ms. xyz states that the pain has now shifted to the left side. she has noticed a marked improvement on the right side, which was subject to a botulinum toxin injection about two weeks ago. she did not have any side effects on the botox injection and she feels that her activities of daily living are increased, but she is still on the oxycodone and methadone. the patient's husband confirms the fact that she is doing a lot better, that she is more active, but there are still issues yet regarding anxiety, depression, and frustration regarding the pain in her neck.,physical examination:, the patient is appropriate. she is well dressed and oriented x3. she still smells of some cigarette smoke. examination of the neck shows excellent reduction in muscle spasm on the right paraspinals, trapezius and splenius capitis muscles. there are no trigger points felt and her range of motion of the neck is still somewhat guarded, but much improved. on the left side, however, there is significant muscle spasm with tight bands involving the multifidus muscle with trigger point activity and a lot of tenderness and guarding. this extends down into the trapezius muscle, but the splenius capitis seems to be not involved.,treatment plan:, after a long discussion with the patient and the husband, we have decided to go ahead and do botulinum toxin injection into the left multifidus/trapezius muscles. a total of 400 units of botox is anticipated. the procedure is being scheduled. the patient's medications are refilled. she will continue to see dr. berry and continue her therapy with mary hotchkinson in victoria.

identifying data:, the patient is a 45-year-old white male. he is unemployed, presumably on disability and lives with his partner.,chief complaint: , "i'm in jail because i was wrongly arrested." the patient is admitted on a 72-hour involuntary treatment act for grave disability.,history of present illness: , the patient has minimal insight into the circumstances that resulted in this admission. he reports being diagnosed with aids and schizophrenia for some time, but states he believes that he has maintained his stable baseline for many months of treatment for either condition. prior to admission, the patient was brought to emergency room after he attempted to shoplift from a local department store, during which he apparently slapped his partner. the patient was disorganized with police and emergency room staff, and he was ultimately detained on a 72-hour involuntary treatment act for grave disability.,on the interview, the patient is still disorganized and confused. he believes that he has been arrested and is in jail. reports a history of mental health treatment, but denies benefiting from this in the past and does not think that it is currently necessary.,i was able to contact his partner by telephone. his partner reports the patient is paranoid and has bizarre behavior at baseline over the time that he has known him for the last 16 years, with occasional episodes of symptomatic worsening, from which he spontaneously recovers. his partner estimates the patient spends about 20% of the year in episodes of worse symptoms. his partner states that in the last one to two months, the patient has become worse than he has ever seen him with increased paranoia above the baseline and he states the patient has been barricading himself in his house and unplugging all electrical appliances for unclear reasons. he also reports the patient has been sleeping less and estimates his average duration to be three to four hours a night. he also reports the patient has been spending money impulsively in the last month and has actually incurred overdraft charges on his checking account on three different occasions recently. he also reports that the patient has been making threats of harm to him and that his partner no longer feels that he is safe having him at home. he reports that the patient has been eating regularly with no recent weight loss. he states that the patient is observed responding to internal stimuli, occasionally at baseline, but this has gotten worse in the last few months. his partner was unaware of any obvious medical changes in the last one to two months coinciding with onset of recent symptomatic worsening. he reports of the patient's longstanding poor compliance with treatment of his mental health or age-related conditions and attributes this to the patient's dislike of taking medicine. he also reports that the patient has expressed the belief in the past that he does not suffer from either condition.,past psychiatric history: , the patient's partner reports that the patient was diagnosed with schizophrenia in his 20s and he has been hospitalized on two occasions in the 1980s and that there was a third admission to a psychiatric facility, but the date of this admission is currently unknown. the patient was last enrolled in an outpatient mental health treatment in mid 2009. he dropped out of care about six months ago when he moved with his partner. his partner reports the patient was most recently prescribed seroquel, which, though the patient denied benefiting from, his partner felt was "useful, but not dosed high enough." past medication trials that the patient reports include haldol and lithium, neither of which he found to be particularly helpful.,medical history: , the patient reports being diagnosed with hiv and aids in 1994 and believes this was secondary to unprotected sexual contact in the years prior to his diagnosis. he is currently followed at clinic, where he has both an assigned physician and a case manager, but treatment compliance has been poor with no use of antiretroviral meds in the last year. the patient is fairly vague on his history of aids related conditions, but does identify the following: thrush, skin lesions, and lung infections; additional details of these problems are not currently known.,current medications: , none.,allergies:, no known drug allergies.,social and developmental history: , the patient lives with his partner. he is unemployed. details of his educational and occupational history are not currently known. his source of finances is also unknown, though social security disability is presumed.,substance and alcohol history: , the patient smoked one to two packs per day for most of the last year, but has increased this to two to three packs per day in the last month. his partner reports that the patient consumed alcohol occasionally, but denies any excessive or binge use recently. the patient reports smoking marijuana a few times in his life, but not recently. denies other illicit substance use.,legal history: ,unknown.,genetic psychiatric history:, also unknown.,mental status exam:,attitude: the patient demonstrates only variable cooperation with interview, requires frequent redirection to respond to questions. his appearance is cachectic. the patient is poorly groomed.,psychomotor: there is no psychomotor agitation or retardation. no other observed extrapyramidal symptoms or tardive dyskinesia.,affect: his affect is fairly detached.,mood: describes his mood is "okay.",speech: his speech is normal rate and volume. tone, his volume was decreased initially, but this improved during the course of the interview.,thought process: his thought processes are markedly tangential.,thought content: the patient is fairly scattered. he will provide history with frequent redirection, but he does not appear to stay on one topic for any length of time. he denies currently auditory or visual hallucinations, though his partner says that this is a feature present at baseline. paranoid delusions are elicited.,homicidal/suicidal ideation: he denies suicidal or homicidal ideation. denies previous suicide attempts.,cognitive assessment: cognitively, he is alert and oriented to person and year only. his memory is intact to names of his madison clinic providers.,insight/judgment: his insight is absent as evidenced by his repeated questioning of the validity of his aids and mental health diagnoses. his judgment is poor as evidenced by his longstanding pattern of minimal engagement in treatment of his mental health and physical health conditions.,assets: his assets include his housing and his history of supportive relationship with his partner over many years.,limitations: his limitations include his aids and his history of poor compliance with treatment.,formulation: ,the patient is a 45-year-old white male with a history of schizophrenia and aids. he was admitted for disorganized and assaultive behaviors while off all medications for the last six months. it is unclear to me how much his presentation is a direct expression of an aids-related condition, though i suspect the impact of his hiv status is likely to be substantial.,diagnoses:,axis i: schizophrenia by history. rule out aids-induced psychosis. rule out aids-related cognitive disorder.,axis ii: deferred.,axis iii: aids (stable by his report). anemia.,axis iv: relationship strain and the possibility that he may be unable to return to his home upon discharge; minimal engagement in mental health and hiv-related providers.,axis v: global assessment functioning is currently 15.,plan: , i will attempt to increase the database, will specifically request records from the last mental health providers. the internal medicine service will evaluate and treat any acute medical issues that could be helpful to collaborate with his providers at clinic regarding issues related to his aids diagnosis. with the patient's permission, i will start quetiapine at a dose of 100 mg at bedtime, given the patient's partner report of partial, but response to this agent in the past. i anticipate titrating further for effect during the course of his admission.

preoperative diagnoses:,1.stage iv endometriosis with severe pelvic pain.,2.status post prior left salpingoophorectomy.,postoperative diagnoses:,1.stage iv endometriosis with severe pelvic pain.,2.status post prior left salpingoophorectomy.,3.severe adhesions.,type of anesthesia: , general endotracheal tube.,technical procedure: , total abdominal hysterectomy, right salpingoophorectomy, and extensive adhesiolysis and enterolysis.,indication for procedure: , the patient is a 42-year-old parous female who had a longstanding history of severe endometriosis unresponsive to hormonal medical therapy and pain medication. she had severe dyspareunia and chronic suprapelvic pain. the patient had had a prior left salpingoophorectomy laparoscopically in 2004 for same disease process. now, she presented with a recurrent right ovarian endometrioma and severe pelvic pain. she desired surgical treatment. she accepted risk of a complete hysterectomy and salpingoophorectomy, risk of injury to underlying organs. the risks, benefits, and alternatives were clearly discussed with the patient as documented in the medical record.,description of findings: , absent left adnexa. right ovary about 6 cm with chocolate cyst and severely adherent to the right pelvic side wall, uterus, and colon. careful dissection to free right ovary and remove it although it is likely that some ovarian tissue remains behind. ureter visualized and palpated on right and appears normal. indigo carmine given iv with no leaks intraperitoneally noted. sigmoid colon dissected free from back of uterus and from cul-de-sac. bowel free of lacerations or denudation. upon inspection, right tube with hydrosalpinx, appendix absent. omental adhesions to ensure abdominal wall was lysed.,technical procedure: , after informed consent was obtained, the patient was taken to the operating room where she underwent smooth induction of general anesthesia. she was placed in a supine position with a transurethral foley in place and compression stockings in place. the abdomen and vagina were thoroughly prepped and draped in the usual sterile fashion.,a pfannenstiel skin incision was made with the scalpel and carried down sharply to the underlying layer of fascia and peritoneum. the peritoneum was bluntly entered and the incision extended caudally and cephaladly with good visualization of underlying organs. next, exploration of the abdominal and pelvic organs revealed the above noted findings. the uterus was enlarged and probably contained adenomyosis. there were dense adhesions, and a large right endometrioma with a chocolate cyst-like material contained within. the sigmoid colon was densely adhered to the cul-de-sac into the posterior aspect of the uterus. a bookwalter retractor was placed into the incision, and the bowel was packed away with moist laparotomy sponges. next, a sharp and blunt dissection was used to free the extensive adhesions, and enterolysis was performed with very careful attention not to injure or denude the bowel. next, the left round ligament and cornual region was divided, transected, and suture-ligated with 0 polysorb. the anterior and posterior leafs of the broad ligament were dissected and opened anteriorly to the level of the bladder. the uterine arteries were skeletonized on the left, and these were suture-clamped and transected with 0 polysorb with good hemostasis noted. next, the bladder flap was developed anteriorly, and the bladder peritoneum was sharply and bluntly dissected off of the lower uterus.,on the right, a similar procedure was performed. the right round ligament was suture-ligated with 0 polysorb. it was transected and divided with electrocautery. the anterior and posterior leafs of the broad ligament were dissected and developed anteriorly and posteriorly, and this area was relatively avascular. the left infundibulopelvic ligament was identified. it was cross-clamped and transected, suture-ligated with 0 polysorb with good hemostasis noted. next, the uterine arteries were skeletonized on the right. they were transected and suture-ligated with 0 polysorb. the uterosacral ligaments were taken bilaterally and transected and suture-ligated with 0 polysorb. the cardinal ligaments were taken near their insertion into the cervical and uterine tissue. pedicles were sharply developed and suture-ligated with 0 polysorb. next, the electrocautery was used to dissect the cervix anteriorly from the underlying vagina. once entry into the vagina was made, the cervix and uterus were amputated with jorgensen scissors. the vaginal cuff angles were suture-ligated with 0 polysorb and transfixed to the ipsilateral, cardinal, and uterosacral ligaments for vaginal support. the remainder of the vagina was closed with figure-of-eight sutures in an interrupted fashion with good hemostasis noted.,next, the right ovarian tissue was densely adherent to the colon. it was sharply and bluntly dissected, and most of the right ovary and endometrioma was removed and dissected off completely; however, there is a quite possibility that small remnants of ovarian tissue were left behind. the right ureter was seen and palpated. it did not appear to be dilated and had good peristalsis noted. next, the retractors were removed. the laparotomy sponges were removed from the abdomen. the rectus fascia was closed with 0 polysorb in a continuous running fashion with 2 sutures meeting in the midline. the subcutaneous tissue was closed with 0 plain gut in an interrupted fashion. the skin was closed with 4-0 polysorb in a subcuticular fashion. a thin layer of dermabond was placed.,the patient tolerated the procedure well. sponge, lap, and needle counts were correct x 2. cefoxitin 2 g was given preoperatively.,intraoperative complications:, none.,description of specimen: , uterus and right adnexa.,estimated blood loss: , 1000 ml.,postoperative condition: , stable.,

preoperative diagnosis:, prostate cancer.,postoperative diagnosis: , prostate cancer.,operative procedure: , radical retropubic prostatectomy with pelvic lymph node dissection.,anesthesia: ,general epidural,estimated blood loss: , 800 cc.,complications: , none.,indications for surgery: , this is a 64-year-old man with adenocarcinoma of the prostate confirmed by needle biopsies. he has elected to undergo radical retropubic prostatectomy with pelvic lymph node dissection. potential complications include, but are not limited to:,1. infection.,2. bleeding.,3. incontinence.,4. impotence.,5. deep venous thrombosis.,6. recurrence of the cancer.,procedure in detail: , epidural anesthesia was administered by the anesthesiologist in the holding area. preoperative antibiotic was also given in the preoperative holding area. the patient was then taken into the operating room after which general lma anesthesia was administered. the patient was shaved and then prepped using betadine solution. a sterile 16-french foley catheter was inserted into the bladder with clear urine drain. a midline infraumbilical incision was performed. the rectus fascia was opened sharply. the perivesical space and the retropubic space were developed bluntly. bookwalter retractor was then placed. bilateral obturator pelvic lymphadenectomy was performed. the obturator nerve was identified and was untouched. the margin for the resection of the lymph node bilaterally were the cooper's ligament, the medial edge of the external iliac artery, the bifurcation of the common iliac vein, the obturator nerve, and the bladder. both hemostasis and lymphostasis was achieved by using silk ties and hemo clips. the lymph nodes were palpably normal and were set for permanent section. the bookwalter retractor was then repositioned and the endopelvic fascia was opened bilaterally using metzenbaum scissors. the puboprostatic ligament was taken down sharply. the superficial dorsal vein complex over the prostate was bunched up by using the allis clamp and then tied by using 2-0 silk sutures. the deep dorsal vein complex was then bunched up by using the allis over the membranous urethral area. the dorsal vein complex was ligated by using 0 vicryl suture on a ct-1 needle. the allis clamp was removed and the dorsal vein complex was transected by using metzenbaum scissors. the urethra was then identified and was dissected out. the urethral opening was made just distal to the apex of the prostate by using metzenbaum scissors. this was extended circumferentially until the foley catheter could be seen clearly. 2-0 monocryl sutures were then placed on the urethral stump evenly spaced out for the anastomosis to be performed later. the foley catheter was removed and the posteriormost aspect of urethra and rectourethralis muscle was transected. the lateral pelvic fascia was opened bilaterally to sweep the neurovascular bundles laterally on both sides. the plane between denonvilliers' fascia and the perirectal fat was developed sharply. no tension was placed on the neurovascular bundle at any point in time. the prostate dissected off the rectal wall easily. once the seminal vesicles were identified, the fascia covering over them were opened transversely. the seminal vesicles were dissected out and the small bleeding vessels leading to them were clipped by using medium clips and then transected. the bladder neck was then dissected out carefully to spare most of the bladder neck muscles. once all of the prostate had been dissected off the bladder neck circumferentially the mucosa lining the bladder neck was transected releasing the entire specimen. the specimen was inspected and appeared to be completely intact. it was sent for permanent section. the bladder neck mucosa was then everted by using 4-0 chromic sutures. inspection at the prostatic bed revealed no bleeding vessels. the sutures, which were placed previously onto the urethral stump, were then placed onto the bladder neck. once the posterior sutures had been placed, the foley was placed into the urethra and into the bladder neck. a 20-french foley catheter was used. the anterior sutures were then placed. the foley was then inflated. the bed was straightened and the sutures were tied down sequentially from anteriorly to posteriorly. mild traction of the foley catheter was placed to assure the anastomosis was tight. two #19-french blake drains were placed in the perivesical spaces. these were anchored to the skin by using 2-0 silk sutures. the instrument counts, lab counts, and sponge counts were verified to be correct, the patient was closed. the fascia was closed in running fashion using #1 pds. subcutaneous tissue was closed by using 2-0 vicryl suture. skin was approximated by using metallic clips. the patient tolerated the operation well.

clinical history: , this is a 64-year-old male patient, who had a previous stress test, which was abnormal and hence has been referred for a stress test with imaging for further classification of coronary artery disease and ischemia.,pertinent medications:, include tylenol, robitussin, colace, fosamax, multivitamins, hydrochlorothiazide, protonix and flaxseed oil.,with the patient at rest 10.5 mci of cardiolite technetium-99 m sestamibi was injected and myocardial perfusion imaging was obtained.,procedure and interpretation: , the patient exercised for a total of 4 minutes and 41 seconds on the standard bruce protocol. the peak workload was 7 mets. the resting heart rate was 61 beats per minute and the peak heart rate was 173 beats per minute, which was 85% of the age-predicted maximum heart rate response. the blood pressure response was normal with the resting blood pressure 126/86, and the peak blood pressure of 134/90. ekg at rest showed normal sinus rhythm with a right-bundle branch block. the peak stress ekg was abnormal with 2 mm of st segment depression in v3 to v6, which remained abnormal till about 6 to 8 minutes into recovery. there were occasional pvcs, but no sustained arrhythmia. the patient had an episode of supraventricular tachycardia at peak stress. the ischemic threshold was at a heart rate of 118 beats per minute and at 4.6 mets. at peak stress, the patient was injected with 30.3 mci of cardiolite technetium-99 m sestamibi and myocardial perfusion imaging was obtained, and was compared to resting images.,myocardial perfusion imaging:,1. the overall quality of the scan was fair in view of increased abdominal uptake, increased bowel uptake seen.,2. there was a large area of moderate to reduced tracer concentration seen in the inferior wall and the inferior apex. this appeared to be partially reversible in the resting images.,3. the left ventricle appeared normal in size.,4. gated spect images revealed normal wall motion and normal left ventricular systolic function with normal wall thickening. the calculated ejection fraction was 70% at rest.,conclusions:,1. average exercise tolerance.,2. adequate cardiac stress.,3. abnormal ekg response to stress, consistent with ischemia. no symptoms of chest pain at rest.,4. myocardial perfusion imaging was abnormal with a large-sized, moderate intensity partially reversible inferior wall and inferior apical defect, consistent with inferior wall ischemia and inferior apical ischemia.,5. the patient had run of svt at peak stress.,6. gated spect images revealed normal wall motion and normal left ventricular systolic function.

admitting diagnosis:, aftercare of multiple trauma from an motor vehicle accident.,discharge diagnoses:,1. aftercare following surgery for injury and trauma.,2. decubitus ulcer, lower back.,3. alcohol induced persisting dementia.,4. anemia.,5. hypokalemia.,6. aftercare healing traumatic fracture of the lower arm.,7. alcohol abuse, not otherwise specified.,8. aftercare healing traumatic lower leg fracture.,9. open wound of the scalp.,10. cervical disk displacement with myelopathy.,11. episodic mood disorder.,12. anxiety disorder.,13. nervousness.,14. psychosis.,15. generalized pain.,16. insomnia.,17. pain in joint pelvic region/thigh.,18. motor vehicle traffic accident, not otherwise specified.,principal procedures:, none.,history of present illness: , as per dr. x without any changes or corrections.,hospital course: ,this is a 50-year-old male, who is initially transferred from medical center after treatment for multiple fractures after a motor vehicle accident. he had a left tibial plateau fracture, right forearm fracture with orif, head laceration, and initially some symptoms of head injury. when he was initially transferred to healthsouth, he was status post orif for his right forearm. he had a brace placed in the left leg for his left tibial plateau fracture. he was confused initially and initially started on rehab. he was diagnosed with some acute psychosis and thought problems likely related to his alcohol abuse history. he did well from orthopedic standpoint. he did have a small sacral decubitus ulcer, which was well controlled with the wound care team and healed quite nicely. he did have some anemia initially and he had dropped down in to the low 9, but he was 9.2 with his lowest on 06/11/2008, which had responded well to iron treatment and by the time of discharge, he was lower at 11.0. he made slow progress from therapy. his confusion gradually cleared. he did have some problems with insomnia and was placed on seroquel to help with both of his moods and other issues and he did quite well with this. he did require some ativan for agitation. he was on chronic pain medications as an outpatient. his medications were adjusted here and he did well with this as well. the patient was followed throughout his entire stay with case management and discussions were made with them and the psychologist concerning the placement upon discharge to an acute alcohol rehab facility; however, the patient refused throughout this entire stay. we did have orthopedic followup. he was taken out of his right leg brace the week of 06/16/2008. he did well with therapy. overall, he was doing much and much better. he had progressed with the therapy to the point where that he was comfortable to go home and receive outpatient therapy and follow up with his primary care physician. on 06/20/2008, with all parties in agreement, the patient was discharged to home in stable condition.,at the time of discharge, the patient's ambulatory status was much better. he was using a wheeled walker. he was able to bear weight on his left leg. his pain level had been well controlled and his moods had improved dramatically. he was no longer having any signs of agitation or confusion and he seemed to be at a stable baseline. his anemia had resolved almost completely and he was doing quite well. ,medications: , on discharge included:,1. calcium with vitamin d 1 tablet twice a day.,2. ferrous sulfate 325 mg t.i.d.,3. multivitamin 1 daily.,4. he was on nicotine patch 21 mg per 24 hour.,5. he was on seroquel 25 mg at bedtime.,6. he was on xenaderm for his sacral pressure ulcer.,7. he was on vicodin p.r.n. for pain.,8. ativan 1 mg b.i.d. for anxiety and otherwise he is doing quite well.,the patient was told to follow up with his orthopedist dr. y and also with his primary care physician upon discharge.

preoperative diagnosis: , chronic cholecystitis without cholelithiasis.,postoperative diagnosis: ,chronic cholecystitis without cholelithiasis.,procedure: , laparoscopic cholecystectomy.,brief description: , the patient was brought to the operating room and anesthesia was induced. the abdomen was prepped and draped and ports were placed. the gallbladder was grasped and retracted. the cystic duct and cystic artery were circumferentially dissected and a critical view was obtained. the cystic duct and cystic artery were then doubly clipped and divided and the gallbladder was dissected off the liver bed with electrocautery and placed in an endo catch bag. the gallbladder fossa and clips were examined and looked good with no evidence of bleeding or bile leak. the ports were removed under direct vision with good hemostasis. the hasson was removed. the abdomen was desufflated. the gallbladder in its endo catch bag was removed. the ports were closed. the patient tolerated the procedure well. please see full hospital dictation.

preoperative diagnoses:, bilateral mammary hypertrophy with breast asymmetry, right breast larger than left.,postoperative diagnoses:, bilateral mammary hypertrophy with breast asymmetry, right breast larger than left.,operation:, bilateral reduction mammoplasty with superior and inferiorly based dermal parenchymal pedicle with transposition of the nipple-areolar complex with resection of 947 g in the larger right breast and 758 g in the smaller left breast.,anesthesia: ,general endotracheal anesthesia.,procedure in detail: ,the patient was placed in the supine position under the effects of general endotracheal anesthesia. the breasts were prepped and draped with duraprep and iodine solution and then draped in appropriate sterile fashion. markings were then made in the standing position preoperatively. the nipple areolar complex was drawn at the level of the anterior projection of the inframammary fold along the central margin of the breast. a mckissock ring was utilized as a pattern. it was centered over the new nipple position and the medial and lateral flaps were drawn tangential to the pigmented areola at a 40-degree angle. medial and lateral flaps were drawn 8 cm in length. at the most medial and lateral extremity inframammary folds, a line was drawn to the lower level at the medial and lateral flaps. on the left side, the epithelialization was performed about the 45-mm nipple-areolar complex within the confines of the superior-medially based dermal parenchymal pedicle. resection of the skin, subcutaneous tissue, and glandular tissue was performed along the inframammary fold, and then cut was made medially and laterally. the resection medially was perpendicular to the chest wall down to the areolar tissue overlying the pectoralis major muscle, and laterally, the resection was performed tangential to the chest wall, skin, subcutaneous tissue, and glandular tissue towards the axillary tail. the pedicle was thinned as well, so it was 2-cm thick beneath the nipple-areolar complex and they were medially 4-cm thick at its base. on the right side, 947 g of breast tissue was removed. hemostasis was achieved with electrocautery. identical procedure was performed on the opposite left side, again with a superiorly and inferiorly based dermal parenchymal pedicle with deepithelialization about the 45-mm diameter nipple-areolar complex. resection of the skin, subcutaneous tissue, and glandular tissue was performed medially down to the chest overlying the pectoralis major muscle and laterally tangential to the chest wall towards the axillary tail setting the pedicle as well beneath the nipple areolar complex. hemostasis was achieved with electrocautery. with pedicle on the left, the breast issue on the left side was weighed at 758 g. hemostasis was achieved with cautery. the patient was placed in the sitting position with wound partially closed and there appeared to be excellent symmetry between the right and left sides. the nipple-areolar complex was transposed within the position and the medial and lateral flaps were brought together beneath the transposed nipple-areolar complex. closure was performed with interrupted 3-0 pds suture for deep subcutaneous tissue and dermis. skin was closed with running subcuticular 4-0 monocryl suture. a jackson-pratt drain had been placed prior to final closure and secured with a 4-0 silk suture. the wound had been irrigated prior to final closure as well with bacitracin irrigation solution prior to final cauterization. closure was performed with an anchor-shaped closure around the nipple-areolar complex, vertically of inframammary folds and across the inframammary folds. dressing was applied. the suture line was treated with dermabond. the patient returned to the recovery room with 2 jackson-pratt drains, 1 on each side and iv foley catheter with instructions to be seen in my office in 2 days. the patient tolerated the procedure well and returned to the recovery room in satisfactory condition.

admitting diagnoses:,1. respiratory distress.,2. reactive airways disease.,discharge diagnoses:,1. respiratory distress.,2. reactive airways disease.,3. pneumonia.,history of present illness: , the patient is a 3-year-old boy previously healthy who has never had a history of asthma or reactive airways disease who presented with a 36-hour presentation of uri symptoms, then had an abrupt onset of cough and increased work of breathing. child was brought to children's hospital and received nebulized treatments in the er and the hospitalist service was contacted regarding admission. the patient was seen and admitted through the emergency room.,he was placed on the hospitalist system and was started on continuous nebulized albuterol secondary to his respiratory distress. he also received inhaled as well as systemic corticosteroids. an x-ray was without infiltrate on initial review by the hospitalist, but there was a right upper lobe infiltrate versus atelectasis per the official radiology reading. the patient was not started on any antibiotics and his fever resolved. however, the crp was relatively elevated at 6.7. the cbc was normal with a white count of 9.6; however, the bands were 84%. given these results, which she is to treat the pneumonia as bacterial and discharge the child with amoxicillin and zithromax.,he was taken off of continuous and he was not on room air all night. in the morning, he still had some bilateral wheezing, but no tachypnea.,discharge physical examination: , ,general: no acute distress, running around the room.,heent: oropharynx moist and clear.,neck: supple without lymphadenopathy, thyromegaly or masses.,chest: bilateral basilar wheezing. no distress.,cardiovascular: regular rate and rhythm. no murmurs noted. well perfused peripherally.,abdomen: bowel sounds present. the abdomen is soft. there is no hepatosplenomegaly, no masses. nontender to palpation.,genitourinary: deferred.,extremities: warm and well perfused.,discharge instructions:, as follows:,1. activity, regular.,2. diet is regular.,3. follow up with dr. x in 2 days.,discharge medications:,1. xopenex mdi 2 puffs every 4 hours for 2 days and then as needed for cough or wheeze.,2. qvar 40, 2 puffs twice daily until otherwise instructed by the primary care provider.,3. amoxicillin 550 mg p.o. twice daily for 10 days.,4. zithromax 150 mg p.o. on day 1, then 75 mg p.o. daily for 4 more days.,total time for this discharge 37 minutes.

preoperative diagnosis:, benign prostatic hyperplasia.,postoperative diagnosis:, benign prostatic hyperplasia.,operation performed: , transurethral electrosurgical resection of the prostate.,anesthesia: , general.,complications:, none.,indications for the surgery:, this is a 77-year-old man with severe benign prostatic hyperplasia. he has had problem with urinary retention and bladder stones in the past. he will need to have transurethral resection of prostate to alleviate the above-mentioned problems. potential complications include, but are not limited to:,1. infection.,2. bleeding.,3. incontinence.,4. impotence.,5. formation of urethral strictures.,procedure in detail: , the patient was identified, after which he was taken into the operating room. general lma anesthesia was then administered. the patient was given prophylactic antibiotic in the preoperative holding area. the patient was then positioned, prepped and draped. cystoscopy was then performed by using a #26-french continuous flow resectoscopic sheath and a visual obturator. the prostatic urethra appeared to be moderately hypertrophied due to the lateral lobes and a large median lobe. the anterior urethra was normal without strictures or lesions. the bladder was severely trabeculated with multiple bladder diverticula. there is a very bladder diverticula located in the right posterior bladder wall just proximal to the trigone. using the ***** resection apparatus and a right angle resection loop, the prostate was resected initially at the area of the median lobe. once the median lobe has completely resected, the left lateral lobe and then the right lateral lobes were taken down. once an adequate channel had been achieved, the prostatic specimen was retrieved from the bladder by using an ellik evacuator. a 3-mm bar electrode was then introduced into the prostate to achieve perfect hemostasis. the sheath was then removed under direct vision and a #24-french foley catheter was then inserted atraumatically with pinkish irrigation fluid obtained. the patient tolerated the operation well.

procedure:, esophagogastroduodenoscopy with biopsy.,reason for procedure:, the child with history of irritability and diarrhea with gastroesophageal reflux. rule out reflux esophagitis, allergic enteritis, and ulcer disease, as well as celiac disease. he has been on prevacid 7.5 mg p.o. b.i.d. with suboptimal control of this irritability.,consent history and physical examinations were performed. the procedure, indications, alternatives available, and complications i.e. bleeding, perforation, infection, adverse medication reactions, possible need for blood transfusion, and surgery associated complication occur were discussed with the mother who understood and indicated this. opportunity for questions was provided and informed consent was obtained.,medications: ,general anesthesia.,instrument: , olympus gif-xq 160.,complications: , none.,estimated blood loss:, less than 5 ml.,findings: , with the patient in the supine position intubated under general anesthesia, the endoscope was inserted without difficulty into the hypopharynx. the proximal, mid, and distal esophagus had normal mucosal coloration and vascular pattern. lower esophageal sphincter appeared normal and was located at 25 cm from the central incisors. a z-line was identified within the lower esophageal sphincter. the endoscope was advanced into the stomach, which was distended with excess air. the rugal folds flattened completely. the gastric mucosa was entirely normal. no hiatal hernia was seen and the pyloric valve appeared normal. the endoscope was advanced into first, second, and third portion of the duodenum, which had normal mucosal coloration and fold pattern. ampule of vater was identified and found to be normal. biopsies were obtained x2 in the second portion of duodenum, antrum, and distal esophagus at 22 cm from the central incisors for histology. additional two antral biopsies were obtained for clo testing. excess air was evacuated from the stomach. the scope was removed from the patient who tolerated the procedure well. the patient was taken to recovery room in satisfactory condition.,impression:, normal esophagus, stomach, and duodenum.,plan:, histologic evaluation and clo testing. continue prevacid 7.5 mg p.o. b.i.d. i will contact the parents next week with biopsy results and further management plans will be discussed at that time.

procedure performed: , laparoscopic cholecystectomy.,procedure: ,after informed consent was obtained, the patient was brought to the operating room and placed supine on the operating room table. general endotracheal anesthesia was induced without incident. the patient was prepped and draped in the usual sterile manner.,a 2 cm infraumbilical midline incision was made. the fascia was then cleared of subcutaneous tissue using a tonsil clamp. a 1-2 cm incision was then made in the fascia, gaining entry into the abdominal cavity without incident. two sutures of 0 vicryl were then placed superiorly and inferiorly in the fascia, and then tied to the special 12 mm hasson trocar fitted with a funnel-shaped adapter in order to occlude the fascial opening. pneumoperitoneum was then established using carbon dioxide insufflation to a steady pressure of 16 mmhg.,the remaining trocars were then placed into the abdomen under direct vision of the 30 degree laparoscope taking care to make the incisions along langer's lines, spreading the subcutaneous tissues with a tonsil clamp, and confirming the entry site by depressing the abdominal wall prior to insertion of the trocar. a total of 3 other trocars were placed. the first was a 10/11 mm trocar in the upper midline position. the second was a 5 mm trocar placed in the anterior iliac spine. the third was a 5 mm trocar placed to bisect the distance between the second and upper midline trocars. all of the trocars were placed without difficulty.,the patient was then placed in reverse trendelenburg position and was rotated slightly to the left. the gallbladder was then grasped through the second and third trocars and retracted cephalad toward the right shoulder. a laparoscopic dissector was then placed through the upper midline cannula, fitted with a reducer, and the structures within the triangle of calot were meticulously dissected free.,a laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic duct proximally and distally. the duct was divided between the clips. the clips were carefully placed to avoid occluding the juncture with the common bile duct. the cystic artery was found medially and slightly posterior to the cystic duct. it was carefully dissected free from its surrounding tissues. a laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic artery proximally and distally. the artery was divided between the clips. the 2 midline port sites were injected with 5% marcaine.,after the complete detachment of the gallbladder from the liver, the video laparoscope was removed and placed through the upper 10/11 mm cannula. the neck of the gallbladder was grasped with a large penetrating forceps placed through the umbilical 12 mm hasson cannula. as the gallbladder was pulled through the umbilical fascial defect, the entire sheath and forceps were removed from the abdomen. the neck of the gallbladder was removed from the abdomen. following gallbladder removal, the remaining carbon dioxide was expelled from the abdomen.,both midline fascial defects were then approximated using 0 vicryl suture. all skin incisions were approximated with 4-0 vicryl in a subcuticular fashion. the skin was prepped with benzoin, and steri-strips were applied. dressings were applied. all surgical counts were reported as correct.,having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.

diagnosis: , ankle sprain, left ankle.,history: , the patient is a 31-year-old female who was referred to physical therapy secondary to a fall on 10/03/08. the patient states that she tripped over her dog toy and fell with her left foot inverted. the patient states that she received a series of x-rays and mris that were unremarkable. after approximately 1 month, the patient continued to have significant debilitating pain in her left ankle. she then received a walking boot and has been in the boot for the past month.,past medical history: , significant for hypertension, asthma, and cervical cancer. the cervical cancer was diagnosed as 15 years old. the patient states that her cancer is "dormant.",medications:,1. hydrochlorothiazide.,2. lisinopril.,3. percocet.,the patient states that the percocet helps to take the edge of her pain, but does not completely eliminate it.,subjective: , the patient rates the pain at 2/10 on the pain analog scale. the patient states that with elevation and rest, her pain subsides.,functional activities/hobbies: , currently limited including basic household chores and activities, this does increases her pain. the patient states she also recently joined weight watchers and was involved in a walking routine and is currently unable to participate in this activity.,work status: , the patient is currently on medical leave as a paraprofessional. the patient states that she works as a teacher's aide in the school system and is required to complete extensive walking and standing activities. the patient states that she is primarily on her feet while at work and rarely has a sitting break for extensive period of time. the patient's goal is to be able to stand and walk without pain.,social history: ,the patient lives in a private home with children and her father. the patient states that she does have stairs to negotiate without the use of a railing. she states that she is able to manage the stairs, however, is very slow with her movement. the patient smokes 1-1/2 packs of cigarettes a day and does not have a history of regular exercise routine.,objective: , upon observation, the patient is a very obese female who is ambulating with significant antalgic gait pattern and altered normal gait due to the pain as well as the walking boot. upon inspection of the left ankle, it appears to have swelling, unsure if this swelling is secondary to injury or water retention as the patient states she has significant water retention. when compared to right ankle edema, it is approximately equal. there is no evidence of discoloration or temperature. the patient states that she had no bruising at the time of injury.,active range of motion of left ankle is as follows: dorsiflexion is 6 degrees past neutral and plantar flexion is 54 degrees, eversion 20 degrees, and inversion is 30 degrees. left ankle dorsiflexion lacks 10 degrees from neutral and plantar flexion is 36 degrees, this motion is very painful. the patient was tearful during this activity. eversion is 3 degrees and inversion is 25 degrees. the patient states this movement was difficult, but not painful. strength testing of the right lower extremity is grossly 4+-5/5 and left ankle is 2/5 as the patient is unable to obtain full range of motion.,palpation: , the patient is very tender to palpation primarily along the lateral malleolus of the left ankle.,joint play: , unable to be assessed secondary to the patient's extreme tenderness and guarding of the ankle joint.,special tests:, a 6-minute walk test. the patient was able to ambulate approximately 600 feet while wearing her walking boot prior to her pain significantly increasing in the ankle and requiring the test to be stopped.,assessment: ,the patient would benefit from skilled physical therapy intervention as a trial of treatment in order to address the following problem list:,1. increased pain.,2. decreased range of motion.,3. decreased strength.,4. decreased ability to complete work task and functional activities in the home.,5. decreased gait pattern.,short-term goals to be completed in 3 weeks:,1. the patient will demonstrate independence with home exercise program.,2. the patient will ambulate without her boot for 48 hours in order to decrease reliance upon the boot for ankle stabilization.,3. the patient will achieve left ankle dorsiflexion to neutral and plantar flexion to 45 degrees without significant increase in pain.,4. the patient will demonstrate 3/5 strength of the left ankle.,5. the patient will tolerate the completion of the 6-minute walk test without the use of a boot with minimal increase in pain.,long-term goals to be completed in 6 weeks:,1. the patient will report 0/10 pain in the 48-hour period without the use of medication and without wearing her boot.,2. the patient will return to go through the work without the use of the walking boot with report of minimal increase in pain and discomfort.,prognosis:, fair for above-stated goals with full compliance to home exercise program and therapy treatment as well as the patient motivation.,plan: , the patient to be seen three times a week for 6 weeks for the following:

operation performed: ,dental prophylaxis under general anesthesia.,preoperative diagnoses:,1. impacted wisdom teeth.,2. moderate gingivitis.,postoperative diagnoses:,1. impacted wisdom teeth.,2. moderate gingivitis.,complications: ,none.,estimated blood loss: ,minimal.,duration of surgery: ,one hour 17 minutes.,brief history: ,the patient was referred to me by dr. x. he contacted myself and stated that angelica was going to have her wisdom teeth extracted in the setting of a hospital operating room at hospital and he inquired if we could pair on the procedure and i could do her full mouth dental rehabilitation before the wisdom teeth were removed by him. i agreed. i saw her in my office and she was cooperative for full mouth set of radiographs in my office and a clinical examination. this clinical and radiographic examination revealed no dental caries; however, she was in need of a good dental cleaning.,operative preparation: ,the patient was brought to hospital day surgery accompanied by her mother. i met with them and discussed the needs of the child, types of restoration to be performed, and the risks and benefits of the treatment as well as the options and alternatives of the treatment. after all their questions and concerns were addressed, they gave their informed consent to proceed with the treatment. the patient's history and physical examination was reviewed. once she was cleared by anesthesia, she was taken back to the operating room.,operative procedure: ,the patient was placed on the surgical table in the usual supine position with all extremities protected. anesthesia was induced by mask. the patient was then intubated with a nasal endotracheal tube and the tube was stabilized. the head was wrapped and the eyes were taped shut for protection. an angiocath was previously placed in preop. the head and neck were draped in sterile towels, and the body was covered with lead apron and sterile sheath. a moist continuous throat pack was placed beyond tonsillar pillars. plastic lip and cheek retractors were then placed. preoperative digital intraoral photographs were taken. no digital radiographs were taken in the operating room, as i stated before i had a full set of digital radiographs taken in my office. a prophylaxis was then performed using a prophy cup and fluoridated prophy paste after scaling and replaning was done. she presented with moderate calculus on the buccal surfaces of her maxillary, first molars and lower molars. she did not require any restorative dentistry.,upon the conclusion of the restorative phase, the oral cavity was aspirated and found to be free of blood, mucus, and other debris. the original treatment plan was verified with the actual treatment provided. postoperative clinical photographs were taken. the continuous gauze throat pack was removed with continuous suction and visualization. topical fluoride was then placed on the teeth.,at the end of the procedure, the child was undraped, extubated, and awakened in the operating room, taken to the recovery room, breathing spontaneously with stable vital signs.,findings: , this patient presented in her permanent dentition. her teeth #1, 16, 17, and 32 were impacted and are going to be removed following my full mouth dental rehabilitation by dr. alexander. oral hygiene was fair. there was generalized plaque and calculus throughout. she did not have any caries, did not require any restorative dentistry.,conclusion:, following my dental surgery, the patient continued to intubated and was prepped for oral surgery procedures by dr. x and his associates. there were no postop pain requirements. i did not have any specific requirements for the patient or her mother and that will be handled by dr. x and their instructions on soft foods, etc., and pain control will be managed by them.

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

preoperative diagnosis:, iron deficiency anemia.,postoperative diagnosis:, diverticulosis.,procedure:, colonoscopy.,medications: , mac.,procedure: , the olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve and the appendiceal orifice. preparation was good, although there was some residual material in the cecum that was difficult to clear completely. the mucosa was normal throughout the colon. no polyps or other lesions were identified, and no blood was noted. some diverticula were seen of the sigmoid colon with no luminal narrowing or evidence of inflammation. a retroflex view of the anorectal junction showed no hemorrhoids. the patient tolerated the procedure well and was sent to the recovery room.,final diagnoses:,1. diverticulosis in the sigmoid.,2. otherwise normal colonoscopy to the cecum.,recommendations:,1. follow up with dr. x as needed.,2. screening colonoscopy in 2 years.,3. additional evaluation for other causes of anemia may be appropriate.

chief complaint (1/1): , this 19 year old female presents today complaining of acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use. location: she indicates the problem location is the chin, right temple and left temple locally. severity: severity of condition is worsening.,menses: onset: 13 years old. interval: 22-27 days. duration: 4-6 days. flow: light. complications: none.,allergies: , patient admits allergies to penicillin resulting in difficulty breathing.,medication history:, patient is currently taking alesse-28, 20 mcg-0.10 mg tablet usage started on 08/07/2001 medication was prescribed by obstetrician-gynecologist a.,past medical history:, female reproductive hx: (+) birth control pill use, childhood illnesses: (+) chickenpox, (+) measles.,past surgical history:, no previous surgeries.,family history: , patient admits a family history of anxiety, stress disorder associated with mother.,social history:, patient admits caffeine use she consumes 3-5 servings per day, patient admits alcohol use drinking is described as social, patient admits good diet habits, patient admits exercising regularly, patient denies std history.,review of systems:, integumentary: (+) periodic reddening of face, (+) acne problems, allergic /,immunologic: (-) allergic or immunologic symptoms, constitutional symptoms: (-) constitutional symptoms,such as fever, headache, nausea, dizziness.,physical exam:, patient is a 19 year old female who appears pleasant, in no apparent distress, her given age, well developed, well nourished and with good attention to hygiene and body habitus. skin: examination of scalp shows no abnormalities. hair growth and distribution is normal. inspection of skin outside of affected area reveals no abnormalities. palpation of skin shows no abnormalities. inspection of eccrine and apocrine glands shows no evidence of hyperidrosis, chromidrosis or bromhidrosis. face shows keratotic papule.,impression:, acne vulgaris.,plan:, recommended treatment is antibiotic therapy. patient received extensive counseling about acne. she understands acne treatment is usually long-term. return to clinic in 4 week (s).,patient instructions:, patient received literature regarding acne vulgaris. discussed with the patient the prescription for tetracycline and handed out information regarding the side effects and the proper method of ingestion.,prescriptions:, tetracycline dosage: 250 mg capsule sig: bid dispense: 60 refills: 0 allow generic: yes

history of present illness: , the patient is a 22-year-old male who sustained a mandible fracture and was seen in the emergency department at hospital. he was seen in my office today and scheduled for surgery today for closed reduction of the mandible fractures.,preoperative diagnoses: , left angle and right body mandible fractures.,postoperative diagnoses: , left angle and right body mandible fractures.,procedure: , closed reduction of mandible fractures with erich arch bars and elastic fixation.,anesthesia:, general nasotracheal.,complications:, none.,condition:, stable to pacu.,description of procedure: , the patient was brought to the operating room and placed on the table in a supine position and after demonstration of an adequate plane of general anesthesia via the nasotracheal route, the patient was prepped and draped in the usual fashion for placement of arch bars. gauze throat pack was placed and upper and lower arch bars were placed on the maxillary and mandibular dentition with a 25-gauge circumdental wires. after the placement of the arch bars, the occlusion was checked and found to be satisfactory and stable. the throat pack was then removed. an ng tube was then passed and approximately 50 cc of stomach contents were suctioned out.,the elastic fixation was then placed on the arch bars holding the patient in maxillomandibular fixation and at this point, the procedure was terminated and the patient was then awakened, extubated, and taken to the pacu in stable condition.

preoperative diagnosis:, hammertoe deformity of the right second digit.,postoperative diagnosis: , hammertoe deformity of the right second digit.,procedure performed: , arthroplasty of the right second digit.,the patient is a 77-year-old hispanic male who presents to abcd hospital for surgical correction of a painful second digit hammertoe. the patient has failed attempts at conservative treatment and is unable to wear shoes without pain to his second toe. the patient presents n.p.o. since mid night last night and consented to sign in the chart. h&p is complete.,procedure in detail:, after an iv was instituted by the department of anesthesia in the preoperative holding area, the patient was escorted to the operating room and placed on the table in the supine position. using webril, the distal leg and ankle was padded and a ankle pneumatic tourniquet was placed around the right ankle, but left deflated at this time. restraining, a lap belt was then placed around the patient's abdomen while laying on the table. after adequate anesthesia was administered by the department of anesthesia, a local digital block using 5 cc of 0.5% marcaine plain was used to provide local anesthesia. the foot was then prepped and draped in the normal sterile orthopedic manner. the foot was then elevated and esmarch bandage was applied, after which time the tourniquet was inflated to 250 mmhg. the foot was then brought down to the level of the table and stockinet was cut and reflected after the esmarch bandage was removed. a wet and dry sponge was then used to cleanse the operative site and using a skin skribe a dorsal incisional line was outlined extending from the proximal phalanx over the proximal interphalangeal joint on to the middle phalanx.,then using a fresh #15 blade, a dorsolinear incision was made, partial thickness through the skin after testing anesthesia with one to two pickup. then using a fresh #15 blade, incision was deepened and using medial to lateral pressure, the incision was opened into the subcutaneous tissue. care was taken to reflect the subcutaneous tissue from the underlying deep fascia to mobilize the skin. this was performed with the combination of blunt and dull dissection. care was taken to avoid proper digital arteries and neurovascular bundles as were identified. attention was then directed to the proximal interphalangeal joint and after identifying the joint line, a transverse linear incision was made over the dorsal surface of the joint. the medial and lateral sides of the joint capsule were then also incised on the superior half in order to provide increased exposure. following this, the proximal portion of the transected extensor digitorum longus tendon was identified using an adson-brown pickup. it was elevated with fresh #15 blade. the tendon and capsule was reflected along with the periosteum from the underlying bone dorsally. following this, the distal portion of the tendon was identified in a like manner. the tendon and the capsule as well as the periosteal tissue was reflected from the dorsal surface of the bone. the proximal interphalangeal joint was then distracted and using careful technique, #15 blade was used to deepen the incision and while maintaining close proximity to the bone and condyles, the lateral and medial collateral ligaments were freed up from the side of the proximal phalanx head.,following this, the head of the proximal phalanx was known to have adequate exposure and was freed from soft tissues. then using a sagittal saw with a #139 blade, the head of he proximal phalanx was resected. care was taken to avoid the deep flexor tendon. the head of the proximal phalanx was taken with the adson-brown and using a #15 blade, the plantar periosteal tissue was freed up and the head was removed and sent to pathology. the wound was then flushed using a sterile saline with gentamicin and the digit was noted to be in good alignment. the digit was also noted to be in rectus alignment. proximal portion of the tendon was shortened to allow for removal of the redundant tendon after correction of the deformity. then using a #3-0 vicryl suture, three simple interrupted sutures were placed for closure of the tendon and capsular tissue. then following this, #4-0 nylon was used in a combination of horizontal mattress and simple interrupted sutures to close the skin. the toe was noted to be in good alignment and then 1 cc of dexamethasone phosphate was injected into the incision site. following this, the incision was dressed using a sterile owen silk soaked in saline and gentamicin. the toe was bandaged using 4 x 4s, kling, and coban. the tourniquet was deflated and immediate hyperemia was noted to the digits i through v of the right foot.,the patient was then transferred to the cart and was escorted to the postanesthesia care unit where the patient was given postoperative surgical shoe. total tourniquet time for the case was 30 minutes. while in the recovery, the patient was given postoperative instructions to include, ice and elevation to his right foot. the patient was given pain medications of tylenol #3, quantity 30 to be taken one to two tablets every six to eight hours as necessary for moderate to severe pain. the patient was also given prescription for cane to aid in ambulation. the patient will followup with dr. x on tuesday in his office for postoperative care. the patient was instructed to keep the dressings clean, dry, and intact and to not remove them before his initial office visit. the patient tolerated the procedure well and the anesthesia with no complications.

title of operation:,1. pars plana vitrectomy.,2. pars plana lensectomy.,3. exploration of exit wound.,4. closure of perforating corneal scleral laceration involving uveal tissue.,5. air-fluid exchange.,6. c3f8 gas.,7. scleral buckling, right eye.,indication for surgery: , the patient was hammering and a piece of metal entered his eye 1 day prior to the procedure giving him a traumatic cataract corneal laceration and the metallic intraocular foreign body was lodged in the posterior eye wall. he undergoes repair of the open globe today.,preop diagnosis: , perforating corneal scleral laceration involving uveal tissue with traumatic cataract and metallic foreign body lodged in the posterior eye wall, right eye.,postop diagnosis: , perforating corneal scleral laceration involving uveal tissue with traumatic cataract and metallic foreign body lodged in the posterior eye wall, right eye.,anesthesia:, general.,specimen:, none.,implants:,1. style number xxx silicone band reference xxx , lot number xxx , exploration 11/13.,2. style number xxx watzke sleeve reference xxx , lot number xxx , exploration 04/14.,procedure: , the risk, benefits, and alternatives to the procedure were reviewed with the patient and his wife. all of their questions were answered. informed consent was signed. the patient was brought into the operating room. a surgical time-out was performed during which all members of the operating room staff agreed upon the patient's name, operation to be performed, and correct operative eye. after administration of general anesthesia, the patient was intubated without incident.,the right eye was prepared and draped in the usual fashion for ophthalmic surgery. a wire lid speculum was used to separate the eyelids of the left eye. a 9 o'clock anterior chamber paracentesis was created with supersharp blade and the anterior chamber was filled with healon. the clear corneal incision was superior to the visual axis and was closed with three interrupted 10-0 nylon sutures with the knots buried. a standard three-port pars plana vitrectomy __________ was initiated by performing partial conjunctival peritomies in the superonasal, superotemporal, and inferotemporal quadrants with westcott scissors. hemostasis was achieved with bipolar cautery. a 7-0 vicryl suture was preplaced in the mattress fashion, 3 mm posterior to the surgical limbus in the inferotemporal quadrant. a microvitreoretinal blade was used to create a sclerotomy at this site and a 4-mm infusion cannula was introduced through the sclerotomy and tied in place with the aforementioned suture. the presence of the tip of the cannula was confirmed to be within the vitreous cavity prior to initiation of posterior infusion. two additional sclerotomies were created superonasally and superotemporally, 3 mm posterior to the surgical limbus with microvitreoretinal blade.,the vitreous cutter was used to perform the pars plana lens actively preserving peripheral anterior capsule. the pars plana vitrectomy was performed with the assistance of the biom non-contact lens indirect viewing system using the light pipe illuminator and the vitreous cutter. the vitreous was trimmed to the vitreous base. a posterior vitreous detachment was created and extended 360 degrees with the assistance of triamcinolone for staining.,the foreign body appeared to exit the posterior pole along the superotemporal arcade and apparently severed a branched retinal artery resulting in an area of macular ischemia with retinal whitening along its course. the exit wound was explored. no intraocular foreign body or mural foreign body was observed with the assistance of intraocular forceps. the intraocular magnet was then inserted through the sclerotomy and no foreign body was again identified.,an air-fluid exchange was performed with the assistance of the soft-tip extrusion cannula and the retinal periphery was examined with scleral depression. no retinal breaks or defects were noted in the periphery. the plugs were placed in the sclerotomies and the conjunctival peritomy was extended at 360 degrees. each of the rectus muscles was isolated on a 2-0 silk suture and a #xxx band was threaded beneath each of the rectus muscle and fixed to itself in the inferonasal quadrant with the watzke sleeve. the buckle was sutured to the eye wall with 5-0 mersilene sutures in each quadrant in a mattress fashion. the buckle was trimmed and the height of the buckle was inspected internally and noted to be adequate.,residual intraocular fluid was removed with a soft-tip extrusion cannula and the sclerotomies were closed with 7-0 vicryl sutures. a 12% concentration of c3f8 gas was flushed through the eye. the infusion cannula was removed and the sclerotomy was closed with the preplaced 7-0 vicryl suture. all of the sclerotomies were noted to be airtight. the intraocular pressure following injection of 0.05 ml each of vancomycin (0.5 mg) and ceftazidime (1 mg) were injected through the superotemporal pars plana, 30-gauge needles.,the conjunctiva was closed with 6-0 plain gut sutures with the knots buried. subconjunctival injections of ancef and decadron were delivered inferotemporally. the lid speculum was removed. pred-g ointment and atropine solution were applied to the ocular surface. the eye was patched and shielded, and the patient was returned to the recovery room in stable condition, having tolerated the procedure well. there were no complications.,i was the attending surgeon, was present and scrubbed for the entirety of the procedure.

chief complaint:, the patient comes for her first pap smear, complaining of irregular periods.,history of present illness:, the patient wishes to discuss considering something to help with her menstrual cramping and irregular periods. she notes that her periods are out of weck. she says that she has cramping and pain before her period starts. sometimes, she is off her period for two weeks and then she bleeds for two whole weeks. she usually has her periods lasting seven days, usually comes on the 19th of each month and now it seems to have changed. the cramping is worse. she said her flow has increased. she has to change her pad every half to one hour and uses a super tampon sometimes. she usually has four days of hard flow and then she might have 10 days where she will have to wear a mini pad. she also notes that her headaches have been worsening a little bit. she has had quite a bit of stress. she had a headache on wednesday again after having had one on the weekend. she said she usually only has an occasional headache and that is not too bad but now she has developed what she would consider to be a migraine and she has not had serious headaches like this and it seems to be worsening and coming a little bit more regularly, and she has not figure out what to do to get rid of them. she avoids caffeine. she only eats chocolate when she is near her period and she usually drinks one can of cola a day.,medications: , none.,allergies:, none.,social history:, she is a nonsmoker. she is not sexually active.,past medical history:, she has had no surgery or chronic illnesses.,family history:, mother has hypertension, depression. father has had renal cysts and sometimes some stomach problems. both of her parents have problems with their knees.,review of systems:, patient denies headache or trauma. no blurred or double vision. hearing is fine, no tinnitus or infection. infrequent sore throat, no hoarseness or cough.,heent: see hpi.,neck: no stiffness, pain or swelling.,respiratory: no shortness of breath, cough or hemoptysis. she is a nonsmoker.,cardiovascular: no chest pain, ankle edema, palpitations or hypertension.,gi: no nausea, vomiting, diarrhea, constipation, melena or jaundice.,gu: no dysuria, frequency, urgency or stress incontinence.,locomotor: no weakness, joint pain, tremor or swelling.,gyn: see hpi.,integumentary: patient performs self-breast examinations and denies any breast masses or nipple discharge. no recent skin or hair changes.,neuropsychiatric: denies depression, anxiety, tearfulness or suicidal thought.,physical examination:,vitals: height 64.5 inches. weight: 162 pounds. blood pressure 104/72. pulse: 72. respirations: 16. lmp: 08/21/04. age: 19.,heent: head is normocephalic. eyes: eoms intact. perrla. conjunctiva clear. fundi: discs flat, cups normal. no av nicking, hemorrhage or exudate. ears: tms intact. mouth: no lesion. throat: no inflammation.,neck: full range of motion. no lymphadenopathy or thyromegaly.,chest: clear to auscultation and percussion.,heart: normal sinus rhythm, no murmur.,integumentary: breasts are without masses, tenderness, nipple retraction or discharge. reviewed self-breast examination. no axillary nodes are palpable.,abdomen: soft. liver, spleen, and kidneys are not palpable. no masses felt, nontender. femoral pulses strong and equal.,back: no cva or spinal tenderness. no deformity noted.,pelvic: bus negative. vaginal mucosa pink, scanty discharge. cervix without lesion. pap was taken. uterus normal size. adnexa: no masses. she does have some pain on palpation of the uterus.,rectal: good sphincter tone. no masses. stool is guaiac negative.,extremities: no edema. pulses strong and equal. reflexes are intact.,rectal: no mass.,assessment:, menorrhagia, pelvic pain, dysmenorrhea, and irregular periods.,plan:, we will evaluate with a cbc, urinalysis and culture, and tsh. the patient has what she describes as migraine headaches of a new onset. because of the pelvic pain, dysmenorrhea, and menorrhagia, we will also evaluate with a pelvic sonogram. we will evaluate with a ct scan of the brain with and without contrast. we will try anaprox ds one every 12 hours for the headache. at this point, she could also use that for menstrual cramping. prescription written for 20 tablets. if her lab findings, sonographic findings, and ct of the brain are normal, we would consider trying birth control pills to regulate her periods and reduce the cramping and excessive flow. the lab x-ray and urinalysis results will be reported to her as soon as they are available.

subjective:, this patient was seen in clinic for a school physical.,nutritional history:, she eats well, takes meats, vegetables, and fruits, but her calcium intake is limited. she does not drink a whole lot of pop. her stools are normal. brushes her teeth, sees a dentist.,developmental history: hearing and vision is okay. she did well in school last year. she will be going to move to texas, will be going to bowie high school. she will be involved in cheerleading, track, volleyball, and basketball. she will be also playing the clarinet and will be a freshman in that school. her menarche was 06/30/2004.,past medical history:, she is still on medications for asthma. she has a problem with her eye lately, this has been bothering her, and she also has had a rash in the left leg. she had been pulling weeds on 06/25/2004 and then developed a rash on 06/27/2004.,review of her immunizations, her last tetanus shot was 06/17/2003.,medications: ,advair 100/50 b.i.d., allegra 60 mg b.i.d., flonase q.d., xopenex, intal, and albuterol p.r.n.,allergies: , no known drug allergies.,objective:,vital signs: weight: 112 pounds about 40th percentile. height: 63-1/4 inches, also the 40th percentile. her body mass index was 19.7, 40th percentile. temperature: 97.7 tympanic. pulse: 80. blood pressure: 96/64.,heent: normocephalic. fundi benign. pupils equal and reactive to light and accommodation. no strabismus. her vision was 20/20 in both eyes and each with contacts. hearing: she passed that test. her tms are bilaterally clear and nonerythematous. throat was clear. good mucous membrane moisture and good dentition.,neck: supple. thyroid normal sized. no increased lymphadenopathy in the submandibular nodes and no axillary nodes.,abdomen: no hepatosplenomegaly.,respiratory: clear. no wheezes. no crackles. no tachypnea. no retractions.,cardiovascular: regular rate and rhythm. s1 and s2 normal. no murmur.,abdomen: soft. no organomegaly and no masses.,gu: normal female genitalia. tanner stage 3, breast development and pubic hair development. examination of the breasts was negative for any masses or abnormalities or discharge from her areola.,extremities: she has good range of motion of upper and lower extremities. deep tendon reflexes were 2+/4+ bilaterally and equal. romberg negative.,back: no scoliosis. she had good circumduction at shoulder joint and her duck walk was normal.,skin: she did have some rash on the anterior left thigh region and also some on the right lower leg that had kebner phenomenon and maculopapular vesicular eruption. no honey crusting was noted on the skin. she also had some mild rash on the anterior abdominal area near the panty line similar to that rash. it was raised and blanch with pressure, it was slightly erythematous.,assessment and plan:,1. sports physical.,2. the patient received her first hepatitis a vaccine. she will get a booster in 6 to 12 months. prescription for atarax 10 mg tablets one to two tablets p.o. q.4-6h. p.r.n. and a prescription for elocon ointment to be applied topically, except for the face, once a day with a refill. she will be following up with an allergist as soon as she gets to texas and needs to find a primary care physician. we talked about anticipatory guidance including breast exam, which we have reviewed with her today, seatbelt use, and sunscreen. we talked about avoidance of drugs and alcohol and sexual activity. continue on her present medications and if her rash is not improved and goes to the neck or the face, she will need to be on po steroid medication, but presently that was held and moved to treatment with atarax and elocon. also talked about cleaning her clothes and bedding in case she has any poison ivy oil that is harboring on any clothing.

preoperative diagnosis:, severe degenerative joint disease of the right knee.,postoperative diagnosis: , severe degenerative joint disease of the right knee.,procedure:, right total knee arthroplasty using a biomet cemented components, 62.5-mm right cruciate-retaining femoral component, 71-mm maxim tibial component, and 12-mm polyethylene insert with 31-mm patella. all components were cemented with cobalt g.,anesthesia:, spinal.,estimated blood loss: , minimal.,tourniquet time: , less than 60 minutes.,the patient was taken to the postanesthesia care unit in stable condition. the patient tolerated the procedure well.,indications: ,the patient is a 51-year-old female complaining of worsening right knee pain. the patient had failed conservative measures and having difficulties with her activities of daily living as well as recurrent knee pain and swelling. the patient requested surgical intervention and need for total knee replacement.,all risks, benefits, expectations, and complications of surgery were explained to her in great detail and she signed informed consent. all risks including nerve and vessel damage, infection, and revision of surgery as well as component failure were explained to the patient and she did sign informed consent. the patient was given antibiotics preoperatively.,procedure detail: ,the patient was taken to the operating suite and placed in supine position on the operating table. she was placed in the seated position and a spinal anesthetic was placed, which the patient tolerated well. the patient was then moved to supine position again and a well-padded tourniquet was placed on the right thigh. right lower extremity was prepped and draped in sterile fashion. all extremities were padded prior to this.,the right lower extremity, after being prepped and draped in the sterile fashion, the tourniquet was elevated and maintained for less than 60 minutes in this case. a midline incision was made over the right knee and medial parapatellar arthrotomy was performed. patella was everted. the infrapatellar fat pad was incised and medial and lateral meniscectomy was performed and the anterior cruciate ligament was removed. the posterior cruciate ligament was intact.,there was severe osteoarthritis of the lateral compartment on the lateral femoral condyle as well as mild-to-moderate osteoarthritis in the medial femoral compartment as well severe osteoarthritis along the patellofemoral compartment. the medial periosteal tissue on the proximal tibia was elevated to the medial collateral ligament and medial collateral ligament was left intact throughout the entirety of the case.,at the extramedullary tibial guide, an extended cut was made adjusting for her alignment. once this was performed, excess bone was removed. the reamer was placed along on the femoral canal, after which a 6-degree valgus distal cut was made along the distal femur. once this was performed, the distal femoral size in 3 degrees external rotation, 62.5-mm cutting block was placed in 3 degrees external rotation with anterior and posterior cuts as well as anterior and posterior chamfer cuts remained in the standard fashion. excess bone was removed.,next, the tibia was brought anterior and excised to 71 mm. it was then punched in standard fashion adjusting for appropriate rotation along the alignment of the tibia. once this was performed, a 71-mm tibial trial was placed as well as a 62.5-mm femoral trial was placed with a 12-mm polyethylene insert.,next, the patella was cut in the standard fashion measuring 31 mm and a patella bed was placed. the knee was taken for range of motion; had excellent flexion and extension as well as adequate varus and valgus stability. there was no loosening appreciated. there is no laxity appreciated along the posterior cruciate ligament.,once this was performed, the trial components were removed. the knee was irrigated with fluid and antibiotics, after which the cement was put on the back table, this being cobalt g, it was placed on the tibia. the tibial components were tagged in position and placed on the femur. the femoral components were tagged into position. all excess cement was removed ___ placement of patella. it was tagged in position. a 12-mm polyethylene insert was placed; knee was held in extension and all excess cement was removed. the cement hardened with the knee in full extension, after which any extra cement was removed.,the wounds were copiously irrigated with saline and antibiotics, and medial parapatellar arthrotomy was closed with #2 vicryl. subcutaneous tissue was approximated with #2-0 vicryl and the skin was closed with staples. the patient was awakened from general anesthetic, transferred to the gurney, and taken into postanesthesia care unit in stable condition. the patient tolerated the procedure well.

discharge date: mm/dd/yyyy,history of present illness: mr. abc is a 60-year-old white male veteran with multiple comorbidities, who has a history of bladder cancer diagnosed approximately two years ago by the va hospital. he underwent a resection there. he was to be admitted to the day hospital for cystectomy. he was seen in urology clinic and radiology clinic on mm/dd/yyyy.,hospital course: mr. abc presented to the day hospital in anticipation for urology surgery. on evaluation, ekg, echocardiogram was abnormal, a cardiology consult was obtained. a cardiac adenosine stress mri was then proceeded, same was positive for inducible ischemia, mild-to-moderate inferolateral subendocardial infarction with peri-infarct ischemia. in addition, inducible ischemia seen in the inferior lateral septum. mr. abc underwent a left heart catheterization, which revealed two vessel coronary artery disease. the rca, proximal was 95% stenosed and the distal 80% stenosed. the mid lad was 85% stenosed and the distal lad was 85% stenosed. there was four multi-link vision bare metal stents placed to decrease all four lesions to 0%. following intervention, mr. abc was admitted to 7 ardmore tower under cardiology service under the direction of dr. xyz. mr. abc had a noncomplicated post-intervention hospital course. he was stable for discharge home on mm/dd/yyyy with instructions to take plavix daily for one month and urology is aware of the same.,discharge exam:,vital signs: temperature 97.4, heart rate 68, respirations 18, blood pressure 133/70.,heart: regular rate and rhythm.,lungs: clear to auscultation.,abdomen: obese, soft, nontender. lower abdomen tender when touched due to bladder cancer.,right groin: dry and intact, no bruit, no ecchymosis, no hematoma. distal pulses are intact.,discharge labs: cbc: white count 5.4, hemoglobin 10.3, hematocrit 30, platelet count 132, hemoglobin a1c 9.1. bmp: sodium 142, potassium 4.4, bun 13, creatinine 1.1, glucose 211. lipid profile: cholesterol 157, triglycerides 146, hdl 22, ldl 106.,procedures:,1. on mm/dd/yyyy, cardiac mri adenosine stress.,2. on mm/dd/yyyy, left heart catheterization, coronary angiogram, left ventriculogram, coronary angioplasty with four multi-link vision bare metal stents, two placed to the lad in two placed to the rca.,discharge instructions: mr. abc is discharged home. he should follow a low-fat, low-salt, low-cholesterol, and heart healthy diabetic diet. he should follow post-coronary artery intervention restrictions. he should not lift greater than 10 pounds for seven days. he should not drive for two days. he should not immerse in water for two weeks. groin site care reviewed with patient prior to being discharged home. he should check groin for bleeding, edema, and signs of infection. mr. abc is to see his primary care physician within one to two weeks, return to dr. xyz's clinic in four to six weeks, appointment card to be mailed him. he is to follow up with urology in their clinic on mm/dd/yyyy at 10 o'clock and then to scheduled ct scan at that time.,discharge diagnoses:,1. coronary artery disease status post percutaneous coronary artery intervention to the right coronary artery and to the lad.,2. bladder cancer.,3. diabetes.,4. dyslipidemia.,5. hypertension.,6. carotid artery stenosis, status post right carotid endarterectomy in 2004.,7. multiple resections of the bladder tumor.,8. distant history of appendectomy.,9. distant history of ankle surgery.

reason for consultation:, acute deep venous thrombosis, right lower extremity with bilateral pulmonary embolism, on intravenous heparin complicated with acute renal failure for evaluation.,history of presenting illness: ,briefly, this is a 36-year-old robust caucasian gentleman with no significant past medical or surgical history, who works as a sales representative, doing a lot of traveling by plane and car and attending several sales shows, developed acute shortness of breath with an episode of syncope this weekend and was brought in by paramedics to hospital. a v/q scan revealed multiple pulmonary perfusion defects consistent with high probability pulmonary embolism. a doppler venous study of the lower extremity also revealed nonocclusive right popliteal vein thrombosis. a ct of the abdomen and pelvis revealed normal-appearing liver, spleen, and pancreas; however, the right kidney appeared smaller compared to left and suggesting possibility of renal infarct. renal function on admission was within normal range; however, serial renal function showed rapid increase in creatinine to 5 today. he has been on intravenous heparin and hemodialysis is being planned for tomorrow. reviewing his history, there is no family members with hypercoagulable state or prior history of any thrombotic complication. he denies any recent injury to his lower extremity and in fact denied any calf pain or swelling.,past medical and surgical history: ,unremarkable.,social history: , he is married and has 1 son. he has a brother who is healthy. there is no history of tobacco use or alcohol use.,family history:, no family history of hypercoagulable condition.,medications: ,advil p.r.n.,allergies: , none.,review of systems: , essentially unremarkable except for sudden onset dyspnea on easy exertion complicated with episode of syncope. he denied any hemoptysis. he denied any calf swelling or pain. lately, he has been traveling and has been sitting behind a desk for a long period of time.,physical examination:,general: he is a robust young gentleman, awake, alert, and hemodynamically stable.,heent: sclerae anicteric. conjunctivae normal. oropharynx normal.,neck: no adenopathy or thyromegaly. no jugular venous distention.,heart: regular.,lungs: bilateral air entry.,abdomen: obese and benign.,extremities: no calf swelling or calf tenderness appreciated.,skin: no petechiae or ecchymosis.,neurologic: nonfocal.,laboratory findings:, blood count obtained showed a white count of 16.8, hemoglobin 14.8 g percent, hematocrit 44.6%, mcv 94, and platelet count 209,000. liver profile normal. thyroid study revealed a tsh of 1.3. prothrombin time/inr 1.5, partial thromboplastin time 78.6 seconds. renal function, bun 44 and creatinine 5.7. echocardiogram revealed left ventricular hypertrophy with ejection fraction of 65%, no intramural thrombus noted.,impression:,1. bilateral pulmonary embolism, most consistent with emboli from right lower extremity, on intravenous heparin, rule out hereditary hypercoagulable state.,2. leukocytosis, most likely leukemoid reaction secondary to acute pulmonary embolism/renal infarction, doubt presence of myeloproliferative disorder.,3. acute renal failure secondary to embolic right renal infarction.,4. obesity.,plan: , from hematologic standpoint, we will await hypercoagulable studies, which have all been sent on admission to see if a hereditary component is at play. for now, we will continue intravenous heparin and subsequent oral anticoagulation with coumadin. in view of worsening renal function, may need temporary hemodialysis until renal function improves. i discussed at length with the patient's wife at the bedside.

preoperative diagnoses: ,1. nasolabial mesiolabial fold.,2. mid glabellar fold.,postoperative diagnoses: ,1. nasolabial mesiolabial fold.,2. mid glabellar fold.,title of procedures: ,1. perlane injection for the nasolabial fold.,2. restylane injection for the glabellar fold.,anesthesia: ,topical with lasercaine.,complications: , none.,procedure: , the patient was evaluated preop and noted to be in stable condition. chart and informed consent were all reviewed preop. all risks, benefits, and alternatives regarding the procedure have been reviewed in detail with the patient. this includes risk of bleeding, infection, scarring, need for further procedure, etc. the patient did sign the informed consent form regarding the perlane and restylane. she is aware of the potential risk of bruising. the patient has had cosmederm in the past and had had a minimal response with this. please note lasercaine had to be applied 30 minutes prior to the procedure. the excess lasercaine was removed with a sterile alcohol swab.,using the linear threading technique, i injected the deep nasolabial fold. we used 2 ml of the perlane for injection of the nasolabial mesiolabial fold. they were carefully massaged into good position at the end of the procedure. she did have some mild erythema noted.,i then used approximately 0.4 ml of the restylane for injection of the mid glabellar site. she has a resting line of the mid glabella that did not respond with previous botox injection. once this was filled, the restylane was massaged into the proper tissue plane. cold compressors were applied afterwards. she is scheduled for a recheck in the next one to two weeks, and we will make further recommendations at that time. post restylane and perlane precautions have been reviewed with the patient as well.

chief complaint:, fever.,history of present illness:, this is an 18-month-old white male here with his mother for complaint of intermittent fever for the past five days. mother states he just completed amoxil several days ago for a sinus infection. patient does have a past history compatible with allergic rhinitis and he has been taking zyrtec serum. mother states that his temperature usually elevates at night. two days his temperature was 102.6. mother has not taken it since, and in fact she states today he seems much better. he is cutting an eye tooth that causes him to be drooling and sometimes fussy. he has had no vomiting or diarrhea. there has been no coughing. nose secretions are usually discolored in the morning, but clear throughout the rest of the day. appetite is fine.,physical examination:,general: he is alert in no distress.,vital signs: afebrile.,heent: normocephalic, atraumatic. pupils equal, round and react to light. tms are clear bilaterally. nares patent. clear secretions present. oropharynx is clear.,neck: supple.,lungs: clear to auscultation.,heart: regular, no murmur.,abdomen: soft. positive bowel sounds. no masses. no hepatosplenomegaly.,skin: normal turgor.,assessment:,1. allergic rhinitis.,2. fever history.,3. sinusitis resolved.,4. teething.,plan:, mother has been advised to continue zyrtec as directed daily. supportive care as needed. reassurance given and he is to return to the office as scheduled.

s:, the patient is here today with his mom for several complaints. number one, he has been having issues with his right shoulder. approximately 10 days ago he fell, slipping on ice, did not hit his head but fell straight on his shoulder. he has been having issues ever since. he is having difficulties raising his arm over his head. he does have some intermittent numbness in his fingers at night. he is not taking any anti-inflammatories or pain relievers. he is also complaining of a sore throat. he did have some exposure to strep and he has a long history of strep throat. denies any fevers, rashes, nausea, vomiting, diarrhea, and constipation. he is also being seen for adhd by dr. b. adderall and zoloft. he takes these once a day. he does notice when he does not take his medication. he is doing well in school. he is socializing well. he is maintaining his weight and tolerating the medications. however, he is having issues with anger control. he realizes when he has anger outbursts that it is a problem. his mom is concerned. he actually was willing to go to counseling and was wondering if there was anything available for him at this time.,past medical/surgical/social history:, reviewed and unchanged.,o:, vss. in general, patient is a&ox3. nad. heart: rrr. lungs: cta. heent: unremarkable. he does have 2+ tonsils, no erythema or exudate noted except for some postnasal drip. musculoskeletal: limited in range of motion, active on the right. he stops at about 95 degrees. no muscle weakness. neurovascularly intact. negative biceps tenderness. psych: no suicidal, homicidal ideations. answering questions appropriately. no hallucinations.

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

reason for exam: , right-sided abdominal pain with nausea and fever.,technique: , axial ct images of the abdomen and pelvis were obtained utilizing 100 ml of isovue-300.,ct abdomen: ,the liver, spleen, pancreas, gallbladder, adrenal glands, and kidney are unremarkable.,ct pelvis: , within the right lower quadrant, the appendix measures 16 mm and there are adjacent inflammatory changes with fluid in the right lower quadrant. findings are compatible with acute appendicitis.,the large and small bowels are normal in course and caliber without obstruction. the urinary bladder is normal. the uterus appears unremarkable. mild free fluid is seen in the lower pelvis.,no destructive osseous lesions are seen. the visualized lung bases are clear.,impression: , acute appendicitis.

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

preoperative diagnosis: , ruptured distal biceps tendon, right elbow.,postoperative diagnosis:, ruptured distal biceps tendon, right elbow.,procedure performed: , repair of distal biceps tendon, right elbow.,procedure: ,the patient was taken to or, room #2 and administered a general anesthetic. the right upper extremity was then prepped and draped in the usual manner. a sterile tourniquet was placed on the proximal aspect of the right upper extremity. the extremity was then elevated and exsanguinated with an esmarch bandage and tourniquet was inflated to 250 mmhg. tourniquet time was 74 minutes. a curvilinear incision was made in the antecubital fossa of the right elbow down through the skin. hemostasis was achieved utilizing electrocautery. subcutaneous fat was separated and the skin flaps elevated. the _________ was identified. it was incised. the finger was placed approximately up the anterior aspect of the arm and the distal aspect of the biceps tendon was found. there was some serosanguineous fluid from the previous rupture. this area was suctioned clean. the biceps tendon ends were then placed over a sterile tongue blade and were then sharply cut approximately 5 mm to 7 mm from the tip to create a fresh surface. at this point, the #2 fiber wire was then passed through the tendon. two fiber wires were utilized in a krackow-type suture. once this was completed, dissection was taken digitally down into the antecubital fossa in the path where the biceps tendon had been previously. the radial tuberosity was palpated. just ulnar to this, a curved hemostat was passed through the soft tissues and was used to tent the skin on the radial aspect of the elbow. a skin incision was made over this area. approximately two inches down to the skin and subcutaneous tissues, the fascia was split and the extensor muscle was also split.,a stat was then attached through the tip of that stat and passed back up through the antecubital fossa. the tails of the fiber wire suture were grasped and pulled down through the second incision. at this point, they were placed to the side. attention was directed at exposure of the radial tuberosity with a forearm fully pronated. the tuberosity came into view. the margins were cleared with periosteal elevator and sharp dissection. utilizing the power bur, a trough approximately 1.5 cm wide x 7 mm to 8 mm high was placed in the radial tuberosity. three small drill holes were then placed along the margin for passage of the suture. the area was then copiously irrigated with gentamicin solution. a #4-0 pullout wire was utilized to pass the sutures through the drill holes, one on each outer hole and two in the center hole. the elbow was flexed and the tendon was then pulled into the trough with the forearm supinated. the suture was tied over the bone islands. both wounds were then copiously irrigated with gentamicin solution and suctioned dry. muscle fascia was closed with running #2-0 vicryl suture on the lateral incision followed by closure of the skin with interrupted #2-0 vicryl and small staples. the anterior incision was approximated with interrupted #2-0 vicryl for subq. and then skin was approximated with small staples. both wounds were infiltrated with a total of 30 cc of 0.25% marcaine solution for postop analgesia. a bulky fluff dressing was applied to the elbow, followed by application of a long-arm plaster splint maintaining the forearm in the supinated position. tourniquet was inflated prior to application of the splint. circulatory status returned to the extremity immediately. the patient was awakened. he was rather boisterous during his awakening, but care was taken to protect the right upper extremity. he was then transferred to the recovery room in apparent satisfactory condition.

cc: , headache.,hpi: , this is a 15-year-old girl presenting with occipital headache for the last six hours. she denies trauma. she has been intermittently nauseated but has not vomited and has some photophobia. denies fever or change in vision. she has no past history of headaches. ,pmh: , none. ,medications: ,tylenol for pain.,allergies:, none.,family history: , grandmother died of cerebral aneurysm. ,ros:, negative.,physical exam: ,vital signs: bp 102/60 p 70 rr 20 t 98.2 ,heent: throat is clear, nasopharynx clear, tms clear, there is no lymphadenopathy, no tenderness to palpations, sinuses nontender. ,neck: supple without meningismus. ,chest: lungs clear; heart regular without murmur.,course in the ed: , the patient was seen in the urgent care and examined. at this time, her photophobia and nausea make migraine highly likely. she is well appearing and we'll try tylenol with codeine for her pain. one day off school and follow up with her primary doctor. ,impression: , migraine headache. ,plan: , see above.

preoperative diagnoses:,1. deformity, right breast reconstruction.,2. excess soft tissue, anterior abdomen and flank.,3. lipodystrophy of the abdomen.,postoperative diagnoses:,1. deformity, right breast reconstruction.,2. excess soft tissue, anterior abdomen and flank.,3. lipodystrophy of the abdomen.,procedures:,1. revision, right breast reconstruction.,2. excision, soft tissue fullness of the lateral abdomen and flank.,3. liposuction of the supraumbilical abdomen.,anesthesia: , general.,indication for operation:, the patient is a 31-year-old white female who previously has undergone latissimus dorsi flap and implant, breast reconstruction. she now had lateralization of the implant with loss of medial fullness for which she desired correction. it was felt that mobilization of the implant medially would provide the patient significant improvement and this was discussed with the patient at length. the patient also had a small dog ear in the flank area on the right from the latissimus flap harvest, which was to be corrected. she had also had liposuction of the periumbilical and infraumbilical abdomen with desire to have great improvement superiorly, was felt to be a candidate for such. the above-noted procedure was discussed with the patient in detail. the risks, benefits and potential complications were discussed. she was marked in the upright position and then taken to the operating room for the above-noted procedure.,operative procedure: , the patient was taken to the operating room and placed in the supine position. following adequate induction of general lma anesthesia, the chest and abdomen was prepped and draped in the usual sterile fashion. the supraumbilical abdomen was then injected with a solution of 5% lidocaine with epinephrine, as was the dog ear. at this time, the superior central scar was then excised, dissection continued through the subcutaneous tissue, the underlying latissimus muscle until the capsule of the implant was reached. this was then opened. the implant was removed and placed on the back table in antibiotic solution. using bovie cautery, the medial capsule was released and undermining was then performed with release of the muscle to the level of the proposed medial projection of the breast. the inframammary fold medially was secured with 2-0 pds suture to create greater takeoff point at this level which in the upright position and using a sizer produced a good form. the lateral pocket was diminished by series of 2-0 pds suture to provide medialization of the implant. the implant was then placed back into the submuscular pocket with much improved positioning and medial fullness. with this completed, the implant was again removed, antibiotic irrigation was performed. a drain was placed and brought out through a separate inferior stab wound incision and hemostasis was confirmed. the implant was then replaced and the wound was then closed in layers using 2-0 pds running suture on the muscle and 3-0 monocryl dermabond subcuticular sutures. the 2.5 cm dog ear was then excised into and including the subcutaneous tissue, even contouring was achieved and this was closed with two layers using 3-0 monocryl suture. using a #3 cannula, a superior umbilical incision, liposuction was carried out into the supraumbilical abdomen, removing approximately 40 to 50 ml of fat with improved supraumbilical contours. this was closed with 6-0 prolene suture. the patient was placed in a compressive garment after treating the incision with dermabond, steri-strips and antibiotic ointment around the drain site and umbilicus. a kerlix dressing and a surgical bra was placed to the chest area. a compressive garment was placed. the patient was then aroused from anesthesia, extubated, and taken to the recovery room in stable condition. sponge, needle, lap, instrument counts were all correct. the patient tolerated the procedure well. there were no complications. the estimated blood loss was approximately 25 ml.

procedure performed:, insertion of a vvir permanent pacemaker.,complications:, none.,estimated blood loss: , minimal.,site:, left subclavian vein access.,indication: , this is an 87-year-old caucasian female with critical aortic stenosis with an aortic valve area of 0.5 cm square and recurrent congestive heart failure symptoms mostly refractory to tachybrady arrhythmias and therefore, this is indicated so that we can give better control of heart rate and to maintain beta-blocker therapy in the order of treatment. it is overall a class-ii indication for permanent pacemaker insertion.,procedure:, the risks, benefits, and alternative of the procedure were all discussed with the patient and the patient's family in detail at great length. overall options and precautions of the pacemaker and indications were all discussed. they agreed to the pacemaker. the consent was signed and placed in the chart. the patient was taken to the cardiac catheterization lab, where she was monitored throughout the whole procedure. the patient was sterilely prepped and draped in the usual manner for permanent pacemaker insertion. myself and dr. wildes spoke for approximately 8 minutes before insertion for the procedure. using a lidocaine with epinephrine, the area of the left subclavian vein and left pectodeltoid region was anesthetized locally.,iv sedation, increments, and analgesics were given. using a #18 gauge needle, the left subclavian vein access was cannulated without difficulty. a guidewire was then passed through the cook needle and the cook needle was then removed. the wire was secured in place with the hemostat. using a #10 and #15 scalpel blade, a 5 cm horizontal incision was made in the left pectoral deltoid region where the skin was dissected and blunted down into the pectoris major muscle fascia. the skin was then undermined used to make a pocket for the pacemaker. the guidewire was then tunneled through the pacer pocket. cordis sheath was then inserted through the guidewire. the guidewire and dilator were removed. ___ cordis sheath was in placed within. this was used for insertion of the ventricular screw and steroid diluted leads where under fluoroscopy. it was placed into the apex. cordis sheath was then split apart and removed and after the ventricular lead was placed in its appropriate position and good thresholds were obtained, the lead was then sutured in place with #1-0 silk suture to the pectoris major muscle. the lead was then connected on pulse generator. the pocket was then irrigated and cleansed. pulse generator and the wire was then inserted into the ____ pocket. the skin was then closed with gut suture. the skin was then closed with #4-0 poly___ sutures using a subcuticular uninterrupted technique. the area was then cleansed and dried. steri-strips and pressure dressing was then applied. the patient tolerated the procedure well. there was no complications.,these are the settings on the pacemaker:,implant device: , pulse generator model name: sigma, model #: 12345, serial #: 123456.,ventricle lead:, model #: 12345, the ventricular lead serial #: 123456.,ventricle lead was a screw and steroid diluted lead placed into the right ventricle apex.,brady parameter settings are as follows:, amplitude was set at 3.5 volts with a pulse of 0.4, sensitivity of 2.8. the pacing mode was set at vvir, lower rate of 60 and upper rate of 120.,stimulation thresholds: ,the right ventricular lead and bipolar, threshold voltage is 0.6 volts, 1 milliapms current, 600 ohms resistance, r-wave sensing 11 millivolts.,the patient tolerated the procedure well. there was no complications. the patient went to recovery in stable condition. chest x-ray will be ordered. she will be placed on iv antibiotics and continue therapy for congestive heart failure and tachybrady arrhythmia.,thank you for allowing me to participate in her care. if you have any questions or concerns, please feel free to contact.

history of present illness: , this is a ** week gestational age ** delivered by ** at ** on **. gestational age was determined by last menstrual period and consistent with ** trimester ultrasound. ** rupture of membranes occurred ** prior to delivery and amniotic fluid was clear. the baby was vertex presentation. the baby was dried, stimulated, and bulb suctioned. apgar scores of ** at one minute and ** at five minutes.,past medical history,maternal history:, the mother is a **-year-old, g**, p** female with blood type **. she is rubella immune, hepatitis surface antigen negative, rpr nonreactive, hiv negative. mother was group b strep **. mother's past medical history is **.,prenatal care: , mother began prenatal care in the ** trimester and had at least ** documented prenatal visits. she did not smoke, drink alcohol, or use illicit drugs during pregnancy.,surgical history: , **,medications:, medications taken during this pregnancy were **.,allergies: , **,family history: , **,social history: , **,physical examination,vital signs: temperature **, heart rate **, respiratory rate **. dextrose stick **. ballard score by the rn is ** weeks. birth weight is ** grams, which is the ** percentile for gestational age. length is ** centimeters which is ** percentile for gestational age. head circumference is ** centimeters which is ** percentile for gestational age.,general: **alert, active, nondysmorphic-appearing infant in no acute distress.,heent: anterior fontanelle open and flat. positive bilateral red reflexes.,ears have normal shape and position with no pits or tags. nares patent. palate intact. mucous membranes moist.,neck: full range of motion.,cardiovascular: normal precordium, regular rate and rhythm. no murmurs. normal femoral pulses.,respiratory; clear to auscultation bilaterally. no retractions.,abdomen: soft, nondistended. normal bowel sounds. no hepatosplenomegaly. umbilical stump is clean, dry, and intact.,genitourinary: normal tanner i **. anus patent.,musculoskeletal: negative barlow and ortolani. clavicles intact. spine straight. no sacral dimple or hair tuft. leg lengths grossly symmetric. five fingers on each hand and five toes on each foot.,skin: warm and pink with brisk capillary refill. no jaundice.,neurological: normal tone. normal root, suck, grasp, and moro reflexes. moves all extremities equally.,diagnostic studies,laboratory data:, **,assessment: , full term, appropriate for gestational age **.,plan:,1. routine newborn care.,2. anticipatory guidance.,3. hepatitis b immunization prior to discharge.,

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

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.

chief complaint - reason for visit: ,pelvic pain and vaginal discharge.,abnormal pap history:, date of abnormal pap: 1998. findings: high grade squamous intraepithelial lesions. previous colposcopic exam and biopsies showed mild dysplasia or cin 1. patient is sexually active and has had 1 partner. there is no history of std’s.,pelvic pain history:, the patient complains of a gradual onset of pelvic pain 1 year ago and states condition is recurrent. location of pain is left lower quadrant. severity is moderately severe, intermittent and lasts for 2 hours. quality of pain is crampy, sharp and variable. pain requires nsaids. menstrual quality is light, flow lasts for 7 days and interval lasts for 28 days. there was no radiation of pain.,vaginitis history:, symptoms have lasted for 2 weeks and persistent. discharge appears thin, white and with odor. denies any itching sensation. denies irritation. the patient denies any self treatment.,personal / social history:, tobacco history: smoke’s 1 pack of cigarettes per day. denies the past history of alcohol. denies past / present illegal drug use of any kind. marital status: married.,past medical history:, negative.,family medical history:, negative.,allergies:, no known drug allergies/intolerances.,current medications:, there are no current medications.,past surgical history:, d & c. 1993,review of systems:,gastrointestinal: the patient has no history of gastrointestinal problems and denies any present problems.,genitourinary: patient denies any genitourinary problems.,gynecological: refer to current history.,pulmonary: denies cough, dyspnea, tachypnea, hemoptysis.,gu: denies frequency, nocturia and hematuria.,neuro: denies any problems, no seizures, no numbness, no dizziness.,physical examination:,vital signs: weight: 104. bp: 100/70.,chest: lungs have equal bilateral expansion and are clear to percussion and auscultation.,cardiovascular / heart: regular heart rate and rhythm without murmur or gallop.,breast: no palpable masses. no dimpling or retraction. no discharge. no axillary lymphadenopathy.,abdomen: tenderness is located in the left upper quadrant. tenderness is mild. bowel sounds are normal. no masses palpated.,gynecologic: inspection reveals the external genitalia to be normal anatomically. cervix appears inflamed, bloody discharge and without aceto-white areas. vagina appears normal. vaginal discharge was white and watery. uterus is normal anteverted. the uterus is normal size and shape, tender to movement and movable. bladder not tender. ,rectal: no additional findings.,lab / tests:, hgb: 17.1 u/a: ph 6.0, spgr 1.025, trace protein, trace blood,impression / diagnosis,1. endometritis / endomyometritis (615.9). ,2. cervicitis - endocervicitis (616.0). ,3. pelvic pain (625.9).,plan:, pap smear done. take metronidazole first then the doxycycline. return in three weeks for reevaluation.,medications prescribed: ,metronidazole 500 mg #14 1 bid for 7 days. doxycycline 100 mg #14 1 bid.

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

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

history of present illness: , this is a ** week gestational age ** delivered by ** at ** on **. gestational age was determined by last menstrual period and consistent with ** trimester ultrasound. ** rupture of membranes occurred ** prior to delivery and amniotic fluid was clear. the baby was vertex presentation. the baby was dried, stimulated, and bulb suctioned. apgar scores of ** at one minute and ** at five minutes.,past medical history,maternal history:, the mother is a **-year-old, g**, p** female with blood type **. she is rubella immune, hepatitis surface antigen negative, rpr nonreactive, hiv negative. mother was group b strep **. mother's past medical history is **.,prenatal care: , mother began prenatal care in the ** trimester and had at least ** documented prenatal visits. she did not smoke, drink alcohol, or use illicit drugs during pregnancy.,surgical history: , **,medications:, medications taken during this pregnancy were **.,allergies: , **,family history: , **,social history: , **,physical examination,vital signs: temperature **, heart rate **, respiratory rate **. dextrose stick **. ballard score by the rn is ** weeks. birth weight is ** grams, which is the ** percentile for gestational age. length is ** centimeters which is ** percentile for gestational age. head circumference is ** centimeters which is ** percentile for gestational age.,general: **alert, active, nondysmorphic-appearing infant in no acute distress.,heent: anterior fontanelle open and flat. positive bilateral red reflexes.,ears have normal shape and position with no pits or tags. nares patent. palate intact. mucous membranes moist.,neck: full range of motion.,cardiovascular: normal precordium, regular rate and rhythm. no murmurs. normal femoral pulses.,respiratory; clear to auscultation bilaterally. no retractions.,abdomen: soft, nondistended. normal bowel sounds. no hepatosplenomegaly. umbilical stump is clean, dry, and intact.,genitourinary: normal tanner i **. anus patent.,musculoskeletal: negative barlow and ortolani. clavicles intact. spine straight. no sacral dimple or hair tuft. leg lengths grossly symmetric. five fingers on each hand and five toes on each foot.,skin: warm and pink with brisk capillary refill. no jaundice.,neurological: normal tone. normal root, suck, grasp, and moro reflexes. moves all extremities equally.,diagnostic studies,laboratory data:, **,assessment: , full term, appropriate for gestational age **.,plan:,1. routine newborn care.,2. anticipatory guidance.,3. hepatitis b immunization prior to discharge.,

review of systems:,constitutional: patient denies fevers, chills, sweats and weight changes.,eyes: patient denies any visual symptoms.,ears, nose, and throat: no difficulties with hearing. no symptoms of rhinitis or sore throat.,cardiovascular: patient denies chest pains, palpitations, orthopnea and paroxysmal nocturnal dyspnea.,respiratory: no dyspnea on exertion, no wheezing or cough.,gi: no nausea, vomiting, diarrhea, constipation, abdominal pain, hematochezia or melena.,gu: no urinary hesitancy or dribbling. no nocturia or urinary frequency. no abnormal urethral discharge.,musculoskeletal: no myalgias or arthralgias.,neurologic: no chronic headaches, no seizures. patient denies numbness, tingling or weakness.,psychiatric: patient denies problems with mood disturbance. no problems with anxiety.,endocrine: no excessive urination or excessive thirst.,dermatologic: patient denies any rashes or skin changes.

diagnosis: , t1 n3 m0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation, completed june, 2006; status post 2 cycles carboplatin/5-fu given as adjuvant therapy, completed september, 2006; hearing loss related to chemotherapy and radiation; xerostomia; history of left upper extremity deep venous thrombosis.,performance status:, 0.,interval history: , in the interim since his last visit he has done quite well. he is working. he did have an episode of upper respiratory infection and fever at the end of april which got better with antibiotics. overall when he compares his strength to six or eight months ago he notes that he feels much stronger. he has no complaints other than mild xerostomia and treatment related hearing loss.,physical examination:,vital signs: height 65 inches, weight 150, pulse 76, blood pressure 112/74, temperature 95.4, respirations 18.,heent: extraocular muscles intact. sclerae not icteric. oral cavity free of exudate or ulceration. dry mouth noted.,lymph: no palpable adenopathy in cervical, supraclavicular or axillary areas.,lungs: clear.,cardiac: rhythm regular.,abdomen: soft, nondistended. neither liver, spleen, nor other masses palpable.,lower extremities: without edema.,neurologic: awake, alert, ambulatory, oriented, cognitively intact.,i reviewed the ct images and report of the study done on may 1. this showed no evidence of metabolically active malignancy.,most recent laboratory studies were performed last september and the tsh was normal. i have asked him to repeat the tsh at the one year anniversary.,he is on no current medications.,in summary, this 57-year-old man presented with t1 n3 cancer of the nasopharynx and is now at 20 months post completion of all therapy. he has made a good recovery. we will continue to follow thyroid function and i have asked him to obtain a tsh at the one year anniversary in september and cbc in follow up. we will see him in six months' time with a pet-ct.,he returns to the general care and direction of dr. abc.

history: , the patient is a 5-1/2-year-old, who recently presented with a cardiac murmur diagnosed due to a patent ductus arteriosus. an echocardiogram from 09/13/2007 demonstrated a 3.8-mm patent ductus arteriosus with restrictive left-to-right shunt. there is mild left atrial chamber enlargement with an la/ao ratio of 1.821. an electrocardiogram demonstrated normal sinus rhythm with possible left atrial enlargement and left ventricular hypertrophy. the patient underwent cardiac catheterization for device closure of a ductus arteriosus.,procedure: ,after sedation and local xylocaine anesthesia, the patient was prepped and draped. cardiac catheterization was performed as outlined in the attached continuation sheets. vascular entry was by percutaneous technique, and the patient was heparinized. monitoring during the procedure included continuous surface ecg, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,using a 5-french sheath, a 5-french wedge catheter was inserted into the right femoral vein and advanced through the right heart structures up to the branch pulmonary arteries. the atrial septum was not probe patent.,using a 4-french sheath, a 4-french marker pigtail catheter was inserted into the right femoral artery advanced retrograde to the descending aorta, ascending aorta, and left ventricle. a descending aortogram demonstrated a small, type a patent ductus arteriosus with a small left-to-right angiographic shunt. minimal diameter was approximately 1.6 mm with ampulla diameter of 5.8 mm and length of 6.2 mm. the wedge catheter could be directed from the main pulmonary artery across the ductus arteriosus to the descending aorta. this catheter exchanged over wire for a 5-french nit-occlude delivery catheter through which a nit-occlude 6/5 flex coil that was advanced and allowed to reconfigure the descending aorta. entire system was then brought into the ductal ampulla or one loop of coil was delivered in the main pulmonary artery. once the stable device configuration was confirmed by fluoroscopy, device was released from the delivery catheter. hemodynamic measurements and angiogram in the descending aorta were then repeated approximately 10 minutes following device implantation.,flows were calculated by the fick technique using a measured assumed oxygen consumption and contents derived from radiometer hemoximeter saturations and hemoglobin capacity.,cineangiograms were obtained with injection in the descending aorta.,after angiography, two normal-appearing renal collecting systems were visualized. the catheters and sheaths were removed and topical pressure applied for hemostasis. the patient was returned to the recovery room in satisfactory condition. there were no complications.,discussion: , oxygen consumption was assumed to be normal. mixed venous saturation was normal with a slight increased saturation of the branch pulmonary arteries due to left-to-right shunt through the ductus arteriosus. the left-sided heart was fully saturated. the phasic right-sided and left-sided pressures were normal. the calculated systemic flow was normal and pulmonary flow was slightly increased with a qp:qs ratio of 1:1. vascular resistances were normal. a cineangiogram with contrast injection in the descending aorta showed a small conical shaped ductus arteriosus with a small left-to-right angiographic shunt. the branch pulmonary arteries appeared normal. there is otherwise a normal left aortic arch.,following coil embolization of the ductus arteriosus, there is no change in mixed venous saturation. no evidence of residual left-to-right shunt. there is no change in right-sided pressures. there is a slight increase in the left-sided phasic pressures. calculated systemic flow was unchanged from the resting state and pulmonary flow was similar with a qp:qs ratio of 1:1. final angiogram with injection in the descending aorta showed a majority of coil mass to be within the ductal ampulla with minimal protrusion in the descending aorta as well as the coil in the main pulmonary artery. there is a trace residual shunt through the center of coil mass.,initial diagnoses:, patent ductus arteriosus.,surgeries (interventions): ,coil embolization of patent ductus arteriosus.,management: ,the case to be discussed at combined cardiology/cardiothoracic surgery case conference. the patient will require a cardiologic followup in 6 months and 1 year's time including clinical evaluation and echocardiogram. further patient care be directed by dr. x.,

history: , the patient is a 52-year-old right-handed female with longstanding bilateral arm pain, which is predominantly in the medial aspect of her arms and hands as well as left hand numbness, worse at night and after doing repetitive work with her left hand. she denies any weakness. no significant neck pain, change in bowel or bladder symptoms, change in gait, or similar symptoms in the past. she is on lyrica for the pain, which has been somewhat successful.,examination reveals positive phalen's test on the left. remainder of her neurological examination is normal.,nerve conduction studies: ,the left median motor distal latency is prolonged with normal evoked response amplitude and conduction velocity. the left median sensory distal latency is prolonged with an attenuated evoked response amplitude. the right median sensory distal latency is mildly prolonged with a mildly attenuated evoked response amplitude. the right median motor distal latency and evoked response amplitude is normal. left ulnar motor and sensory and left radial sensory responses are normal. left median f-wave is normal.,needle emg:, needle emg was performed on the left arm, right first dorsal interosseous muscle, and bilateral cervical paraspinal muscles. it revealed spontaneous activity in the left abductor pollicis brevis muscle. there is increased insertional activity in the right first dorsal interosseous muscle. both interosseous muscles showed signs of reinnervation. left extensor digitorum communis muscle showed evidence of reduced recruitment. cervical paraspinal muscles were normal.,impression: , this electrical study is abnormal. it reveals the following: a left median neuropathy at the wrist consistent with carpal tunnel syndrome. electrical abnormalities are moderate-to-mild bilateral c8 radiculopathies. this may be an incidental finding.,i have recommended mri of the spine without contrast and report will be sent to dr. xyz. she will follow up with dr. xyz with respect to treatment of the above conditions.

preoperative diagnoses: , bilateral chronic otitis media,postoperative diagnoses:, bilateral chronic otitis media,anesthesia:, general mask,name of operation:, bilateral myringotomy with placement of pe tubes,procedure:, the patient was taken to the operating room and placed in the supine position. after adequate general inhalation anesthesia was obtained, the operating microscope with brought in for full use throughout the case. first, the left and then the right tympanic membrane, was approached. an anterior-inferior radial incision was made in the left tympanic membrane. suction revealed a substantial amount of mucopurulent drainage. a sheehy pressure equalization tube was placed in the myringotomy site. floxin drops were added. the same procedure was repeated on the right side with similar findings noted of mucopurulent drainage. the patient tolerated the procedure well and returned to the recovery room awake and in stable condition.