diff --git a/12_Neurology.txt b/12_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..c2252323cfaf69ad33694c2352912ca6622df068 --- /dev/null +++ b/12_Neurology.txt @@ -0,0 +1,81 @@ +CC: + + Confusion and slurred speech. + +HX + + (primarily obtained from boyfriend): This 31 y/o RHF experienced a "flu-like illness 6-8 weeks prior to presentation. 3-4 weeks prior to presentation, she was found "passed out" in bed, and when awoken appeared confused, and lethargic. She apparently recovered within 24 hours. For two weeks prior to presentation she demonstrated emotional lability, uncharacteristic of her ( outbursts of anger and inappropriate laughter). She left a stove on. + +She began slurring her speech 2 days prior to admission. On the day of presentation she developed right facial weakness and began stumbling to the right. She denied any associated headache, nausea, vomiting, fever, chills, neck stiffness or visual change. There was no history of illicit drug/ETOH use or head trauma. + +PMH: + + Migraine Headache. + +FHX: + + Unremarkable. + +SHX: + +Divorced. Lives with boyfriend. 3 children alive and well. Denied tobacco/illicit drug use. Rarely consumes ETOH. + +ROS: + + Irregular menses. + +EXAM: + +BP118/66. HR83. RR 20. T36.8C. + +MS: Alert and oriented to name only. Perseverative thought processes. Utilized only one or two word answers/phrases. Non-fluent. Rarely followed commands. Impaired writing of name. + +CN: Flattened right nasolabial fold only. + +Motor: Mild weakness in RUE manifested by pronator drift. Other extremities were full strength. + +Sensory: withdrew to noxious stimulation in all 4 extremities. + +Coordination: difficult to assess. + +Station: Right pronator drift. + +Gait: unremarkable. + +Reflexes: 2/2BUE + + 3/3BLE + + Plantars were flexor bilaterally. + +General Exam: unremarkable. + +INITIAL STUDIES: + + CBC + + GS + + UA + + PT + + PTT + + ESR + + CRP + + EKG were all unremarkable. Outside HCT showed hypodensities in the right putamen, left caudate, and at several subcortical locations (not specified). + +COURSE: + +MRI Brian Scan, 2/11/92 revealed an old lacunar infarct in the right basal ganglia, edema within the head of the left caudate nucleus suggesting an acute ischemic event, and arterial enhancement of the left MCA distribution suggesting slow flow. The latter suggested a vasculopathy such as Moya Moya, or fibromuscular dysplasia. HIV + + ANA + + Anti-cardiolipin Antibody titer, Cardiac enzymes, TFTs, B12, and cholesterol studies were unremarkable. + +She underwent a cerebral angiogram on 2/12/92. This revealed an occlusion of the left MCA just distal to its origin. The distal distribution of the left MCA filled on later films through collaterals from the left ACA. There was also an occlusion of the right MCA just distal to the temporal branch. Distal branches of the right MCA filled through collaterals from the right ACA. No other vascular abnormalities were noted. These findings were felt to be atypical but nevertheless suspicious of a large caliber vasculitis such as Moya Moya disease. She was subsequently given this diagnosis. Neuropsychologic testing revealed widespread cognitive dysfunction with particular impairment of language function. She had long latencies responding and understood only simple questions. Affect was blunted and there was distinct lack of concern regarding her condition. She was subsequently discharged home on no medications. + +In 9/92 she was admitted for sudden onset right hemiparesis and mental status change. Exam revealed the hemiparesis and in addition she was found to have significant neck lymphadenopathy. OB/GYN exam including cervical biopsy, and abdominal/pelvic CT scanning revealed stage IV squamous cell cancer of the cervix. She died 9/24/92 of cervical cancer. \ No newline at end of file diff --git a/1490_Radiology.txt b/1490_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..7257ce4d159461c2b97f8aa52d4f1f1e4f581746 --- /dev/null +++ b/1490_Radiology.txt @@ -0,0 +1,7 @@ +GENERAL EVALUATION: + +Fetal Cardiac Activity: Normal at 150BPM. Fetal Lie: Longitudinal. Fetal Presentation: Cephalic. Placenta: Anterior Grade I. Uterus: Normal. Cervix: Closed. Adnexa: Not seen. Amniotic Fluid: Normal. + +BIOMETRY: + +BPD: 8.4 cm consistent with 33 weeks, 6 days gestation,HC: 29.8 cm consistent with 33 weeks, 0 days gestation,AC: 29.7 cm consistent with 33 weeks, 5 days gestation,FL: \ No newline at end of file diff --git a/1492_Radiology.txt b/1492_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..1f0d6d22ef8f0d9928f537eab6b05bdc08ac4c60 --- /dev/null +++ b/1492_Radiology.txt @@ -0,0 +1,7 @@ +GENERAL EVALUATION: + +Fetal Cardiac Activity: Normal at 140 BPM + +Fetal Position: Variable,Placenta: Posterior without evidence of placenta previa. + +Uterus: Normal,Cervix: \ No newline at end of file diff --git a/1494_Radiology.txt b/1494_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..3ace251344557807393c8c8537598d786b87ad62 --- /dev/null +++ b/1494_Radiology.txt @@ -0,0 +1,17 @@ +GENERAL EVALUATION: + +Twin B,Fetal Cardiac Activity: Normal at 166 BPM + +Fetal Lie: Longitudinal, to the maternal right. + +Fetal Presentation: Cephalic. + +Placenta: Fused, posterior placenta, Grade I to II. + +Uterus: Normal,Cervix: Closed. + +Adnexa: Not seen,Amniotic Fluid: AFI 5.5cm in a single AP pocket. + +BIOMETRY: + +BPD: 7.9cm consistent with 31weeks, 5 days gestation,HC: 31.1cm consistent with 33 weeks, 3 days gestation,AC: 30.0cm consistent with 34 weeks, 0 days gestation,FL: \ No newline at end of file diff --git a/1497_Radiology.txt b/1497_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..5087e3b1a7395602a7bb1ac807997851b01f0640 --- /dev/null +++ b/1497_Radiology.txt @@ -0,0 +1,19 @@ +EXAM: + + Transvaginal ultrasound. + +HISTORY: + + Pelvic pain. + +FINDINGS: + + The right ovary measures 1.6 x 3.4 x 2.0 cm. There are several simple-appearing probable follicular cysts. There is no abnormal flow to suggest torsion on the right. Left ovary is enlarged, demonstrating a 6.0 x 3.5 x 3.7 cm complex cystic mass of uncertain etiology. This could represent a large hemorrhagic cyst versus abscess. There is no evidence for left ovarian torsion. There is a small amount of fluid in the cul-de-sac likely physiologic. + +The uterus measures 7.7 x 5.0 cm. The endometrial echo is normal at 6 mm. + +IMPRESSION: + +1. No evidence for torsion. + +2. Large, complex cystic left ovarian mass as described. This could represent a large hemorrhagic cyst; however, an abscess/neoplasm cannot be excluded. Recommend either short interval followup versus laparoscopic evaluation given the large size and complex nature. \ No newline at end of file diff --git a/1498_Radiology.txt b/1498_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..14d3a5f71e3670ef1508f256b259bb235ab6a2d9 --- /dev/null +++ b/1498_Radiology.txt @@ -0,0 +1,27 @@ +EXAM: + + OB Ultrasound. + +HISTORY: + + A 29-year-old female requests for size and date of pregnancy. + +FINDINGS: + + A single live intrauterine gestation in the cephalic presentation, fetal heart rate is measured 147 beats per minute. Placenta is located posteriorly, grade 0 without previa. Cervical length is 4.2 cm. There is normal amniotic fluid index of 12.2 cm. There is a 4-chamber heart. There is spontaneous body/limb motion. The stomach, bladder, kidneys, cerebral ventricles, heel, spine, extremities, and umbilical cord are unremarkable. + +BIOMETRIC DATA: + +BPD = 7.77 cm = 31 weeks, 1 day,HC = 28.26 cm = 31 weeks, 1 day,AC = 26.63 cm = 30 weeks, 5 days,FL = 6.06 cm = 31 weeks, 4 days,Composite sonographic age 30 weeks 6 days plus minus 17 days. + +ESTIMATED DATE OF DELIVERY: + + Month DD + + YYYY. + +Estimated fetal weight is 3 pounds 11 ounces plus or minus 10 ounces. + +IMPRESSION: + + Single live intrauterine gestation without complications as described. \ No newline at end of file diff --git a/1499_Radiology.txt b/1499_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..37908f099016931aed924d7a3d2ecd33c794f788 --- /dev/null +++ b/1499_Radiology.txt @@ -0,0 +1,21 @@ +EXAM: + + Bilateral lower extremity ultrasound for deep venous thrombus. + +REASON FOR EXAM: + + Lower extremity edema bilaterally. + +TECHNIQUE: + + Colored, grayscale, and Doppler imaging is all employed. + +FINDINGS: + + This examination is limited. There is prominent edema bilaterally and there is large body habitus. These two limit assessment especially of the right lower extremity. + +As visualized, there is no gross evidence of DVT. The right leg grayscale images are limited. No obvious clot identified on the color flow or Doppler images. The left leg is better visualized than the right, but again is limited. No definite clot is seen. + +IMPRESSION: + + Limited study secondary to body habitus and edema. No obvious DVT as visualized. \ No newline at end of file diff --git a/1503_Radiology.txt b/1503_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..5424f652ee7147d9170ae6d6774d153786ef7018 --- /dev/null +++ b/1503_Radiology.txt @@ -0,0 +1,23 @@ +REASON FOR EXAM: + + Followup for fetal growth. + + + +INTERPRETATION: + + Real-time exam demonstrates a single intrauterine fetus in cephalic presentation with a regular cardiac rate of 147 beats per minute documented. + +FETAL BIOMETRY: + +BPD = 8.3 cm = 33 weeks, 4 days,HC = 30.2 cm = 33 weeks, 4 days,AC = 27.9 cm = 32 weeks, 0 days,FL = 6.4 cm = 33 weeks, 1 day,The head to abdomen circumference ratio is normal at 1.08, and the femur length to abdomen circumference ratio is normal at 23.0%. Estimated fetal weight is 2,001 grams. + +The amniotic fluid volume appears normal, and the calculated index is normal for the age at 13.7 cm. + +A detailed fetal anatomic exam was not performed at this setting, this being a limited exam for growth. The placenta is posterofundal and grade 2. + + + +IMPRESSION: + + Single viable intrauterine pregnancy in cephalic presentation with a composite gestational age of 32 weeks, 5 days, plus or minus 17 days, giving and estimated date of confinement of 8/04/05. There has been normal progression of fetal growth compared to the two prior exams of 2/11/05 and 4/04/05. The examination of 4/04/05 questioned an echogenic focus within the left ventricle. The current examination does not demonstrate any significant persistent echogenic focus involving the left ventricle. \ No newline at end of file diff --git a/1505_Radiology.txt b/1505_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..abfbab3658396bccc4b6c348abcdf3e4b4e9fe28 --- /dev/null +++ b/1505_Radiology.txt @@ -0,0 +1,31 @@ +HISTORY OF PRESENT ILLNESS: + + I was kindly asked to see this patient for transesophageal echocardiogram performance by Dr. A and Neurology. Please see also my cardiovascular consultation dictated separately. But essentially, this is a pleasant 72-year-old woman admitted to the hospital with a large right MCA CVA causing a left-sided neurological deficit incidentally found to have atrial fibrillation on telemetry. She has been recommended for a transesophageal echocardiogram for cardioembolic source of her CNS insult. + +I discussed the procedure in detail with the patient as well as with her daughter, who was present at the patient's bedside with the patient's verbal consent. I then performed a risk/benefit/alternative analysis with benefits being more definitive exclusion of intracardiac thrombus as well as assessment for intracardiac shunts; alternatives being transthoracic echo imaging, which she had already had, with an inherent false negativity for this indication as well as empiric medical management, which the patient was not interested in; risks including, but not limited to, and the patient was aware this was not an all-inclusive list, of oversedation from conscious sedation, risk of aspiration pneumonia from regurgitation of stomach contents, risk of oropharyngeal, esophageal, oral, tracheal, pulmonary and/or gastric perforation, hemorrhage, or tear. The patient expressed understanding of this risk/benefit/alternative analysis, had the opportunity to ask questions, which I invited from her and her daughter, all of which were answered to their self-stated satisfaction. The patient then stated in a clear competent and coherent fashion that she wished to go forward with the transesophageal echocardiogram. + +PROCEDURE: + + The appropriate time-out procedure was performed as per Medical Center protocol under my direct supervision with appropriate identification of the patient, position, physician, procedure documentation; there were no safety issues identified by staff nor myself. She received 20 cc of viscous lidocaine for topical oral anesthetic effect. She received a total of 4 mg of Versed and 100 micrograms of fentanyl utilizing titrated conscious sedation with continuous hemodynamic and oximetric monitoring with reasonable effect. The multi-plane probe was passed using digital guidance for several passes, after an oral bite block had been put into place for protection of oral dentition. This was placed into the posterior oropharynx and advanced into the esophagus, then advanced into the stomach and then rotated and withdrawn and removed with adequate imaging obtained throughout. She was recovered as per the Medical Center conscious sedation protocol, and there were no apparent complications of the procedure. + +FINDINGS: + + Normal left ventricular size and systolic function. LVEF of 60%. Mild left atrial enlargement. Normal right atrial size. Normal right ventricular size and systolic function. No left ventricular wall motion abnormalities identified. The four pulmonary veins are identified. The left atrial appendage is interrogated, including with Doppler and color flow, and while there is good to-and-fro motion seen, echo smoke is seen, and in fact, an intracardiac thrombus is identified and circumscribed at 1.83 cm in circumference at the base of the left atrial appendage. No intracardiac vegetations nor endocarditis seen on any of the intracardiac valves. The mitral valve is seen. There is mild mitral regurgitation with two jets. No mitral stenosis. Four pulmonary veins were identified without reversible pulmonary venous flow. There are three cusps of the aortic valve seen. No aortic stenosis. There is trace aortic insufficiency. There is trace pulmonic insufficiency. The pulmonary artery is seen and is within normal limits. There is trace to mild tricuspid regurgitation. Unable to estimate PA systolic pressure accurately; however, on the recent transthoracic echocardiogram (which I would direct the reader to) on January 5, 2010, RVSP was calculated at 40 mmHg on that study. E wave velocity on average is 0.95 m/sec with a deceleration time of 232 milliseconds. The proximal aorta is within normal limits, annulus 1.19 cm, sinuses of Valsalva 2.54 cm, ascending aorta 2.61 cm. The intra-atrial septum is identified as are the SVC and IVC + + and these are within normal limits. The intra-atrial septum is interrogated with color flow as well as agitated D5W and there is no evidence of intracardiac shunting, including no atrial septal defect nor patent foramen ovale. No pericardial effusion. There is mild nonmobile descending aortic atherosclerosis seen. + +IMPRESSION: + +1. Normal left ventricular size and systolic function. Left ventricular ejection fraction visually estimated at 60% without regional wall motion abnormalities. + +2. Mild left atrial enlargement. + +3. Intracardiac thrombus identified at the base of the left atrial appendage. + +4. Mild mitral regurgitation with two jets. + +5. Mild nonmobile descending aortic atherosclerosis. + +Compared to the transthoracic echocardiogram done previously, other than identification of the intracardiac thrombus, other findings appear quite similar. + +These results have been discussed with Dr. A of inpatient Internal Medicine service as well as the patient, who was recovering from conscious sedation, and her daughter with the patient's verbal consent. \ No newline at end of file diff --git a/1507_Radiology.txt b/1507_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..a168a6f02006f25313ea6bc8e08ef827992802af --- /dev/null +++ b/1507_Radiology.txt @@ -0,0 +1,23 @@ +EXAM: + + Ultrasound Abdomen. + + + +REASON FOR EXAM: + + Elevated liver function tests. + + + +INTERPRETATION: + + The liver demonstrates heterogeneously increased echotexture with significant fatty infiltration. The gallbladder is surgically absent. There is no fluid collection in the cholecystectomy bed. There is dilatation of the common bile duct up to 1 cm. There is also dilatation of the pancreatic duct that measures up to 3 mm. There is caliectasis in the right kidney. The bladder is significantly distended measuring 937 cc in volume. The caliectasis in the right kidney may be secondary to back pressure from the distended bladder. The aorta is normal in caliber. + + + +IMPRESSION: + +1. Dilated common duct as well as pancreatic duct as described. Given the dilatation of these two ducts, ERCP versus MRCP is recommended to exclude obstructing mass. The findings could reflect changes of cholecystectomy. + +2. Significantly distended bladder with probably resultant caliectasis in the right kidney. Clinical correlation recommended. \ No newline at end of file diff --git a/1511_Radiology.txt b/1511_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..90c7bbafc408016d1ea918a6f5494de3c907b18c --- /dev/null +++ b/1511_Radiology.txt @@ -0,0 +1,32 @@ +CLINICAL INDICATIONS: + + MRSA bacteremia, rule out endocarditis. The patient has aortic stenosis. + +DESCRIPTION OF PROCEDURE: + + The transesophageal echocardiogram was performed after getting verbal and a written consent signed. Then a multiplane TEE probe was introduced into the upper esophagus, mid esophagus, lower esophagus, and stomach and multiple views were obtained. There were no complications. The patient's throat was numbed with Cetacaine spray and IV sedation was achieved with Versed and fentanyl. + +FINDINGS: + +1. Aortic valve is thick and calcified, a severely restricted end opening and there is 0.6 x 8 mm vegetation attached to the right coronary cusp. The peak velocity across the aortic valve was 4.6 m/sec and mean gradient was 53 mmHg and peak gradient 84 mmHg with calculated aortic valve area of 0.6 sq cm by planimetry. + +2. Mitral valve is calcified and thick. No vegetation seen. There is mild-to-moderate MR present. There is mild AI present also. + +3. Tricuspid valve and pulmonary valve are structurally normal. + +4. There is a mild TR present. + +5. There is no clot seen in the left atrial appendage. The velocity in the left atrial appendage was 0.6 m/sec. + +6. Intraatrial septum was intact. There is no clot or mass seen. + +7. Normal LV and RV systolic function. + +8. There is thick raised calcified plaque seen in the thoracic aorta and arch. + +SUMMARY: + +1. There is a 0.6 x 0.8 cm vegetation present in the aortic valve with severe aortic stenosis. Calculated aortic valve area was 0.6 sq. cm. + +2. Normal LV systolic function. + diff --git a/1513_Radiology.txt b/1513_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..3b11ef91815913ab660cd36995ef9abf632826f5 --- /dev/null +++ b/1513_Radiology.txt @@ -0,0 +1,17 @@ +TESTICULAR ULTRASOUND + +REASON FOR EXAM: + +Left testicular swelling for one day. + +FINDINGS: + +The left testicle is normal in size and attenuation, it measures 3.2 x 1.7 x 2.3 cm. The right epididymis measures up to 9 mm. There is a hydrocele on the right side. Normal flow is seen within the testicle and epididymis on the right. + +The left testicle is normal in size and attenuation, it measures 3.9 x 2.1 x 2.6 cm. The left testicle shows normal blood flow. The left epididymis measures up to 9 mm and shows a markedly increased vascular flow. There is mild scrotal wall thickening. A hydrocele is seen on the left side. + +IMPRESSION: + +1. Hypervascularity of the left epididymis compatible with left epididymitis. + +2. Bilateral hydroceles. \ No newline at end of file diff --git a/1516_Radiology.txt b/1516_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..9420c364897bd5c4370bc6ff3620fa2ab745947b --- /dev/null +++ b/1516_Radiology.txt @@ -0,0 +1,45 @@ +REASON FOR EXAM: + + Aortic valve replacement. Assessment of stenotic valve. Evaluation for thrombus on the valve. + +PREOPERATIVE DIAGNOSIS: + +Atrial valve replacement. + +POSTOPERATIVE DIAGNOSES: + + Moderate stenosis of aortic valve replacement. Mild mitral regurgitation. Normal left ventricular function. + +PROCEDURES IN DETAIL: + + The procedure was explained to the patient with risks and benefits. The patient agreed and signed the consent form. The patient received a total of 3 mg of Versed and 50 mcg of fentanyl for conscious sedation and pain control. The oropharynx anesthetized with benzocaine spray and lidocaine solution. + +Esophageal intubation was done with no difficulty with the second attempt. In a semi-Fowler position, the probe was passed to transthoracic views at about 40 to 42 cm. Multiple pictures obtained. Assessment of the peak velocity was done later. + +The probe was pulled to the mid esophageal level. Different pictures including short-axis views of the aortic valve was done. Extubation done with no problems and no blood on the probe. The patient tolerated the procedure well with no immediate postprocedure complications. + +INTERPRETATION: + + The left atrium was mildly dilated. No masses or thrombi were seen. The left atrial appendage was free of thrombus. Pulse wave interrogation showed peak velocities of 60 cm per second. + +The left ventricle was normal in size and contractility with mild LVH. EF is normal and preserved. + +The right atrium and right ventricle were both normal in size. + +Mitral valve showed no vegetations or prolapse. There was mild-to-moderate regurgitation on color flow interrogation. Aortic valve was well-seated mechanical valve, bileaflet with acoustic shadowing beyond the valve noticed. No perivalvular leak was noticed. There was increased velocity across the valve with peak velocity of 3.2 m/sec with calculated aortic valve area by continuity equation at 1.2 cm2 indicative of moderate aortic valve stenosis based on criteria for native heart valves. + +No AIC. + +Pulmonic valve was somewhat difficult to see because of acoustic shadowing from the aortic valve. Overall showed no abnormalities. The tricuspid valve was structurally normal. + +Interatrial septum appeared to be intact, confirmed by color flow interrogation as well as agitated saline contrast study. + +The aorta and aortic arch were unremarkable. No dissection. + +IMPRESSION: + +1. Mildly dilated left atrium. + +2. Mild-to-moderate regurgitation. + +3. Well-seated mechanical aortic valve with peak velocity of 3.2 m/sec and calculated valve area of 1.2 cm2 consistent with moderate aortic stenosis. Reevaluation in two to three years with transthoracic echocardiogram will be recommended. \ No newline at end of file diff --git a/1524_Radiology.txt b/1524_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..e87d4ed0337c1b0820e54d96ad1380a2f41ffcb5 --- /dev/null +++ b/1524_Radiology.txt @@ -0,0 +1,21 @@ +INDICATIONS: + +Chest pain, hypertension, type II diabetes mellitus. + +PROCEDURE DONE: + + Dobutamine Myoview stress test. + +STRESS ECG RESULTS: + + The patient was stressed by dobutamine infusion at a rate of 10 mcg/kg/minute for three minutes, 20 mcg/kg/minute for three minutes, and 30 mcg/kg/minute for three additional minutes. Atropine 0.25 mg was given intravenously eight minutes into the dobutamine infusion. The resting electrocardiogram reveals a regular sinus rhythm with heart rate of 86 beats per minute, QS pattern in leads V1 and V2, and diffuse nonspecific T wave abnormality. The heart rate increased from 86 beats per minute to 155 beats per minute, which is about 90% of the maximum predicted target heart rate. The blood pressure increased from 130/80 to 160/70. A maximum of 1 mm J-junctional depression was seen with fast up sloping ST segments during dobutamine infusion. No ischemic ST segment changes were seen during dobutamine infusion or during the recovery process. + +MYOCARDIAL PERFUSION IMAGING: + + Resting myocardial perfusion SPECT imaging was carried out with 10.9 mCi of Tc-99m Myoview. Dobutamine infusion myocardial perfusion imaging and gated scan were carried out with 29.2 mCi of Tc-99m Myoview. The lung heart ratio is 0.36. Myocardial perfusion images were normal both at rest and with stress. Gated myocardial scan revealed normal regional wall motion and ejection fraction of 67%. + +CONCLUSIONS: + +1. Stress test is negative for dobutamine-induced myocardial ischemia. + +2. Normal left ventricular size, regional wall motion, and ejection fraction. \ No newline at end of file diff --git a/1530_Radiology.txt b/1530_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..dfdc87826279b8a0448b738c109d9dab7416fd3c --- /dev/null +++ b/1530_Radiology.txt @@ -0,0 +1,23 @@ +EXAM: + + Single frontal view of the chest. + +HISTORY: + + Atelectasis. Patient is status-post surgical correction for ASD. + +TECHNIQUE: + + A single frontal view of the chest was evaluated and correlated with the prior film dated mm/dd/yy. + +FINDINGS: + + Current film reveals there is a right-sided central venous catheter, the distal tip appears to be in the superior vena cava. Endotracheal tube with the distal tip appears to be in appropriate position, approximately 2 cm superior to the carina. Sternotomy wires are noted. They appear in appropriate placement. There are no focal areas of consolidation to suggest pneumonia. Once again seen is minimal amount of bilateral basilar atelectasis. The cardiomediastinal silhouette appears to be within normal limits at this time. No evidence of any pneumothoraces or pleural effusions. + +IMPRESSION: + +1. There has been interval placement of a right-sided central venous catheter, endotracheal tube, and sternotomy wires secondary to patient's most recent surgical intervention. + +2. Minimal bilateral basilar atelectasis with no significant interval changes from the patient's most recent prior. + +3. Interval decrease in the patient's heart size which may be secondary to the surgery versus positional and technique. \ No newline at end of file diff --git a/1534_Radiology.txt b/1534_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..9e3b9f4bc724c2b085d0dbb0d78aa4c4c825efb4 --- /dev/null +++ b/1534_Radiology.txt @@ -0,0 +1,39 @@ +INDICATION FOR STUDY: + + Elevated cardiac enzymes, fullness in chest, abnormal EKG + + and risk factors. + +MEDICATIONS: + + Femara, verapamil, Dyazide, Hyzaar, glyburide, and metformin. + +BASELINE EKG: + + Sinus rhythm at 84 beats per minute, poor anteroseptal R-wave progression, mild lateral ST abnormalities. + +EXERCISE RESULTS: + +1. The patient exercised for 3 minutes stopping due to fatigue. No chest pain. + +2. Heart rate increased from 84 to 138 or 93% of maximum predicted heart rate. Blood pressure rose from 150/88 to 210/100. There was a slight increase in her repolorization abnormalities in a non-specific pattern. + +NUCLEAR PROTOCOL: + +Same day rest/stress protocol was utilized with 11 mCi for the rest dose and 33 mCi for the stress test. + +NUCLEAR RESULTS: + +1. Nuclear perfusion imaging, review of the raw projection data reveals adequate image acquisition. The resting images showed decreased uptake in the anterior wall. However the apex is spared of this defect. There is no significant change between rest and stress images. The sum score is 0. + +2. The Gated SPECT shows moderate LVH with slightly low EF of 48%. + +IMPRESSION: + +1. No evidence of exercise induced ischemia at a high myocardial workload. This essentially excludes obstructive CAD as a cause of her elevated troponin. + +2. Mild hypertensive cardiomyopathy with an EF of 48%. + +3. Poor exercise capacity due to cardiovascular deconditioning. + +4. Suboptimally controlled blood pressure on today's exam. \ No newline at end of file diff --git a/1535_Radiology.txt b/1535_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..12166a99ef2d1ae126dc7827ce6084bdd6d8afa9 --- /dev/null +++ b/1535_Radiology.txt @@ -0,0 +1,21 @@ +PROCEDURE: + + Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain. + +ANESTHESIA: + + Local sedation. + +VITAL SIGNS: + + See nurse's notes. + +COMPLICATIONS: + + None. + +DETAILS OF PROCEDURE: + +INT was placed. The patient was in the operating room in the prone position with the back prepped and draped in a sterile fashion. The patient was given sedation and monitored. Lidocaine 1.5% for skin wheal was made 10 cm from the midline to the bilateral L2 distal vertebral body. A 20-gauge, 15 cm SMK needle was then directed using AP and fluoroscopic guidance so that the tip of the needle was noted to be along the distal one-third and anterior border on the lateral view and on the AP view the tip of the needle was inside the lateral third of the border of the vertebral body. At this time a negative motor stimulation was obtained. Injection of 10 cc of 0.5% Marcaine plus 10 mg of Depo-Medrol was performed. Coagulation was then carried out for 90oC for 90 seconds. At the conclusion of this, the needle under fluoroscopic guidance was withdrawn approximately 5 mm where again a negative motor stimulation was obtained and the sequence of injection and coagulation was repeated. This was repeated one more time with a 5 mm withdrawal and coagulation. + +At that time, attention was directed to the L3 body where the needle was placed to the upper one-third/distal two-thirds junction and the sequence of injection, coagulation, and negative motor stimulation with needle withdrawal one time of a 5 mm distance was repeated. There were no compilations from this. The patient was discharged to operating room recovery in stable condition. \ No newline at end of file diff --git a/1538_Radiology.txt b/1538_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..c636f85a5689eb39697776565bf61643329e594d --- /dev/null +++ b/1538_Radiology.txt @@ -0,0 +1,15 @@ +EXAM: + + Cervical, lumbosacral, thoracic spine flexion and extension. + +HISTORY: + + Back and neck pain. + +CERVICAL SPINE + +FINDINGS: + +AP + + lateral with flexion and extension, and both oblique projections of the cervical spine demonstrate alignment and soft tissue structures to be unremarkable. \ No newline at end of file diff --git a/1539_Radiology.txt b/1539_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..6fda1663a2853fbd37e5b4db87bed91505b5ebc2 --- /dev/null +++ b/1539_Radiology.txt @@ -0,0 +1,5 @@ +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. \ No newline at end of file diff --git a/1540_Radiology.txt b/1540_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..c544550c985cf33ddcf6bde7c35fe1da43fe036d --- /dev/null +++ b/1540_Radiology.txt @@ -0,0 +1,15 @@ +EXAM: + + Right foot series. + +REASON FOR EXAM: + +Injury. + +FINDINGS: + + Three images of the right foot were obtained. On the AP image only, there is a subtle lucency seen in the proximal right fourth metatarsal and a mild increased sclerosis in the proximal fifth metatarsal. Also on a single image, there is a lucency seen in the lateral aspect of the calcaneus that is seen on the oblique image only. Fractures in these bones cannot be completely excluded. There is soft tissue swelling seen overlying the calcaneus within this region. + +IMPRESSION: + + Cannot exclude nondisplaced fractures in the lateral aspect of the calcaneus or at the base of the fourth and fifth metatarsals. Recommend correlation with site of pain in addition to conservative management and followup imaging. A phone call will be placed to the emergency room regarding these findings. \ No newline at end of file diff --git a/1542_Radiology.txt b/1542_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..1ccb912b7d29ac5f8fc0d804b04009d90defec2e --- /dev/null +++ b/1542_Radiology.txt @@ -0,0 +1,19 @@ +EXAM: + + Nuclear medicine lymphatic scan. + +REASON FOR EXAM: + + Left breast cancer. + +TECHNIQUE: + + 1.0 mCi of Technetium-99m sulfur colloid was injected within the dermis surrounding the left breast biopsy site at four locations. A 16-hour left anterior oblique imaging was performed with and without shielding of the original injection site. + +FINDINGS: + +There are two small foci of increased activity in the left axilla. This is consistent with the sentinel lymph node. No other areas of activity are visualized outside of the injection site and two axillary lymph nodes. + +IMPRESSION: + +Technically successful lymph node injection with two areas of increased activity in the left axilla consistent with sentinel lymph node. \ No newline at end of file diff --git a/1544_Radiology.txt b/1544_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..5347136664c21a2ce640145ba56857a5d26d7a91 --- /dev/null +++ b/1544_Radiology.txt @@ -0,0 +1,29 @@ +INDICATION: + + Lung carcinoma. + +Whole body PET scanning was performed with 11 mCi of 18 FDG. Axial, coronal and sagittal imaging was performed over the neck, chest abdomen and pelvis. + +FINDINGS: + +There is normal physiologic activity identified in the myocardium, liver, spleen, ureters, kidneys and bladder. + +There is abnormal FDG-avid activity identified in the posterior left paraspinal region best seen on axial images 245-257 with an SUV of 3.8, no definite bone lesion is identified on the CT scan or the bone scan dated 08/14/2007 (It may be purely lytic). + +Additionally there is a significant area of activity corresponding to a mass in the region of the left hilum that is visible on the CT scan with an SUV of 18.1, the adjacent atelectasis as likely post obstructive in nature. + +Additionally, although there is no definite lesion identified on CT + + there is a tiny satellite nodule in the left upper lobe that is hypermetabolic with an SUV of 5.0. The spiculated density seen in the right upper lobe on the CT scan does not demonstrate FDG activity on this PET scan. + +There is a hypermetabolic lymph node identified in the aorta pulmonary window with an SUV of 3.7 in the mediastinum. + +IMPRESSION: + +No prior PET scans for comparison, there is a large lesion identified in the area of the left hilum with an SUV of 18.1 likely causing the obstructive atelectasis seen on the CT scan. + +There is a tiny satellite area of hypermetabolic FDG in the left upper lobe adjacent to the pleura with an SUV of 5.0. + +There is a area of hypermetabolic activity in the left paraspinal soft tissues at the level of the lung apices which may represent a focal bone lesion. However no lesion is identified on bone scan or CT scan. + +There is a hypermetabolic lymph node identified. The aorta pulmonary window with a corresponding finding on CT scan with an SUV of 3.7. \ No newline at end of file diff --git a/1545_Radiology.txt b/1545_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..7c917c57fccbf541c46a510274e9f9f65ce7c7c1 --- /dev/null +++ b/1545_Radiology.txt @@ -0,0 +1,19 @@ +EXAM: + + Nuclear medicine tumor localization, whole body. + +HISTORY: + + Status post subtotal thyroidectomy for thyroid carcinoma, histology not provided. + +FINDINGS: + + Following the oral administration of 4.3 mCi Iodine-131, whole body planar images were obtained in the anterior and posterior projections at 24, 48, and 72 hours. + +There is increased uptake in the left upper quadrant, which persists throughout the examination. There is a focus of increased activity in the right lower quadrant, which becomes readily apparent at 72 hours. Physiologic uptake in the liver, spleen, and transverse colon is noted. Physiologic urinary bladder uptake is also appreciated. There is low-grade uptake in the oropharyngeal region. + +IMPRESSION: + +Iodine-avid foci in the right lower quadrant and left upper quadrant medially suspicious for distant metastasis. Anatomical evaluation, i.e. + + CT is advised to determine if there are corresponding mesenteric lesions. Ultimately (provided that the original pathology of the thyroid tumor with iodine-avid) PET scanning may be necessary. No evidence of iodine added locoregional metastasis. \ No newline at end of file diff --git a/1547_Radiology.txt b/1547_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..d8fd3668223e1ca251e8d3eb58a566712a492b49 --- /dev/null +++ b/1547_Radiology.txt @@ -0,0 +1,19 @@ +INDICATIONS: + + Previously markedly abnormal dobutamine Myoview stress test and gated scan. + +PROCEDURE DONE: + + Resting Myoview perfusion scan and gated myocardial scan. + +MYOCARDIAL PERFUSION IMAGING: + + Resting myocardial perfusion SPECT imaging and gated scan were carried out with 32.6 mCi of Tc-99m Myoview. Rest study was done and compared to previous dobutamine Myoview stress test done on Month DD + + YYYY. The lung heart ratio is 0.34. There appears to be a moderate size inferoapical perfusion defect of moderate degree. The gated myocardial scan revealed mild apical and distal inferoseptal hypokinesis with ejection fraction of 55%. + +CONCLUSIONS: + + Study done at rest only revealed findings consistent with an inferior non-transmural scar of moderate size and moderate degree. The left ventricular systolic function is markedly improved with much better regional wall motion of all left ventricular segments when compared to previous study done on Month DD + + YYYY. We cannot assess the presence of any reversible perfusion defects because no stress imaging was performed. \ No newline at end of file diff --git a/1550_Radiology.txt b/1550_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..5d88a5e812f9380e0788d95b74d8d6920b8b460f --- /dev/null +++ b/1550_Radiology.txt @@ -0,0 +1,8 @@ +DIAGNOSIS: + +Shortness of breath. Fatigue and weakness. Hypertension. Hyperlipidemia. + +INDICATION: + + To evaluate for coronary artery disease. + diff --git a/1551_Radiology.txt b/1551_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..ea44fb6cfe80ffb68bebd04f00dcc3be0ba73a8b --- /dev/null +++ b/1551_Radiology.txt @@ -0,0 +1,31 @@ +FINDINGS: + +There are posttraumatic cysts along the volar midline and volar lateral aspects of the lunate which are likely posttraumatic. There is no acute marrow edema (series #12 images #5-7). Marrow signal is otherwise normal in the distal radius and ulna, throughout the carpals and throughout the proximal metacarpals. + +There is a partial tear of the volar component of the scapholunate ligament in the region of the posttraumatic lunate cyst with retraction and thickening towards the scaphoid (series #6 image #5, series #8 images #22-36). There is tearing of the membranous portion of the ligament. The dorsal component is intact. + +The lunatotriquetral ligament is thickened and lax, but intact (series #8 image #32). + +There is no tearing of the radial or ulnar attachment of the triangular fibrocartilage (series #6 image #7). There is a mildly positive ulnar variance. Normal ulnar collateral ligament. + +The patient was positioned in dorsiflexion. Carpal alignment is normal and there are no tears of the dorsal or ventral intercarpal ligaments (series #14 image #9). + +There is a longitudinal split tear of the ECU tendon which is enlarged both at the level of and distal to the ulnar styloid with severe synovitis (series #4 images #8-16, series #3 images #9-16). + +There is thickening of the extensor tendon sheaths within the fourth dorsal compartment with intrinsically normal tendons (series #4 image #12). + +There is extensor carpi radialis longus and brevis synovitis in the second dorsal compartment (series #4 image #13). + +Normal flexor tendons within the carpal tunnel. There is mild thickening of the tendon sheaths and the median nerve demonstrates increased signal without compression or enlargement (series #3 image #7, series #4 image #7). + +There are no pathological cysts or soft tissue masses. + +IMPRESSION: + +Partial tear of the volar and membranous components of the scapholunate ligament with an associated posttraumatic cyst in the lunate. There is thickening and laxity of the lunatotriquetral ligament. + +Longitudinal split tear of the ECU tendon with tendinosis and severe synovitis. + +Synovitis of the second dorsal compartment and tendon sheath thickening in the fourth dorsal compartment. + +Tendon sheath thickening within the carpal tunnel with increased signal within the median nerve. \ No newline at end of file diff --git a/1560_Radiology.txt b/1560_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..81eafbb0a8a222500625d9b9e1c3118757986d10 --- /dev/null +++ b/1560_Radiology.txt @@ -0,0 +1,31 @@ +EXAM: + +MRI LEFT SHOULDER + +CLINICAL: + +This is a 69-year-old male with pain in the shoulder. Evaluate for rotator cuff tear. + +FINDINGS: + +Examination was performed on 9/1/05. + +There is marked supraspinatus tendinosis and extensive tearing of the substance of the tendon and articular surface, extending into the myotendinous junction as well. There is still a small rim of tendon along the bursal surface, although there may be a small tear at the level of the rotator interval. There is no retracted tendon or muscular atrophy (series #6 images #6-17). + +Normal infraspinatus tendon. + +There is subscapularis tendinosis with fraying and partial tearing of the superior most fibers extending to the level of the rotator interval (series #9 images #8-13; series #3 images #8-14). There is no complete tear, gap or fiber retraction and there is no muscular atrophy. + +There is tendinosis and superficial tearing of the long biceps tendon within the bicipital groove, and there is high grade (near complete) partial tearing of the intracapsular portion of the tendon. The biceps anchor is intact. There are degenerative changes in the greater tuberosity of the humerus but there is no fracture or subluxation. + +There is degeneration of the superior labrum and there is a small nondisplaced tear in the posterior superior labrum at the one to two o’clock position (series #6 images #12-14; series #3 images #8-10; series #9 images #5-8). There is a small sublabral foramen at the eleven o’clock position (series #9 image #6). There is no osseous Bankart lesion. + +Normal superior, middle and inferior glenohumeral ligaments. + +There is hypertrophic osteoarthropathy of the acromioclavicular joint with narrowing of the subacromial space and flattening of the superior surface of the supraspinatus musculotendinous junction, which in the appropriate clinical setting is an MRI manifestation of an impinging lesion (series #8 images #3-12). + +Normal coracoacromial, coracohumeral and coracoclavicular ligaments. There is minimal fluid within the glenohumeral joint. There is no atrophy of the deltoid muscle. + +IMPRESSION: + + There is extensive supraspinatus tendinosis and partial tearing as described. There is no retracted tendon or muscular atrophy, but there may be a small tear along the anterior edge of the tendon at the level of the rotator interval, and this associated partial tearing of the superior most fibers of the subscapularis tendon. There is also a high-grade partial tear of the long biceps tendon as it courses under the transverse humeral ligament. There is no evidence of a complete tear or retracted tendon. Small nondisplaced posterior superior labral tear. Outlet narrowing from the acromioclavicular joint, which in the appropriate clinical setting is an MRI manifestation of an impinging lesion. \ No newline at end of file diff --git a/1567_Radiology.txt b/1567_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..a1c9096d6718a6477ce536e18f4dd0979991e241 --- /dev/null +++ b/1567_Radiology.txt @@ -0,0 +1,27 @@ +EXAM: + + MRI orbit/face/neck with and without contrast; MR angiography of the head,CLINICAL HISTORY: + + 1-day-old female with facial mass. + +TECHNIQUE: + +1. Multisequence, multiplanar images of the orbits/face/neck were obtained with and without contrast. 0.5 ml Magnevist was used as the intravenous contrast agent. + +2. MR angiography of the head was obtained using a time-of-flight technique. + +3. The patient was under general anesthesia during the exam. + +FINDINGS: + + MRI orbits/face/neck: There is a pedunculated mass measuring 5.7 x 4.4 x 6.7 cm arising from the patient's lip on the right side. The mass demonstrates a heterogeneous signal. There is also heterogeneous enhancement which may relate to a high vascular tumor given the small amount of contrast for the exam. The origin of the mass from the upper lip demonstrates intact soft tissue planes. + +Limited evaluation of the head demonstrates normal appearing midline structures. Incidental note is made of a small arachnoid cyst within the anterior left middle cranial fossa. The mastoid air cells on the right are opacified; while the left demonstrates appropriate aeration. + +MR angiography of the head: Angiography is limited such that the vessel feeding the mass cannot be identified with certainty. The right external carotid artery is noted to be asymmetrically larger than the left, the phenomenon likely related to provision of feeding vessels to the mass. There is no carotid stenosis. + +IMPRESSION: + +1. The mass arising from the right upper lip measures 5.7 x 4.4 x 6.7 cm with a heterogeneous appearance and enhancement pattern. Hemangioma should be considered in the differential diagnosis as well as other mesenchymal neoplasms. + +2. MR angiography is suboptimal such that feeding vessels to the mass cannot be identified with certainty. \ No newline at end of file diff --git a/1569_Radiology.txt b/1569_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..0c36fa8ea11ad9063a528b84e196a6aaa5e07733 --- /dev/null +++ b/1569_Radiology.txt @@ -0,0 +1,39 @@ +CC: + + Found unresponsive. + +HX: + + 39 y/o RHF complained of a severe HA at 2AM 11/4/92. It was unclear whether she had been having HA prior to this. She took an unknown analgesic, then vomited, then lay down in bed with her husband. When her husband awoke at 8AM he found her unresponsive with "stiff straight arms" and a "strange breathing pattern." A Brain CT scan revealed a large intracranial mass. She was intubated and hyperventilated to ABG (7.43/36/398). Other local lab values included: WBC 9.8, RBC 3.74, Hgb 13.8, Hct 40.7, Cr 0.5, BUN 8.5, Glucose 187, Na 140, K 4.0, Cl 107. She was given Mannitol 1gm/kg IV load, DPH 20mg/kg IV load, and transferred by helicopter to UIHC. + +PMH: + + 1)Myasthenia Gravis for 15 years, s/p Thymectomy,MEDS: + + Imuran, Prednisone, Mestinon, Mannitol, DPH + + IV NS + +FHX/SHX: + + Married. Tobacco 10 pack-year; quit nearly 10 years ago. ETOH/Substance Abuse unknown. + +EXAM: + + 35.8F, 99BPM + + BP117/72, Mechanically ventilated at a rate of 22RPM on !00%FiO2. Unresponsive to verbal stimulation. CN: Pupils 7mm/5mm and unresponsive to light (fixed). No spontaneous eye movement or blink to threat. No papilledema or intraocular hemorrhage noted. Trace corneal reflexes bilaterally. No gag reflex. No oculocephalic reflex. MOTOR/SENSORY: No spontaneous movement. On noxious stimulation (Deep nail bed pressure) she either extended both upper extremities (RUE>LUE) + + or withdrew the stimulated extremity (right > left). Gait/Station/Coordination no tested. Reflexes: 1+ on right and 2+ on left with bilateral Babinski signs. + +HCT 11/4/92: Large heterogeneous mass in the right temporal-parietal region causing significant parenchymal distortion and leftward subfalcine effect . There is low parenchymal density within the white matter. A hyperdense ring lies peripherally and may represent hemorrhage or calcification. The mass demonstrates inhomogeneous enhancement with contrast. + +COURSE: + + Head of bed elevated to 30 degrees, Mannitol and DPH were continued. MRI of Brain demonstrated a large right parietal mass with necrotic appearing center and leftward shift of midline structures. She underwent surgical resection of the tumor. Pathological analysis was consistent with adenocarcinoma. GYN exam, CT Abdomen and Pelvis, Bone scan were unremarkable. CXR revealed an right upper lobe lung nodule. She did not undergo thoracic biopsy due to poor condition. She received 3000 cGy cranial XRT in ten fractions and following this was discharged to a rehabilitation center. + +In March, 1993 the patient exhibited right ptosis, poor adduction and abduction OD + + 4/4 strength in the upper extremities and 5-/5- strength in the lower extremities. She was ambulatory with an ataxic gait. + +She was admitted on 7/12/93 for lower cervical and upper thoracic pain, paraparesis and T8 sensory level. MRI brainstem/spine on that day revealed decreased T1 signal in the C2, C3, C6 vertebral bodies, increased T2 signal in the anterior medulla, and tectum, and spinal cord (C7-T3). Following injection of Gadolinium there was diffuse leptomeningeal enhancement from C7-T7 These findings were felt consistent with metastatic disease including possible leptomeningeal spread. Neurosurgery and Radiation Oncology agreed that the patients symptoms could be due to either radiation injury and/or metastasis. The patient was treated with Decadron and analgesics and discharged to a hospice center (her choice). She died a few months later. \ No newline at end of file diff --git a/1570_Radiology.txt b/1570_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..5806536e53164805ddedcd6551e31d62d8468318 --- /dev/null +++ b/1570_Radiology.txt @@ -0,0 +1,87 @@ +CC: + +Low Back Pain (LBP) with associated BLE weakness. + +HX: + + This 75y/o RHM presented with a 10 day h/o progressively worsening LBP. The LBP started on 12/3/95; began radiating down the RLE + + on 12/6/95; then down the LLE + + on 12/9/95. By 12/10/95, he found it difficult to walk. On 12/11/95, he drove himself to his local physician, but no diagnosis was rendered. He was given some NSAID and drove home. By the time he got home he had great difficulty walking due to LBP and weakness in BLE + + but managed to feed his pets and himself. On 12/12/95 he went to see a local orthopedist, but on the way to his car he crumpled to the ground due to BLE weakness and LBP pain. He also had had BLE numbness since 12/11/95. He was evaluated locally and an L-S-Spine CT scan and L-S Spine X-rays were "negative." He was then referred to UIHC. + +MEDS: + +SLNTC + + Coumadin 4mg qd, Propranolol, Procardia XL + + Altace, Zaroxolyn. + +PMH: + +1) MI 11/9/78, 2) Cholecystectomy, 3) TURP for BPH 1980's, 4) HTN + + 5) Amaurosis Fugax, OD + + 8/95 (Mayo Clinic evaluation--TEE (-) + + but Carotid Doppler (+) but "non-surgical" so placed on Coumadin). + +FHX: + + Father died age 59 of valvular heart disease. Mother died of DM. Brother had CABG 8/95. + +SHX: + + retired school teacher. 0.5-1.0 pack cigarettes per day for 60 years. + +EXAM: + + BP130.56, HR68, RR16, Afebrile. + +MS: A&O to person, place, time. Speech fluent without dysarthria. Lucid. Appeared uncomfortable. + +CN: Unremarkable. + +MOTOR: 5/5 strength in BUE. Lower extremity strength: Hip flexors & extensors 4-/4- + + Hip abductors 3+/3+ + + Hip adductors 5/5, Knee flexors & extensors 4/4- + + Ankle flexion 4-/4- + + Tibialis Anterior 2/2- + + Peronei 3-/3-. Mild atrophy in 4 extremities. Questionable fasciculations in BLE. Spasms illicited on striking quadriceps with reflex hammer (? percussion myotonia). No rigidity and essential normal muscle tone on passive motion. + +SENSORY: Decreased vibratory sense in stocking distribution from toes to knees in BLE (worse on right). No sensory level. PP/LT/TEMP testing unremarkable. + +COORD: Normal FNF-RAM. Slowed HKS due to weakness. + +Station: No pronator drift. Romberg testing not done. + +Gait: Unable to stand. + +Reflexes: 2/2 BUE. 1/trace patellae, 0/0 Achilles. Plantar responses were flexor, bilaterally. Abdominal reflex was present in all four quadrants. Anal reflex was illicited from all four quadrants. No jaw jerk or palmomental reflexes illicited. + +Rectal: normal rectal tone, guaiac negative stool. + +GEN EXAM: Bilateral Carotid Bruits, No lymphadenopathy, right inguinal hernia, rhonchi and inspiratory wheeze in both lung fields. + +COURSE: + +WBC 11.6, Hgb 13.4, Hct 38% + + Plt 295. ESR 40 (normal 0-14) + + CRP 1.4 (normal <0.4) + + INR 1.5, PTT 35 (normal) + + Creatinine 2.1, CK 346. EKG normal. The differential diagnosis included Amyotrophy, Polymyositis, Epidural hematoma, Disc Herniation and Guillain-Barre syndrome. An MRI of the lumbar spine was obtained, 12/13/95. This revealed an L3-4 disc herniation extending inferiorly and behind the L4 vertebral body. This disc was located more on the right than on the left + + compromised the right neural foramen, and narrowed the spinal canal. The patient underwent a L3-4 laminectomy and diskectomy and subsequently improved. He was never seen in follow-up at UIHC. \ No newline at end of file diff --git a/1575_Radiology.txt b/1575_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..af6b1d5129090c8f78f45fe5b4dd5398d7476252 --- /dev/null +++ b/1575_Radiology.txt @@ -0,0 +1,32 @@ +EXAM: + + MRI Head W&WO Contrast. + +REASON FOR EXAM: + + Dyspnea. + +COMPARISON: + + None. + +TECHNIQUE: + + MRI of the head performed without and with 12 ml of IV gadolinium (Magnevist). + +INTERPRETATION: + + There are no abnormal/unexpected foci of contrast enhancement. There are no diffusion weighted signal abnormalities. There are minimal, predominantly periventricular, deep white matter patchy foci of FLAIR/T2 signal hyperintensity, the rest of the brain parenchyma appearing unremarkable in signal. The ventricles and sulci are prominent, but proportionate. Per T2 weighted sequence, there is no hyperdense vascularity. There are no calvarial signal abnormalities. There is no significant mastoid air cell fluid. No significant sinus mucosal disease per MRI. + +IMPRESSION: + +1. No abnormal/unexpected foci of contrast enhancement; specifically, no evidence for metastases or masses. + +2. No evidence for acute infarction. + +3. Mild, scattered, patchy, chronic small vessel ischemic disease changes. + +4. Diffuse cortical volume loss, consistent with patient's age. + +5. Preliminary report was issued at the time of dictation. + diff --git a/1576_Radiology.txt b/1576_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..8cb97471c20009a31e8528401e49cfff38fed342 --- /dev/null +++ b/1576_Radiology.txt @@ -0,0 +1,53 @@ +EXAM: + +MRI LEFT FOOT + +CLINICAL: + + A 49-year-old female with ankle pain times one month, without a specific injury. Patient complains of moderate to severe pain, worse with standing or walking on hard surfaces, with tenderness to palpation at the plantar aspect of the foot and midfoot region and tenderness over the course of the posterior tibialis tendon. + +FINDINGS: + +Received for second opinion interpretations is an MRI examination performed on 05/27/2005. + +There is edema of the subcutis adipose space extending along the medial and lateral aspects of the ankle. + +There is edema of the subcutis adipose space posterior to the Achilles tendon. Findings suggest altered biomechanics with crural fascial strains. + +There is tendinosis of the posterior tibialis tendon as it rounds the tip of the medial malleolus with mild tendon thickening. There is possible partial surface tearing of the anterior aspect of the tendon immediately distal to the tip of the medial malleolus (axial inversion recovery image #16) which is a possible hypertrophic tear less than 50% in cross sectional diameter. The study has been performed with the foot in neutral position. Confirmation of this possible partial tendon tear would require additional imaging with the foot in a plantar flexed position with transaxial images of the posterior tibialis tendon as it rounds the tip of the medial malleolus oriented perpendicular to the course of the posterior tibialis tendon. + +There is minimal synovitis of the flexor digitorum longus and flexor hallucis longus tendon sheaths consistent with flexor splinting but intrinsically normal tendons. + +Normal peroneal tendons. + +There is tendinosis of the tibialis anterior tendon with thickening but no demonstrated tendon tear. Normal extensor hallucis longus and extensor digitorum tendons. + +Normal Achilles tendon. There is a low-lying soleus muscle that extends to within 2cm of the teno-osseous insertion of the Achilles tendon. + +Normal distal tibiofibular syndesmotic ligamentous complex. + +Normal lateral, subtalar and deltoid ligamentous complexes. + +There are no erosions of the inferior neck of the talus and there are no secondary findings of a midfoot pronating force. + +Normal plantar fascia. There is no plantar calcaneal spur. + +There is venous engorgement of the plantar veins of the foot extending along the medial and lateral plantar cutaneous nerves which may be acting as intermittent entrapping lesions upon the medial and lateral plantar cutaneous nerves. + +Normal tibiotalar, subtalar, talonavicular and calcaneocuboid articulations. + +The metatarsophalangeal joint of the hallux was partially excluded from the field-of-view of this examination. + +IMPRESSION: + +Tendinosis of the posterior tibialis tendon with tendon thickening and possible surface fraying / tearing of the tendon immediately distal to the tip of the medial malleolus, however, confirmation of this finding would require additional imaging. + +Minimal synovitis of the flexor digitorum longus and flexor hallucis longus tendon sheaths, consistent with flexor splinting. + +Edema of the subcutis adipose space along the medial and lateral aspects of the ankle suggesting altered biomechanics and crural fascial strain. + +Mild tendinosis of the tibialis anterior tendon with mild tendon thickening. + +Normal plantar fascia and no plantar fasciitis. + +Venous engorgement of the plantar veins of the foot which may be acting as entrapping lesions upon the medial and lateral plantar cutaneous nerves. \ No newline at end of file diff --git a/1579_Radiology.txt b/1579_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..00aa723854d0af85ecb6a25391e3f0505334d5fd --- /dev/null +++ b/1579_Radiology.txt @@ -0,0 +1,21 @@ +EXAM: + +MRI LEFT KNEE WITHOUT CONTRAST + +CLINICAL: + +Left knee pain. + +FINDINGS: + +Comparison is made with 10/13/05 radiographs. + +There is a prominent suprapatellar effusion. Patient has increased signal within the medial collateral ligament as well as fluid around it, compatible with type 2 sprain. There is fluid around the lateral collateral ligament without increased signal within the ligament itself, compatible with type 1 sprain. + +Medial and lateral menisci contain some minimal increased signal centrally that does not extend through an articular surface and findings are felt to represent minimal myxoid degeneration. No tear is seen. Anterior cruciate and posterior cruciate ligaments are intact. There is a bone bruise of medial patellar facet measuring approximately 8 x 5 mm. There is suggestion of some mild posterior aspect of the lateral tibial plateau. MR signal on the bone marrow is otherwise normal. + +IMPRESSION: + +Type 2 sprain in the medial collateral ligament and type sprain in the lateral collateral ligament. + +Joint effusion and bone bruise with suggestion of some minimal overlying chondromalacia and medial patellar facet. \ No newline at end of file diff --git a/1580_Radiology.txt b/1580_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..e171a374e85c3b632f42ea6f4bc99d0862f8087e --- /dev/null +++ b/1580_Radiology.txt @@ -0,0 +1,59 @@ +EXAM: + +MRI RIGHT FOOT + +CLINICAL: + +Pain and swelling in the right foot. + +FINDINGS: + +Obtained for second opinion interpretation is an MRI examination performed on 11-04-05. + +There is a transverse fracture of the anterior superior calcaneal process of the calcaneus. The fracture is corticated however and there is an active marrow stress phenomenon. There is a small ganglion measuring approximately 8 x 5 x 5mm in size extending along the bifurcate ligament. + +There is no substantial joint effusion of the calcaneocuboid articulation. There is minimal interstitial edema involving the short plantar calcaneal cuboid ligament. + +Normal plantar calcaneonavicular spring ligament. + +Normal talonavicular articulation. + +There is minimal synovial fluid within the peroneal tendon sheaths. + +Axial imaging of the ankle has not been performed orthogonal to the peroneal tendon distal to the retromalleolar groove. The peroneus brevis tendon remains intact extending to the base of the fifth metatarsus. The peroneus longus tendon can be identified in its short axis extending to its distal plantar insertion upon the base of the first metatarsus with minimal synovitis. + +There is minimal synovial fluid within the flexor digitorum longus and flexor hallucis longus tendon sheath with pooling of the fluid in the region of the knot of Henry. + +There is edema extending along the deep surface of the extensor digitorum brevis muscle. + +Normal anterior, subtalar and deltoid ligamentous complex. + +Normal naviculocuneiform, intercuneiform and tarsometatarsal articulations. + +The Lisfranc’s ligament is intact. + +The Achilles tendon insertion has been excluded from the field-of-view. + +Normal plantar fascia and intrinsic plantar muscles of the foot. + +There is mild venous distention of the veins of the foot within the tarsal tunnel. + +There is minimal edema of the sinus tarsus. The lateral talocalcaneal and interosseous talocalcaneal ligaments are normal. + +Normal deltoid ligamentous complex. + +Normal talar dome and no occult osteochondral talar dome defect. + +IMPRESSION: + +Transverse fracture of the anterior calcaneocuboid articulation with cortication and cancellous marrow edema. + +Small ganglion intwined within the bifurcate ligament. + +Interstitial edema of the short plantar calcaneocuboid ligament. + +Minimal synovitis of the peroneal tendon sheaths but no demonstrated peroneal tendon tear. + +Minimal synovitis of the flexor tendon sheaths with pooling of fluid within the knot of Henry. + +Minimal interstitial edema extending along the deep surface of the extensor digitorum brevis muscle. \ No newline at end of file diff --git a/1584_Radiology.txt b/1584_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..5589579e323cfe73e4e214bbf8a8fe919202f042 --- /dev/null +++ b/1584_Radiology.txt @@ -0,0 +1,49 @@ +CC: + + Right shoulder pain. + +HX: + +This 46 y/o RHF presented with a 4 month history of right neck and shoulder stiffness and pain. The symptoms progressively worsened over the 4 month course. 2 weeks prior to presentation she began to develop numbness in the first and second fingers of her right hand and RUE pain. The later was described as a throbbing pain. She also experienced numbness in both lower extremities and pain in the coccygeal region. The pains worsened at night and impaired sleep. She denied any visual change, bowel or bladder difficulties and symptoms involving the LUE. She occasionally experienced an electric shock like sensation shooting down her spine when flexing her neck (Lhermitte's phenomena). She denied any history of neck/back/head trauma. + +She had been taking Naprosyn with little relief. + +PMH: + +1) Catamenial Headaches. 2) Allergy to Macrodantin. + +SHX/FHX: + + Smokes 2ppd cigarettes. + +EXAM: + +Vital signs were unremarkable. + +CN: unremarkable. + +Motor: full strength throughout. Normal tone and muscle bulk. + +Sensory: No deficits on LT/PP/VIB/TEMP/PROP testing. + +Coord/Gait/Station: Unremarkable. + +Reflexes: 2/2 in BUE except 2+ at left biceps. 1+/1+BLE except an absent right ankle reflex. + +Plantar responses were flexor bilaterally. Rectal exam: normal tone. + +IMPRESSION: + + C-spine lesion. + +COURSE: + +MRI C-spine revealed a central C5-6 disk herniation with compression of the spinal cord at that level. EMG/NCV showed normal NCV + + but 1+ sharps and fibrillations in the right biceps (C5-6) + + brachioradialis (C5-6) + + triceps (C7-8) and teres major; and 2+ sharps and fibrillations in the right pronator terres. There was increased insertional activity in all muscles tested on the right side. The findings were consistent with a C6-7 radiculopathy. + +The patient subsequently underwent C5-6 laminectomy and her symptoms resolved. \ No newline at end of file diff --git a/1586_Radiology.txt b/1586_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..7dc4204f9fbe35541a63c6f45fdf8c90fe4b3897 --- /dev/null +++ b/1586_Radiology.txt @@ -0,0 +1,55 @@ +CC: + + Left third digit numbness and wrist pain. + +HX: + +This 44 y/o LHM presented with a one month history of numbness and pain of the left middle finger and wrist. The numbness began in the left middle finger and gradually progressed over the course of a day to involve his wrist as well. Within a few days he developed pain in his wrist. He had been working as a cook and cut fish for prolonged periods of time. This activity exacerbated his symptoms. He denied any bowel/bladder difficulties, neck pain, or weakness. He had no history of neck injury. + +SHX/FHX: + + 1-2 ppd Cigarettes. Married. Off work for two weeks due to complaints. + +EXAM: + +Vital signs unremarkable. + +MS: + + A & O to person, place, time. Fluent speech without dysarthria. + +CN II-XII: + +Unremarkable,MOTOR: + + 5/5 throughout, including intrinsic muscles of hands. No atrophy or abnormal muscle tone. + +SENSORY: + + Decreased PP in third digit of left hand only (palmar and dorsal sides). + +STATION/GAIT/COORD: + + Unremarkable. + +REFLEXES: + +1+ throughout, plantar responses were downgoing bilaterally. + +GEN EXAM: + +Unremarkable. + +Tinel's manuever elicited pain and numbness on the left. Phalens sign present on the left. + +CLINICAL IMPRESSION: + +Left Carpal Tunnel Syndrome,EMG/NCV: + +Unremarkable. + +MRI C-spine, 12/1/92: Congenitally small spinal canal is present. Superimposed on this is mild spondylosis and disc bulge at C6-7, C5-6, C4-5, and C3-4. There is moderate central spinal stenosis at C3-4. Intervertebral foramina at these levels appear widely patent. + +COURSE: + + The MRI findings did not correlate with the clinical findings and history. The patient was placed on Elavil and was subsequently lost to follow-up. \ No newline at end of file diff --git a/1589_Radiology.txt b/1589_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..c99d62ff88f476ac56df75a07e33f4f7e7a33544 --- /dev/null +++ b/1589_Radiology.txt @@ -0,0 +1,23 @@ +EXAM: + +MRI SPINAL CORD CERVICAL WITHOUT CONTRAST + +CLINICAL: + +Right arm pain, numbness and tingling. + +FINDINGS: + +Vertebral alignment and bone marrow signal characteristics are unremarkable. The C2-3 and C3-4 disk levels appear unremarkable. + +At C4-5, broad based disk/osteophyte contacts the ventral surface of the spinal cord and may mildly indent the cord contour. A discrete cord signal abnormality is not identified. There may also be some narrowing of the neuroforamina at this level. + +At C5-6, central disk-osteophyte contacts and mildly impresses on the ventral cord contour. Distinct neuroforaminal narrowing is not evident. + +At C6-7, mild diffuse disk-osteophyte impresses on the ventral thecal sac and contacts the ventral cord surface. Distinct cord compression is not evident. There may be mild narrowing of the neuroforamina at his level. + +A specific abnormality is not identified at the C7-T1 level. + +IMPRESSION: + +Disk/osteophyte at C4-5 through C6-7 with contact and may mildly indent the ventral cord contour at these levels. Some possible neuroforaminal narrowing is also noted at levels as stated above. \ No newline at end of file diff --git a/1590_Radiology.txt b/1590_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..062dcb53ef7d4958733bd1f68a149292b3d1249b --- /dev/null +++ b/1590_Radiology.txt @@ -0,0 +1,87 @@ +CC: + +Sensory loss. + +HX: + +25y/o RHF began experiencing pruritus in the RUE + + above the elbow and in the right scapular region, on 10/23/92. In addition she had paresthesias in the proximal BLE and toes of the right foot. Her symptoms resolved the following day. On 10/25/92, she awoke in the morning and her legs felt "asleep" with decreased sensation. The sensory loss gradually progressed rostrally to the mid chest. She felt unsteady on her feet and had difficulty ambulating. In addition she also began to experience pain in the right scapular region. She denied any heat or cold intolerance, fatigue, weight loss. + +MEDS: + + None. + +PMH: + + Unremarkable. + +FHX: + +GF with CAD + + otherwise unremarkable. + +SHX: + + Married, unemployed. 2 children. Patient was born and raised in Iowa. Denied any h/o Tobacco/ETOH/illicit drug use. + +EXAM: + + BP121/66 HR77 RR14 36.5C,MS: A&O to person, place and time. Speech normal with logical lucid thought process. + +CN: mild optic disk pallor OS. No RAPD. EOM full and smooth. No INO. The rest of the CN exam was unremarkable. + +MOTOR: Full strength throughout all extremities except for 5/4+ hip extensors. Normal muscle tone and bulk. + +Sensory: Decreased PP/LT below T4-5 on the left side down to the feet. Decreased PP/LT/VIB in BLE (left worse than right). Allodynic in RUE. + +Coord: Intact FNF + + HKS and RAM + + bilaterally. + +Station: No pronator drift. Romberg's test not documented. + +Gait: Unsteady wide-based. Able to TT and HW. Poor TW. + +Reflexes: 3/3 BUE. Hoffman's signs were present bilaterally. 4/4 patellae. 3+/3+ Achilles with 3-4 beat nonsustained clonus. Plantar responses were extensor on the right and flexor on the left. + +Gen. Exam: Unremarkable. + +COURSE: + + CBC + + GS + + PT + + PTT + + ESR + + FT4, TSH + + ANA + + Vit B12, Folate, VDRL and Urinalysis were normal. MRI T-spine, 10/27/92, was unremarkable. MRI Brain, 10/28/92, revealed multiple areas of abnormally increased signal on T2 weighted images in the white matter regions of the right corpus callosum, periventricular region, brachium pontis and right pons. The appearance of the lesions was felt to be strongly suggestive of multiple sclerosis. 10/28/92, Lumbar puncture revealed the following CSF results: RBC 1, WBC 9 (8 lymphocytes, 1 histiocyte) + + Glucose 55mg/dl, Protein 46mg/dl (normal 15-45) + + CSF IgG 7.5mg/dl (normal 0.0-6.2) + + CSF IgG index 1.3 (normal 0.0-0.7) + + agarose gel electrophoresis revealed oligoclonal bands in the gamma region which were not seen on the serum sample. Beta-2 microglobulin was unremarkable. An abnormal left tibial somatosensory evoked potential was noted consistent with central conduction slowing. Visual and Brainstem Auditory evoked potentials were normal. HTLV-1 titers were negative. CSF cultures and cytology were negative. She was not treated with medications as her symptoms were primarily sensory and non-debilitating, and she was discharged home. + +She returned on 11/7/92 as her symptoms of RUE dysesthesia, lower extremity paresthesia and weakness, all worsened. On 11/6/92, she developed slow slurred speech and had marked difficulty expressing her thoughts. She also began having difficulty emptying her bladder. Her 11/7/92 exam was notable for normal vital signs, lying motionless with eyes open and nodding and rhythmically blinking every few minutes. She was oriented to place and time of day, but not to season, day of the week and she did not know who she was. She had a leftward gaze preference and right lower facial weakness. Her RLE was spastic with sustained ankle clonus. There was dysesthetic sensory perception in the RUE. Jaw jerk and glabellar sign were present. + +MRI brain, 11/7/92, revealed multiple enhancing lesions in the peritrigonal region and white matter of the centrum semiovale. The right peritrigonal region is more prominent than on prior study. The left centrum semiovale lesion has less enhancement than previously. Multiple other white matter lesions are demonstrated on the right side, in the posterior limb of the internal capsule, the anterior periventricular white matter, optic radiations and cerebellum. The peritrigonal lesions on both sides have increased in size since the 10/92 MRI. The findings were felt more consistent with demyelinating disease and less likely glioma. Post-viral encephalitis, Rapidly progressive demyelinating disease and tumor were in the differential diagnosis. Lumbar Puncture, 11/8/92, revealed: RBC 2, WBC 12 (12 lymphocytes) + + Glucose 57, Protein 51 (elevated) + + cytology and cultures were negative. HIV 1 titer was negative. Urine drug screen, negative. A stereotactic brain biopsy of the right parieto-occipital region was consistent with demyelinating disease. She was treated with Decadron 6mg IV qhours and Cytoxan 0.75gm/m2 (1.25gm). On 12/3/92, she has a focal motor seizure with rhythmic jerking of the LUE + + loss of consciousness and rightward eye deviation. EEG revealed diffuse slowing with frequent right-sided sharp discharges. She was placed on Dilantin. She became depressed. \ No newline at end of file diff --git a/1599_Radiology.txt b/1599_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..8bbe39a10d6d2a978208f3561f8ac94768e15068 --- /dev/null +++ b/1599_Radiology.txt @@ -0,0 +1,29 @@ +FINDINGS: + +There is moderate to severe generalized neuronal loss of the cerebral hemispheres with moderate to severe ventricular enlargement and prominent CSF within the subarachnoid spaces. There is confluent white matter hyperintensity in a bi-hemispherical centrum semiovale distribution extending to the lateral ventricles consistent with severe vasculopathic small vessel disease and extensive white matter ischemic changes. There is normal enhancement of the dural sinuses and cortical veins and there are no enhancing intra-axial or extraaxial mass lesions. There is a cavum velum interpositum (normal variant). + +There is a linear area of T1 hypointensity becoming hyperintense on T2 images in a left para-atrial trigonal region representing either a remote lacunar infarction or prominent perivascular space. + +Normal basal ganglia and thalami. Normal internal and external capsules. Normal midbrain. + +There is amorphus hyperintensity of the basis pontis consistent with vasculopathic small vessel disease. There are areas of T2 hyperintensity involving the bilateral brachium pontis (left greater than right) with no enhancement following gadolinium augmentation most compatible with areas of chronic white matter ischemic changes. The area of white matter signal alteration in the left brachium pontis is of some concern in that is has a round morphology. Interval reassessment of this lesion is recommended. + +There is a remote lacunar infarction of the right cerebellar hemisphere. Normal left cerebellar hemisphere and vermis. + +There is increased CSF within the sella turcica and mild flattening of the pituitary gland but no sellar enlargement. There is elongation of the basilar artery elevating the mammary bodies but no dolichoectasia of the basilar artery. + +Normal flow within the carotid arteries and circle of Willis. + +Normal calvarium, central skull base and temporal bones. There is no demonstrated calvarium metastases. + +IMPRESSION: + +Severe generalized cerebral atrophy. + +Extensive chronic white matter ischemic changes in a bi-hemispheric centrum semiovale distribution with involvement of the basis pontis and probable bilateral brachium pontis. The area of white matter hyperintensity in the left brachium pontis is of some concern is that it has a round morphology but no enhancement following gadolinium augmentation. Interval reassessment of this lesion is recommended. + +Remote lacunar infarction in the right cerebellar hemisphere. + +Linear signal alteration of the left periatrial trigonal region representing either a prominent vascular space or,lacunar infarction. + +No demonstrated calvarial metastases. \ No newline at end of file diff --git a/1601_Radiology.txt b/1601_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..17e3e5526d03ffdb61303d65d097f07f2078769c --- /dev/null +++ b/1601_Radiology.txt @@ -0,0 +1,75 @@ +CC: + +Fall with subsequent nausea and vomiting. + +HX: + +This 52 y/o RHM initailly presented in 10/94 with a two year hisotry of gradual progressive difficulty with speech. He "knew what he wanted to say, but could not say it." + +His speech was slurred and he found it difficult to control his tongue. Examination at that time was notable for phonemic paraphasic errors, fair repetition of short phrases with decreased fluency, and slurred nasal speech. He could read, but could not write. He exhibited facial-limb apraxia, decreased gag reflex and positive grasp reflex. He was thougth to have possible Pick's disease vs. Cortical Basal Ganglia Degeneration. + +On 11/18/94, he fell and was seen in Neurology clinic on 11/23/94. EEG showed borderline background slowing and no other abnormalities. An MRI on 11/8/94, revealed mild atrophy of the left temporal lobe. Neuropsychological evaluations were obtained on 10/25/94 and 11/8/94. These were consistent with progressive aphasia and apraxia with relative sparing of nonverbal reasoning. + +He reported consuming 8 beers on the evening of 1/1/95. On 1/2/95, at 9:30AM + + he fell forward while stading in his kitchen and struck his forehead on the counter top, and then struck his occiput on the floor. He subsequently developed nausea and vomiting, tinnitus, vertigo, headache and mild shortness of breath. He was taken to the ETC at UIHC. Skull films were negative and he was treated with IV Compazine and IV fluid hydration and sent home. His nausea and vomiting persisted and he became generally weak. He returned to the ETC at UIHC on 1/5/95. HCT scan revealed a right frontal SDH containing signs of both chronic and acute bleeding. + +MEDS: + + None. + +PMH: + + 1)fell in 1990 from 15 feet up and landed on his feet sustaining crush injury to both feet and ankles. He reportedly had brief loss of consciousness with no reported head injury. + +2)Progressive aphasia. In 10/93, he was able to draw blue prints and write checks for his family business, 3) Left frontoparietal headache for 1.5 years prior to 10/94. Headaches continue to occur once a week, 4)right ankle fusion 4/94, right ankle fusion pending at present. + +FHX: + + No neurologic disease in family. + +SHX: + + Divorced and lives with girlfriend. One child by current girlfriend. He has 3 children with former wife. Smoked more than 15 years ago. Drinks 1-2 beers/day. Former Iron worker. + +EXAM: + +BP128/83, HR68, RR18, 36.5C. Supine: BP142/71, HR64; Sitting: BP127/73, HR91 and lightheaded. + +MS: Appeared moderately distressed and persistently held his forehead. A&O to person, place and time. Dysarthric and dysphagic. Non-fluent speech and able to say single syllable words such as "up" or "down". He comprehended speech, but could not repeat or write. + +CN: Pupils 4/3.5 decreasing to 2/2 on exposure to light. EOM were full and smooth. Optic disks were flat and without sign of hemorrhage. Moderate facial apraxia, but had intact facial sensation. + +Motor: 5/5 strength with normal muscle bulk and tone. + +Sensory: no abnormalities noted. + +Coord: Decreased RAM in the RUE. He had difficulty mmicking movements and postures with his RUE + +Gait: ND. + +Station: No truncal ataxia, but he had a slight RUE upward drift. + +Reflexes 2/2 BUE + + 2+/2+ patellae, 2/2 archilles, and plantar responses were flexor, bilaterally. + +Rectal exam was unremarkable. The rest of the General Physical exam was unremarkable. + +HEENT: atraumatic normocephalic skull. No carotid bruitts. + +COURSE: + + PT + + PTT + + CBC + + GS + + UA and Skull XR were negative. HCT brain, revealed a left frontal SDH with acute and cronic componenets. + +He was markedly orthostatic during the first few days of his hospital stay. He was given a 3 day trial of Florinef, which showed mild to moderate improvement of his symptoms of lightheadedness. This improved still further with a trial of Sigvaris pressure stockings. A second HCT was obtained on 12/10/94 and revealed decreased intensity and sized of the left frontal SDH. He was discharged home. + +His ideomotor apraxia worsened by 1/96. He developed seizures and was treated with CBZ. He progressively worsened and his overall condition was marked by aphasia, dysphagia, apraxia, and rigidity. He was last seen in 10/96 and the working diagnosis was CBGD vs. Pick's Disease. \ No newline at end of file diff --git a/1602_Radiology.txt b/1602_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..2368f322de46fe5b2be896f59460fab0ddcb089e --- /dev/null +++ b/1602_Radiology.txt @@ -0,0 +1,73 @@ +CC: + + Lethargy. + +HX: + + This 28y/o RHM was admitted to a local hospital on 7/14/95 for marked lethargy. He had been complaining of intermittent headaches and was noted to have subtle changes in personality for two weeks prior to 7/14/95. On the morning of 7/14/95, his partner found him markedly lethargic and complaingin of abdominal pain and vomiting. He denied fevers, chills, sweats, cough, CP + + SOB or diarrhea. Upon evaluation locally, he had a temperature of 99.5F and appeared lethargic. He also had anisocoria with left pupil 0.5mm bigger than the right. There was also question of left facial weakness. An MRI was obtained and revealed a large left hemispheric mass lesion with surrounding edema and mass effect. He was given 10mg of IV Decardron,100gm of IV Mannitol, intubated and hyperventilated and transferred to UIHC. + +He was admitted to the Department of Medicine on 7/14/95, and transferred to the Department of Neurology on 7/17/95, after being extubated. + +MEDS ON ADMISSION: + + Bactrim DS qd, Diflucan 100mg qd, Acyclovir 400mg bid, Xanax, Stavudine 40mg bid, Rifabutin 300mg qd. + +PMH: + + 1) surgical correction of pyoloric stenosis, age 1, 2)appendectomy, 3) HIV/AIDS dx 1991. He was initially treated with AZT + + then DDI. He developed chronic diarrhea and was switched to D4T in 1/95. However, he developed severe neuropathy and this was stopped 4/95. The diarrhea recured. He has Acyclovir resistant genital herpes and generalized psoriasis. He most recent CD4 count (within 1 month of admission) was 20. + +FHX: + + HTN and multiple malignancies of unknown type. + +SHX: + + Homosexual, in monogamous relationship with an HIV infected partner for the past 3 years. + +EXAM: + +7/14/95 (by Internal Medicine): BP134/80, HR118, RR16 on vent, 38.2C, Intubated. + +MS: Somnolent, but opened eyes to loud voices and would follow most commands. + +CN: Pupils 2.5/3.0 and "equally reactive to light." Mild horizontal nystagmus on rightward gaze. EOM were otherwise intact. + +MOTOR: Moved 4 extremities well. + +Sensory/Coord/Gait/Station/Reflexes: not done. + +Gen EXAM: Penil ulcerations. + +EXAM: + + 7/17/96 (by Neurology): BP144/73, HR59, RR20, 36.0, extubated. + +MS: Alert and mildly lethargic. Oriented to name only. Thought he was a local hospital and that it was 1/17/1994. Did not understand he had a brain lesion. + +CN: Pupils 6/5.5 decreasing to 4/4 on exposure to light. EOM were full and smooth. No RAPD or light-near dissociation. papilledema (OU). Right lower facial weakness and intact facial sensation to PP testing. Gag-shrug and corneal responses were intact, bilaterally. Tongue midline. + +MOTOR: Grade 5- strength on the right side. + +Sensory: no loss of sensation on PP/VIB/PROP testing. + +Coord: reduced speed and accuracy on right FNF and right HKS movements. + +Station: RUE pronator drift. + +Gait: not done. + +Reflexes: 2+/2 throughout. Babinski sign present on right and absent on left. + +Gen Exam: unremarkable except for the genital lesion noted by Internal medicine. + +COURSE: + + The outside MRI was reviewed and was notable for the left frontal/parietal mass lesion with surround edema. The mass inhomogenously enhanced with gadolinium contrast. + +The findings were consistent most with lymphoma, though toxoplasmosis could not be excluded. He refused brain biopsy and was started on empiric treatment for toxoplasmosis. This consisted of Pyrimethamine 75mg qd and Sulfadiazine 2 g bid. He later became DNR and was transferred at his and his partner's request Back to a local hospital. + +He never returned for follow-up. \ No newline at end of file diff --git a/1603_Radiology.txt b/1603_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..0d90f5a4f9053e81c6d53d4b5527ef5110a5cfa0 --- /dev/null +++ b/1603_Radiology.txt @@ -0,0 +1,61 @@ +CC: + + Sudden onset blindness. + +HX: + + This 58 y/o RHF was in her usual healthy state, until 4:00PM + + 1/8/93, when she suddenly became blind. Tongue numbness and slurred speech occurred simultaneously with the loss of vision. The vision transiently improved to "severe blurring" enroute to a local ER + + but worsened again once there. While being evaluated she became unresponsive, even to deep noxious stimuli. She was transferred to UIHC for further evaluation. Upon arrival at UIHC her signs and symptoms were present but markedly improved. + +PMH: + + 1) Hysterectomy many years previous. 2) Herniorrhaphy in past. 3) DJD + + relieved with NSAIDs. + +FHX/SHX: + + Married x 27yrs. Husband denied Tobacco/ETOH/illicit drug use for her. + +Unremarkable FHx. + +MEDS: + + none. + +EXAM: + + Vitals: 36.9C. HR 93. BP 151/93. RR 22. 98% O2Sat. + +MS: somnolent, but arousable to verbal stimulation. minimal speech. followed simple commands on occasion. + +CN: Blinked to threat from all directions. EOM appeared full, Pupils 2/2 decreasing to 1/1. +/+Corneas. Winced to PP in all areas of Face. +/+Gag. Tongue midline. Oculocephalic reflex intact. + +Motor: UE 4/5 proximally. Full strength in all other areas. Normal tone and muscle bulk. + +Sensory: Withdrew to PP in all extremities. + +Gait: ND. + +Reflexes: 2+/2+ throughout UE + + 3/3 patella, 2/2 ankles, Plantar responses were flexor bilaterally. + +Gen exam: unremarkable. + +COURSE: + +MRI Brain revealed bilateral thalamic strokes. Transthoracic echocardiogram (TTE) showed an intraatrial septal aneurysm with right to left shunt. Transesophageal echocardiogram (TEE) revealed the same. No intracardiac thrombus was found. Lower extremity dopplers were unremarkable. Carotid duplex revealed 0-15% bilateral ICA stenosis. Neuroophthalmologic evaluation revealed evidence of a supranuclear vertical gaze palsy OU (diminished up and down gaze). Neuropsychologic assessment 1/12-15/93 revealed severe impairment of anterograde verbal and visual memory, including acquisition and delayed recall and recognition. Speech was effortful and hypophonic with very defective verbal associative fluency. Reading comprehension was somewhat preserved, though she complained that despite the ability to see type clearly, she could not make sense of words. There was impairment of 2-D constructional praxis. A follow-up Neuropsychology evaluation in 7/93 revealed little improvement. Laboratory studies, TSH + + FT4, CRP + + ESR + + GS + + PT/PTT were unremarkable. Total serum cholesterol 195, Triglycerides 57, HDL 43, LDL 141. She was placed on ASA and discharged1/19/93. + +She was last seen on 5/2/95 and was speaking fluently and lucidly. She continued to have mild decreased vertical eye movements. Coordination and strength testing were fairly unremarkable. She continues to take ASA 325 mg qd. \ No newline at end of file diff --git a/1608_Radiology.txt b/1608_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..38f8881ae8d2d66a6b32f5c6c93f4573a438ca41 --- /dev/null +++ b/1608_Radiology.txt @@ -0,0 +1,15 @@ +EXAM: + +MRI OF THE RIGHT ANKLE + +CLINICAL: + +Pain. + +FINDINGS: + +The bone marrow demonstrates normal signal intensity. There is no evidence of bone contusion or fracture. There is no evidence of joint effusion. Tendinous structures surrounding the ankle joint are intact. No abnormal mass or fluid collection is seen surrounding the ankle joint. + +IMPRESSION + +: NORMAL MRI OF THE RIGHT ANKLE. \ No newline at end of file diff --git a/1614_Radiology.txt b/1614_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..ef23a892afc56581d9c785360ed1a2210002451f --- /dev/null +++ b/1614_Radiology.txt @@ -0,0 +1,33 @@ +EXAM: + + Lexiscan Nuclear Myocardial Perfusion Scan. + +INDICATION: + + Chest pain. + +TYPE OF TEST: + +Lexiscan, unable to walk on a treadmill. + +INTERPRETATION: + + Resting heart rate of 96, blood pressure of 141/76. EKG + + normal sinus rhythm, nonspecific ST-T changes, left bundle branch block. Post Lexiscan 0.4 mg injected intravenously by standard protocol. Peak heart rate was 105, blood pressure of 135/72. EKG remains the same. No symptoms are noted. + +SUMMARY: + +1. Nondiagnostic Lexiscan. + +2. Nuclear interpretation as below. + +NUCLEAR MYOCARDIAL PERFUSION SCAN WITH STANDARD PROTOCOL: + + Resting and stress images were obtained with 10.4, 32.5 mCi of tetrofosmin injected intravenously by standard protocol. Myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake. There is no evidence of reversible or fixed defect. Gated SPECT revealed mild global hypokinesis, more pronounced in the septal wall possibly secondary to prior surgery. Ejection fraction calculated at 41%. End-diastolic volume of 115, end-systolic volume of 68. + +IMPRESSION: + +1. Normal nuclear myocardial perfusion scan. + +2. Ejection fraction 41% by gated SPECT. \ No newline at end of file diff --git a/1617_Radiology.txt b/1617_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..24b2a68fdcdd01d746038a49d57b2edf936aa360 --- /dev/null +++ b/1617_Radiology.txt @@ -0,0 +1,31 @@ +PREOPERATIVE DIAGNOSIS: + + Low back pain. + +POSTOPERATIVE DIAGNOSIS: + + Low back pain. + +PROCEDURE PERFORMED: + +1. Lumbar discogram L2-3. + +2. Lumbar discogram L3-4. + +3. Lumbar discogram L4-5. + +4. Lumbar discogram L5-S1. + +ANESTHESIA: + +IV sedation. + +PROCEDURE IN DETAIL: + +The patient was brought to the Radiology Suite and placed prone onto a radiolucent table. The C-arm was brought into the operative field and AP + + left right oblique and lateral fluoroscopic images of the L1-2 through L5-S1 levels were obtained. We then proceeded to prepare the low back with a Betadine solution and draped sterile. Using an oblique approach to the spine, the L5-S1 level was addressed using an oblique projection angled C-arm in order to allow for perpendicular penetration of the disc space. A metallic marker was then placed laterally and a needle entrance point was determined. A skin wheal was raised with 1% Xylocaine and an #18-gauge needle was advanced up to the level of the disc space using AP + + oblique and lateral fluoroscopic projections. A second needle, #22-gauge 6-inch needle was then introduced into the disc space and with AP and lateral fluoroscopic projections, was placed into the center of the nucleus. We then proceeded to perform a similar placement of needles at the L4-5, L3-4 and L2-3 levels. + +A solution of Isovue 300 with 1 gm of Ancef was then drawn into a 10 cc syringe and without informing the patient of our injecting, we then proceeded to inject the disc spaces sequentially. \ No newline at end of file diff --git a/1623_Radiology.txt b/1623_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..f8804fb5465dcbe2db9201b1c8579703cbf9316f --- /dev/null +++ b/1623_Radiology.txt @@ -0,0 +1,31 @@ +PREOPERATIVE DIAGNOSIS: + + Acute cholecystitis. + +POSTOPERATIVE DIAGNOSIS: + + Acute gangrenous cholecystitis with cholelithiasis. + +OPERATION PERFORMED: + + Laparoscopic cholecystectomy with cholangiogram. + +FINDINGS: + +The patient had essentially a dead gallbladder with stones and positive wide bile/pus coming from the gallbladder. + +COMPLICATIONS: + +None. + +EBL: + + Scant. + +SPECIMEN REMOVED: + + Gallbladder with stones. + +DESCRIPTION OF PROCEDURE: + +The patient was prepped and draped in the usual sterile fashion under general anesthesia. A curvilinear incision was made below the umbilicus. Through this incision, the camera port was able to be placed into the peritoneal cavity under direct visualization. Once this complete, insufflation was begun. Once insufflation was adequate, additional ports were placed in the epigastrium as well as right upper quadrant. Once all four ports were placed, the right upper quadrant was then explored. The patient had significant adhesions of omentum and colon to the liver, the gallbladder constituting definitely an acute cholecystitis. This was taken down using Bovie cautery to free up visualization of the gallbladder. The gallbladder was very thick and edematous and had frank necrosis of most of the anterior gallbladder wall. Adhesions were further taken down between the omentum, the colon, and the gallbladder slowly starting superiorly and working inferiorly towards the cystic duct area. Once the adhesions were fully removed, the cholangiogram was done which did not show any evidence of any common bile duct dilatation or obstruction. At this point, due to the patient's gallbladder being very necrotic, it was deemed that the patient should have a drain placed. The cystic duct and cystic artery were serially clipped and transected. The gallbladder was removed from the gallbladder fossa removing the entire gallbladder. Adequate hemostasis with Bovie cautery was achieved. The gallbladder was then placed into a bag and removed from the peritoneal cavity through the camera port. A JP drain was then run through the anterior port and out of one of the trochar sites and secured to the skin using 3-0 nylon suture. Next, the right upper quadrant was copiously irrigated out using the suction irrigator. Once this was complete, the additional ports were able to be removed. The fascial opening at the umbilicus was reinforced by closing it using a 0 Vicryl suture in a figure-of-8 fashion. All skin incisions were injected using Marcaine 1/4 percent plain. The skin was reapproximated further using 4-0 Monocryl sutures in a subcuticular technique. The patient tolerated the procedure well and was able to be transferred to the recovery room in stable condition. \ No newline at end of file diff --git a/1624_Radiology.txt b/1624_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..b48d347e3f8cd6ff7c8eecf4b1c6f2e69f409f59 --- /dev/null +++ b/1624_Radiology.txt @@ -0,0 +1,79 @@ +CC: + + HA and vision loss. + +HX: + +71 y/o RHM developed a cataclysmic headache on 11/5/92 associated with a violent sneeze. The headache lasted 3-4 days. On 11/7/92, he had acute pain and loss of vision in the left eye. Over the following day his left pupil enlarged and his left upper eyelid began to droop. He was seen locally and a brain CT showed no sign of bleeding, but a tortuous left middle cerebral artery was visualized. The patient was transferred to UIHC 11/12/92. + +FHX: + + HTN + + stroke, coronary artery disease, melanoma. + +SHX: + + Quit smoking 15 years ago. + +MEDS: + + Lanoxin, Capoten, Lasix, KCL + + ASA + + Voltaren, Alupent MDI + +PMH: + +CHF + + Atrial Fibrillation, Obesity, Anemia, Duodenal Ulcer, Spinal AVM resection 1986 with residual T9 sensory level, hyperreflexia and bilateral babinski signs, COPD. + +EXAM: + +35.5C, BP 140/91, P86, RR20. Alert and oriented to person, place, and time. CN: No light perception OS + + Pupils: 3/7 decreasing to 2/7 on exposure to light (i.e. + + fixed/dilated pupil OS). Upon neutral gaze the left eye deviated laterally and inferiorly. There was complete ptosis OS. On downward gaze their was intorsion OS. The left eye could not move superiorly, medially or effectively downward, but could move laterally. EOM were full OD. The rest of the CN exam was unremarkable. Motor, Coordination, Station and Gait testing were unremarkable. Sensory exam revealed decreased pinprick and light touch below T9 (old). Muscle stretch reflexes were increased (3+/3+) in both lower extremities and there were bilateral babinski signs (old). The upper extremity reflexes were symmetrical (2/2). Cardiovascular exam revealed an irregularly irregular rhythm and lung sounds were coarse bilaterally. The rest of the general exam was unremarkable. + +LAB: + + CBC + + PT/PTT + + General Screen were unremarkable except for a BUN 21mg/DL. CSF: protein 88mg/DL + + glucose 58mg/DL + + RBC 2800/mm3, WBC 1/mm3. ANA + + RF + + TSH + + FT4 were WNL. + +IMPRESSION: + + CN3 palsy and loss of vision. Differential diagnosis: temporal arteritis, aneurysm, intracranial mass. + +COURSE: + + The outside Brain CT revealed a tortuous left MCA. A four-vessel cerebral angiogram revealed a dolichoectatic basilar artery and tortuous LICA. There was no evidence of aneursym. Transesophageal Echocardiogram revealed atrial enlargement only. Neuroopthalmologic evaluation revealed: Loss of color vision and visual acuity OS + + RAPD OS + + bilateral optic disk pallor (OS > OD) + + CN3 palsy and bilateral temporal field loss, OS >> OD . ESR + + CRP + + MRI were recommended to rule out temporal arteritis and intracranial mass. ESR 29mm/Hr, CRP 4.3mg/DL (high) + + The patient was placed on prednisone. Temporal artery biopsy showed no evidence of vasculitis. MRI scan could not be obtained due to patient weight. Sellar CT was done instead: coronal sections revealed sellar enlargement and upward bowing of the diaphragm sella suggesting a pituitary mass. In retrospect sellar enlargement could be seen on the angiogram X-rays. Differential consideration was given to cystic pituitary adenoma, noncalcified craniopharyngioma, or Rathke's cleft cyst with solid component. The patient refused surgery. He was seen in Neuroopthalmology Clinic 2/18/93 and was found to have mild recovery of vision OS and improved visual fields. Aberrant reinnervation of the 3rd nerve was noted as there was constriction of the pupil (OS) on adduction, downgaze and upgaze. The upper eyelid, OS + + elevated on adduction and down gaze, OS. EOM movements were otherwise full and there was no evidence of ptosis. In retrospect he was felt to have suffered pituitary apoplexy in 11/92. \ No newline at end of file diff --git a/1629_Radiology.txt b/1629_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..055839c6c81c6b2b747becdb9d38ec79705f46ca --- /dev/null +++ b/1629_Radiology.txt @@ -0,0 +1,5 @@ +HYPERFRACTIONATION + +This patient is to undergo a course of hyperfractionated radiotherapy in the treatment of known malignancy. The radiotherapy will be given in a hyperfractionated fraction (decreased dose per fraction but 2 fractions delivered daily separated by a period of at least 6 hours). The rationale for this treatment is based on radiobiologic principles that make this type of therapy more effective in rapidly growing, previously irradiated or poorly oxygenated tumors. The dose per fraction and the total dose are calculated by me, and this is individualized for each patient according to radiobiologic principles. + +During the hyperfractionated radiotherapy, the chance of severe acute side effects is increased, so the patient will be followed more intensively for the development of any side effects and treatment instituted accordingly. \ No newline at end of file diff --git a/1630_Radiology.txt b/1630_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..d7afe725d0ab85669b50443c628e2acf8a976bb1 --- /dev/null +++ b/1630_Radiology.txt @@ -0,0 +1,23 @@ +EXAM: + + Five views of the right knee. + +HISTORY: + + Pain. The patient is status-post surgery, he could not straighten his leg, pain in the back of the knee. + +TECHNIQUE: + + Five views of the right knee were evaluated. There are no priors for comparison. + +FINDINGS: + + Five views of the right knee were evaluated and they reveal there is no evidence of any displaced fractures, dislocations, or subluxations. There are multiple areas of growth arrest lines seen in the distal aspect of the femur and proximal aspect of the tibia. There is also appearance of a high-riding patella suggestive of patella alta. + +IMPRESSION: + +1. No evidence of any displaced fractures, dislocations, or subluxations. + +2. Growth arrest lines seen in the distal femur and proximal tibia. + +3. Questionable appearance of a slightly high-riding patella, possibly suggesting patella alta. \ No newline at end of file diff --git a/1632_Radiology.txt b/1632_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..f526d4bfeb10fe1fe99fad642eb974426f3a2f5a --- /dev/null +++ b/1632_Radiology.txt @@ -0,0 +1,37 @@ +EXAM: + + Screening full-field digital mammogram. + +HISTORY: + + Screening examination of a 58-year-old female who currently denies complaints. Patient has had diagnosis of right breast cancer in 1984 with subsequent radiation therapy. The patient's sister was also diagnosed with breast cancer at the age of 59. + +TECHNIQUE: + + Standard digital mammographic imaging was performed. The examination was performed with iCAD Second Look Version 7.2. + +COMPARISON: + + Most recently obtained __________. + +FINDINGS: + + The right breast is again smaller than the left. There is a scar marker with underlying skin thickening and retraction along the upper margin of the right breast. The breasts are again composed of a mixture of adipose tissue and a moderate amount of heterogeneously-dense fibroglandular tissue. There is again some coarsening of the right breast parenchyma with architectural distortion which is unchanged and most consistent with postsurgical and postradiation changes. A few benign-appearing microcalcifications are present. + +No dominant malignant-appearing mass lesion, developing area of architectural distortion or suspicious-appearing cluster of microcalcifications are identified. The skin is stable. No enlarged axillary lymph node is seen. + +IMPRESSION: + +1. No significant interval changes are seen. No mammographic evidence of malignancy is identified. + +2. Annual screening mammography is recommended or sooner if clinical symptoms warrant. + +BIRADS Classification 2 - Benign,MAMMOGRAPHY INFORMATION: + +1. A certain percentage of cancers, probably 10% to 15% + + will not be identified by mammography. + +2. Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present. + +3. These images were obtained with FDA-approved digital mammography equipment, and iCAD Second Look Software Version 7.2 was utilized. \ No newline at end of file diff --git a/1641_Radiology.txt b/1641_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..c103474309079865bd853d524ae621eae523b2f2 --- /dev/null +++ b/1641_Radiology.txt @@ -0,0 +1,6 @@ +There is normal and symmetrical filling of the caliceal system. Subsequent films demonstrate that the kidneys are of normal size and contour bilaterally. The caliceal system and ureters are in their usual position and show no signs of obstruction or intraluminal defects. The postvoid films demonstrate normal emptying of the collecting system, including the urinary bladder. + +IMPRESSION: + + Negative intravenous urogram. + diff --git a/1645_Radiology.txt b/1645_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..73d070ad8ee60bec8f60cc09fa34b46022f54b2d --- /dev/null +++ b/1645_Radiology.txt @@ -0,0 +1,21 @@ +HISTORY: + + The patient is a 46-year-old right-handed gentleman with a past medical history of a left L5-S1 lumbar microdiskectomy in 1998 with complete resolution of left leg symptoms, who now presents with a four-month history of gradual onset of right-sided low back pain with pain radiating down into his buttock and posterior aspect of his right leg into the ankle. Symptoms are worsened by any activity and relieved by rest. He also feels that when the pain is very severe, he has some subtle right leg weakness. No left leg symptoms. No bowel or bladder changes. + +On brief examination, full strength in both lower extremities. No sensory abnormalities. Deep tendon reflexes are 2+ and symmetric at the patellas and absent at both ankles. Positive straight leg raising on the right. + +MRI of the lumbosacral spine was personally reviewed and reveals a right paracentral disc at L5-S1 encroaching upon the right exiting S1 nerve root. + +NERVE CONDUCTION STUDIES: + + Motor and sensory distal latencies, evoked response amplitudes, and conduction velocities are normal in the lower extremities. The right common peroneal F-wave is minimally prolonged. The right tibial H reflex is absent. + +NEEDLE EMG: + + Needle EMG was performed on the right leg, left gastrocnemius medialis muscle, and right lumbosacral paraspinal muscles using a disposable concentric needle. It revealed spontaneous activity in the right gastrocnemius medialis, gluteus maximus, and lower lumbosacral paraspinal muscles. There was evidence of chronic denervation in right gastrocnemius medialis and gluteus maximus muscles. + +IMPRESSION: + + This electrical study is abnormal. It reveals an acute right S1 radiculopathy. There is no evidence for peripheral neuropathy or left or right L5 radiculopathy. + +Results were discussed with the patient and he is scheduled to follow up with Dr. X in the near future. \ No newline at end of file diff --git a/1646_Radiology.txt b/1646_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..e87285ed31f7b3729697af327a2e934704214b5f --- /dev/null +++ b/1646_Radiology.txt @@ -0,0 +1,21 @@ +HISTORY: + + The patient is a 78-year-old right-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back pain radiating into the right leg. She was undergoing a spinal epidural injection about a month ago and had worsening of right low back pain, which radiates down into her buttocks and down to posterior aspect of her thigh into her knee. This has required large amounts of opioid analgesics to control. She has been basically bedridden because of this. She was brought into hospital for further investigations. + +PHYSICAL EXAMINATION: + + On examination, she has positive straight leg rising on the right with severe shooting, radicular type pain with right leg movement. Difficult to assess individual muscles, but strength is largely intact. Sensory examination is symmetric. Deep tendon reflexes reveal hyporeflexia in both patellae, which probably represents a cervical myelopathy from prior cord compression. She has slightly decreased right versus left ankle reflexes. The Babinski's are positive. On nerve conduction studies, motor and sensory distal latencies, evoked response amplitudes, conduction velocities, and F-waves are normal in lower extremities. + +NEEDLE EMG: + + Needle EMG was performed on the right leg and lumbosacral paraspinal muscles using a disposable concentric needle. It reveals the spontaneous activity in right peroneus longus and gastrocnemius medialis muscles as well as the right lower lumbosacral paraspinal muscles. There is evidence of denervation in right gastrocnemius medialis muscle. + +IMPRESSION: + + This electrical study is abnormal. It reveals the following: + +1. Inactive right S1 (L5) radiculopathy. + +2. There is no evidence of left lower extremity radiculopathy, peripheral neuropathy or entrapment neuropathy. + +Results were discussed with the patient and she is scheduled for imaging studies in the next day. \ No newline at end of file diff --git a/1648_Radiology.txt b/1648_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..ecc2c6989ca99c8ae2c94f5ac7d0bb288b44b246 --- /dev/null +++ b/1648_Radiology.txt @@ -0,0 +1,31 @@ +REASON FOR EXAM: + +1. Angina. + +2. Coronary artery disease. + +INTERPRETATION: + +This is a technically acceptable study. + +DIMENSIONS: + +Anterior septal wall 1.2, posterior wall 1.2, left ventricular end diastolic 6.0, end systolic 4.7. The left atrium is 3.9. + +FINDINGS: + + Left atrium was mildly to moderately dilated. No masses or thrombi were seen. The left ventricle was mildly dilated with mainly global hypokinesis, more prominent in the inferior septum and inferoposterior wall. The EF was moderately reduced with estimated EF of 40% with near normal thickening. The right atrium was mildly dilated. The right ventricle was normal in size. + +Mitral valve showed to be structurally normal with no prolapse or vegetation. There was mild mitral regurgitation on color flow interrogation. The mitral inflow pattern was consistent with pseudonormalization or grade 2 diastolic dysfunction. The aortic valve appeared to be structurally normal. Normal peak velocity. No significant AI. Pulmonic valve showed mild PI. Tricuspid valve showed mild tricuspid regurgitation. Based on which, the right ventricular systolic pressure was estimated to be mildly elevated at 40 to 45 mmHg. Anterior septum appeared to be intact. No pericardial effusion was seen. + +CONCLUSION: + +1. Mild biatrial enlargement. + +2. Normal thickening of the left ventricle with mildly dilated ventricle and EF of 40%. + +3. Mild mitral regurgitation. + +4. Diastolic dysfunction grade 2. + +5. Mild pulmonary hypertension. \ No newline at end of file diff --git a/1651_Radiology.txt b/1651_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..03abd356fc8c1c3c466b907d5c9a385aa98354ab --- /dev/null +++ b/1651_Radiology.txt @@ -0,0 +1,35 @@ +REASON FOR EXAM: + + CVA. + +INDICATIONS: + + CVA. + +This is technically acceptable. There is some limitation related to body habitus. + +DIMENSIONS: + +The interventricular septum 1.2, posterior wall 10.9, left ventricular end-diastolic 5.5, and end-systolic 4.5, the left atrium 3.9. + +FINDINGS: + + The left atrium was mildly dilated. No masses or thrombi were seen. The left ventricle showed borderline left ventricular hypertrophy with normal wall motion and wall thickening, EF of 60%. The right atrium and right ventricle are normal in size. + +Mitral valve showed mitral annular calcification in the posterior aspect of the valve. The valve itself was structurally normal. No vegetations seen. No significant MR. Mitral inflow pattern was consistent with diastolic dysfunction grade 1. The aortic valve showed minimal thickening with good exposure and coaptation. Peak velocity is normal. No AI. + +Pulmonic and tricuspid valves were both structurally normal. + +Interatrial septum was appeared to be intact in the views obtained. A bubble study was not performed. + +No pericardial effusion was seen. Aortic arch was not assessed. + +CONCLUSIONS: + +1. Borderline left ventricular hypertrophy with normal ejection fraction at 60%. + +2. Mitral annular calcification with structurally normal mitral valve. + +3. No intracavitary thrombi is seen. + +4. Interatrial septum was somewhat difficult to assess, but appeared to be intact on the views obtained. \ No newline at end of file diff --git a/1652_Radiology.txt b/1652_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..0462e2458494d5528ebed860d16e9ef263b7033a --- /dev/null +++ b/1652_Radiology.txt @@ -0,0 +1,19 @@ +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. \ No newline at end of file diff --git a/1653_Radiology.txt b/1653_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..8be45db1b39f3a8f0a0931ea020e438367978b49 --- /dev/null +++ b/1653_Radiology.txt @@ -0,0 +1,17 @@ +EXAM: + + Echocardiogram. + +INTERPRETATION: + + Echocardiogram was performed including 2-D and M-mode imaging, Doppler analysis continuous wave and pulse echo outflow velocity mapping was all seen in M-mode. Cardiac chamber dimensions, left atrial enlargement 4.4 cm. Left ventricle, right ventricle, and right atrium are grossly normal. LV wall thickness and wall motion appeared normal. LV ejection fraction is estimated at 65%. Aortic root and cardiac valves appeared normal. No evidence of pericardial effusion. No evidence of intracardiac mass or thrombus. Doppler analysis outflow velocity through the aortic valve normal, inflow velocities through the mitral valve are normal. There is mild tricuspid regurgitation. Calculated pulmonary systolic pressure 42 mmHg. + +ECHOCARDIOGRAPHIC DIAGNOSES: + +1. LV Ejection fraction, estimated at 65%. + +2. Mild left atrial enlargement. + +3. Mild tricuspid regurgitation. + +4. Mildly elevated pulmonary systolic pressure. \ No newline at end of file diff --git a/1654_Radiology.txt b/1654_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..2ae554ab214ea2bd3d20248100264a116810e9bd --- /dev/null +++ b/1654_Radiology.txt @@ -0,0 +1,11 @@ +DIAGNOSIS: + + Possible cerebrovascular accident. + +DESCRIPTION: + + The EEG was obtained using 21 electrodes placed in scalp-to-scalp and scalp-to-vertex montages. The background activity appears to consist of fairly organized somewhat pleomorphic low to occasional medium amplitude of 7-8 cycle per second activity and was seen mostly posteriorly bilaterally symmetrically. A large amount of movement artifacts and electromyographic effects were noted intermixed throughout the recording session. Transient periods of drowsiness occurred naturally producing irregular 5-7 cycle per second activity mostly over the anterior regions. Hyperventilation was not performed. No epileptiform activity or any definite lateralizing findings were seen. + +IMPRESSION: + + Mildly abnormal study. The findings are suggestive of a generalized cerebral disorder. Due to the abundant amount of movement artifacts, any lateralizing findings, if any cannot be well appreciated. Clinical correlation is recommended. \ No newline at end of file diff --git a/1655_Radiology.txt b/1655_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..3ccc90a250d84f56458e0c537ceed3a2d4bf5968 --- /dev/null +++ b/1655_Radiology.txt @@ -0,0 +1,21 @@ +REASON FOR EXAMINATION: + + Cardiac arrhythmia. + +INTERPRETATION: + + No significant pericardial effusion was identified. + +The aortic root dimensions are within normal limits. The four cardiac chambers dimensions are within normal limits. No discrete regional wall motion abnormalities are identified. The left ventricular systolic function is preserved with an estimated ejection fraction of 60%. The left ventricular wall thickness is within normal limits. + +The aortic valve is trileaflet with adequate excursion of the leaflets. The mitral valve and tricuspid valve motion is unremarkable. The pulmonic valve is not well visualized. + +Color flow and conventional Doppler interrogation of cardiac valvular structures revealed mild mitral regurgitation and mild tricuspid regurgitation with an RV systolic pressure calculated to be 28 mmHg. Doppler interrogation of the mitral in-flow pattern is within normal limits for age. + +IMPRESSION: + +1. Preserved left ventricular systolic function. + +2. Mild mitral regurgitation. + +3. Mild tricuspid regurgitation. \ No newline at end of file diff --git a/1656_Radiology.txt b/1656_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..f018742be00c2e482ef0c0273ea56f1d12dacc6c --- /dev/null +++ b/1656_Radiology.txt @@ -0,0 +1,21 @@ +EXAM: + + Echocardiogram. + +INDICATION: + + Aortic stenosis. + +INTERPRETATION: + + Transthoracic echocardiogram was performed of adequate technical quality. Left ventricle reveals concentric hypertrophy with normal size and dimensions and normal function. Ejection fraction is 60% without any obvious wall motion abnormality. Left atrium and right side chambers are of normal size and dimensions. Aortic root has normal diameter. + +Mitral and tricuspid valves are structurally normal except for minimal annular calcification. Valvular leaflet excursion is adequate. Aortic valve reveals annular calcification. Fibrocalcific valve leaflets with decreased excursion. Atrial and ventricular septum are intact. Pericardium is intact without any effusion. No obvious intracardiac mass or thrombi noted. + +Doppler reveals mild mitral regurgitation, mild-to-moderate tricuspid regurgitation. Estimated pulmonary pressure of 48. Systolic consistent with mild-to-moderate pulmonary hypertension. Peak velocity across the aortic valve is 3.0 with a peak gradient of 37, mean gradient of 19, valve area calculated at 1.1 sq. cm consistent with moderate aortic stenosis. + +IN SUMMARY: + +1. Concentric hypertrophy of the left ventricle with normal function. + +2. Doppler study as above, most pronounced being moderate aortic stenosis, valve area of 1.1 sq. cm. \ No newline at end of file diff --git a/1657_Radiology.txt b/1657_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..3f29d966813baf3cde07167422375a868c693015 --- /dev/null +++ b/1657_Radiology.txt @@ -0,0 +1,13 @@ +DUPLEX ULTRASOUND OF LEGS + +RIGHT LEG: + + Duplex imaging was carried out according to normal protocol with a 7.5 Mhz imaging probe using B-mode ultrasound. Deep veins were imaged at the level of the common femoral and popliteal veins. All deep veins demonstrated compressibility without evidence of intraluminal thrombus or increased echogenicity. + +The long saphenous system displayed compressibility without evidence of thrombosis. The long saphenous vein measured * cm at the proximal thigh with reflux of * seconds after release of distal compression and * cm at the knee with reflux of * seconds after release of distal compression. The small saphenous system measured * cm at the proximal calf with reflux of * seconds after release of distal compression. + +LEFT LEG: + + Duplex imaging was carried out according to normal protocol with a 7.5 Mhz imaging probe using B-mode ultrasound. Deep veins were imaged at the level of the common femoral and popliteal veins. All deep veins demonstrated compressibility without evidence of intraluminal thrombus or increased echogenicity. + +The long saphenous system displayed compressibility without evidence of thrombosis. The long saphenous vein measured * cm at the proximal thigh with reflux of * seconds after release of distal compression and * cm at the knee with reflux of * seconds after release of distal compression. The small saphenous system measured * cm at the proximal calf with reflux of * seconds after release of distal compression. \ No newline at end of file diff --git a/1658_Radiology.txt b/1658_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..82b00e705ca8cfea7796bf503bf92a8fadd66913 --- /dev/null +++ b/1658_Radiology.txt @@ -0,0 +1,35 @@ +DOBUTAMINE STRESS ECHOCARDIOGRAM + +REASON FOR EXAM: + + Chest discomfort, evaluation for coronary artery disease. + +PROCEDURE IN DETAIL: + + The patient was brought to the cardiac center. Cardiac images at rest were obtained in the parasternal long and short axis, apical four and apical two views followed by starting with a dobutamine drip in the usual fashion at 10 mcg/kg per minute for low dose, increased every 2 to 3 minutes by 10 mcg/kg per minute. The patient maximized at 30 mcg/kg per minute. Images were obtained at that level after adding 0.7 mg of atropine to reach maximal heart rate of 145. Maximal images were obtained in the same windows of parasternal long and short axis, apical four and apical two windows. + +Wall motion assessed at all levels as well as at recovery. + +The patient got nauseated, had some mild shortness of breath. No angina during the procedure and the maximal amount of dobutamine was 30 mcg/kg per minute. + +The resting heart rate was 78 with the resting blood pressure 186/98. Heart rate reduced by the vasodilator effects of dobutamine to 130/80. Maximal heart rate achieved was 145, which is 85% of age-predicted heart rate. + +The EKG at rest showed sinus rhythm with no ST-T wave depression suggestive of ischemia or injury. Incomplete right bundle-branch block was seen. The maximal stress test EKG showed sinus tachycardia. There was subtle upsloping ST depression in III and aVF + + which is a normal response to the tachycardia with dobutamine, but no significant depression suggestive of ischemia and no ST elevation seen. + +No ventricular tachycardia or ventricular ectopy seen during the test. The heart rate recovered in a normal fashion after using metoprolol 5 mg. + +The heart images were somewhat suboptimal to evaluate because of obesity and some problems with the short axis windows mainly at peak exercise. + +The EF at rest appeared to be normal at 55 to 60 with normal wall motion including anterior, anteroseptal, inferior, lateral, and septal walls at low dose. All walls mentioned were augmented in a normal fashion. At maximum dose, all walls were augmented on all views except for the short axis was foreshortened, was uncertain about the anterolateral wall at peak exercise; however, of the other views, the lateral wall was showing normal thickening and normal augmentation. EF improved to about 70%. + +The wall motion score was unchanged. + +IMPRESSION: + +1. Maximal dobutamine stress echocardiogram test achieving more than 85% of age-predicted heart rate. + +2. Negative EKG criteria for ischemia. + +3. Normal augmentation at low and maximum stress test with some uncertainty about the anterolateral wall in peak exercise only on the short axis view. This is considered the negative dobutamine stress echocardiogram test, medical management. \ No newline at end of file diff --git a/1659_Radiology.txt b/1659_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..6f23b854808e6a4520e33d6c3e2bb4393370db15 --- /dev/null +++ b/1659_Radiology.txt @@ -0,0 +1,31 @@ +EXAM: + +1. Diagnostic cerebral angiogram. + +2. Transcatheter infusion of papaverine. + +ANESTHESIA: + + General anesthesia,FLUORO TIME: + + 19.5 minutes,CONTRAST: + + Visipaque-270, 100 mL,INDICATIONS FOR PROCEDURE: + + The patient is a 13-year-old boy who had clipping for a left ICA bifurcation aneurysm. He was referred for a routine postop check angiogram. He is doing fine clinically. All questions were answered, risks explained, informed consent taken and patient was brought to angio suite. + +TECHNIQUE: + + After informed consent was taken patient was brought to angio suite, both groin sites were prepped and draped in sterile manner. Patient was placed under general anesthesia for entire duration of the procedure. Groin access was obtained with a stiff micropuncture wire and a 4-French sheath was placed in the right common femoral artery and connected to a continuous heparinized saline flush. A 4-French angled Glide catheter was then taken up into the descending thoracic aorta was double flushed and connected to a continuous heparinized saline flush. The catheter was then taken up into the aortic arch and both common and internal carotid arteries were selectively catheterized followed by digital subtraction imaging in multiple projections. The images showed spasm of the left internal carotid artery and the left A1, it was thought planned to infused papaverine into the ICA and the left A1. After that the diagnostic catheter was taken up into the distal internal carotid artery. SL-10 microcatheter was then prepped and was taken up with the support of Transcend platinum micro guide wire. The microcatheter was then taken up into the internal carotid artery under biplane roadmapping and was taken up into the distal internal carotid artery and was pointed towards the A1. 60 mg of papaverine was then slowly infused into the internal carotid artery and the anterior cerebral artery. Post-papaverine infusion images showed increased caliber of the internal carotid artery as well as the left A1. The catheter was then removed from the patient, pressure was held for 10 minutes leading to hemostasis. Patient was then transferred back to the ICU in the Children's Hospital where he was extubated without any deficits. + +INTERPRETATION OF IMAGES: + +1. LEFT COMMON/INTERNAL CAROTID ARTERY INJECTIONS: The left internal carotid artery is of normal caliber. In the intracranial projection there is moderate spasm of the left internal carotid artery and moderately severe spasm of the left A1. There is poor filling of the A2 through left internal carotid artery injection. There is opacification of the ophthalmic and the posterior communicating artery MCA along with the distal branches are filling normally. Capillary filling and venous drainage in MCA distribution is normal and it is very slow in the ACA distribution,2. RIGHT INTERNAL CAROTID ARTERY INJECTION: The right internal carotid artery is of normal caliber. There is opacification of the right ophthalmic and the posterior communicating artery. The right ACA A1 is supplying bilateral A2 and there is no spasm of the distal anterior cerebral artery. Right MCA along with the distal branches are filling normally. Capillary filling and venous drainage are normal. + +3. POST-PAPAVERINE INJECTION: The post-papaverine injection shows increased caliber of the internal carotid artery as well as the anterior cerebral artery. Of note the previously clipped internal carotid ICA bifurcation aneurysm is well clipped and there is no residual neck or filling of the dome of the aneurysm. + +IMPRESSION: + +1. Well clipped left ICA bifurcation aneurysm. + +2. Moderately severe spasm of the internal carotid artery and left A1. 60 milligrams of papaverine infused leading to increased flow in the aforementioned vessels. \ No newline at end of file diff --git a/1660_Radiology.txt b/1660_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..9feaddea5e14f2a8bad4a05ecb3a681c781a5204 --- /dev/null +++ b/1660_Radiology.txt @@ -0,0 +1,23 @@ +EXAM: + + Bilateral diagnostic mammogram and right breast ultrasound. + +History of palpable abnormality at 10 o'clock in the right breast. Family history of a sister with breast cancer at age 43. + +TECHNIQUE: + + CC and MLO views of both breasts were obtained. Spot compression views of the palpable area were also obtained. Right breast ultrasound was performed. Comparison is made with mm/dd/yy. + +FINDINGS: + + The breast parenchymal pattern is stable with heterogeneous scattered areas of fibroglandular tissue. No new mass or architectural distortion is evident. Asymmetric density in the upper outer posterior left breast and a nodule in the upper outer right breast are unchanged. There is no suspicious cluster of microcalcifications. + +Directed ultrasonography of the upper outer quadrant of the right breast revealed no cystic or hypoechoic solid mass. + +IMPRESSION: + +1. Stable mammographic appearance from mm/dd/yy. + +2. No sonographic evidence of a mass at 10 o'clock in the right breast to correspond to the palpable abnormality. The need for further assessment of a palpable abnormality should be determined clinically. + +BIRADS Classification 2 - Benign \ No newline at end of file diff --git a/1664_Radiology.txt b/1664_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..ef0dda5490922004bc0afae0f60e613c49fda061 --- /dev/null +++ b/1664_Radiology.txt @@ -0,0 +1,21 @@ +EXAM: + + Modified barium swallow. + +SYMPTOM: + + Dysphagia with possible aspiration. + +FINDINGS: + + A cookie deglutition study was performed. The patient was examined in the direct lateral position. + +Patient was challenged with thin liquids, thick liquid, semisolids and solids. + +Persistently demonstrable is the presence of penetration with thin liquids. This is not evident with thick liquids, semisolids or solids. + +There is weakness in the oral phase of deglutition. Subglottic region appears normal. There is no evidence of aspiration demonstrated. + +IMPRESSION: + + Penetration demonstrated with thin liquids with weakness of the oral phase of deglutition. \ No newline at end of file diff --git a/1666_Radiology.txt b/1666_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..a4cf85569aebba8a1156987b77500be17e5f06dd --- /dev/null +++ b/1666_Radiology.txt @@ -0,0 +1,81 @@ +CC: + + Confusion. + +HX: + + A 71 y/o RHM + +with a history of two strokes ( one in 11/90 and one in 11/91) + + had been in a stable state of health until 12/31/92 when he became confused, and displayed left-sided weakness and difficulty speaking. The symptoms resolved within hours and recurred the following day. He was then evaluated locally and HCT revealed an old right parietal stroke. Carotid duplex scan revealed a "high grade stenosis" of the RICA. Cerebral Angiogram revealed 90%RICA and 50%LICA stenosis. He was then transferred to UIHC Vascular Surgery for carotid endarterectomy. His confusion persisted and he was evaluated by Neurology on 1/8/93 and transferred to Neurology on 1/11/93. + +PMH: + + 1)cholecystectomy. 2)inguinal herniorrhaphies, bilaterally. 3)ETOH abuse: 3-10 beers/day. 4)Right parietal stroke 10/87 with residual left hemiparesis (Leg worse than arm). 5) 2nd stoke in distant past of unspecified type. + +MEDS: + + None on admission. + +FHX: + + Alzheimer's disease and stroke on paternal side of family. + +SHX: + + 50+pack-yr cigarette use. + +ROS: + + no weight loss. poor appetite/selective eater. + +EXAM: + + BP137/70 HR81 RR13 O2Sat 95% Afebrile. + +MS: Oriented to city and month, but did not know date or hospital. Naming and verbal comprehension were intact. He could tell which direction Iowa City and Des Moines were from Clinton and remembered 2-3 objects in two minutes, but both with assistance only. Incorrectly spelled "world" backward, as "dlow." + +CN: unremarkable except neglects left visual field to double simultaneous stimulation. + +Motor: Deltoids 4+/4- + + biceps 5-/4, triceps 5/4+ + + grip 4+/4+ + + HF4+/4- + + HE 4+/4+ + + Hamstrings 5-/5- + + AE 5-/5- + + AF 5-/5-. + +Sensory: intact PP/LT/Vib. + +Coord: dysdiadochokinesis on RAM + + bilaterally. + +Station: dyssynergic RUE on FNF movement. + +Gait: ND + +Reflexes: 2+/2+ throughout BUE and at patellae. Absent at ankles. Right plantar was flexor; and Left plantar was equivocal. + +COURSE: + + CBC revealed normal Hgb, Hct, Plt and WBC + + but Mean corpuscular volume was large at 103FL (normal 82-98). Urinalysis revealed 20+WBC. GS + + TSH + + FT4, VDRL + + ANA and RF were unremarkable. He was treated for a UTI with amoxacillin. Vitamin B12 level was reduced at 139pg/ml (normal 232-1137). Schillings test was inconclusive dure to inability to complete a 24-hour urine collection. He was placed on empiric Vitamin B12 1000mcg IM qd x 7 days; then qMonth. He was also placed on Thiamine 100mg qd, Folate 1mg qd, and ASA 325mg qd. His ESR and CRP were elevated on admission, but fell as his UTI was treated. + +EEG showed diffuse slowing and focal slowing in the theta-delta range in the right temporal area. HCT with contrast on 1/19/93 revealed a gyriform enhancing lesion in the left parietal lobe consistent with a new infarct; and an old right parietal hypodensity (infarct). His confusion was ascribed to the UTI in the face of old and new strokes and Vitamin B12 deficiency. He was lost to follow-up and did not undergo carotid endarterectomy. \ No newline at end of file diff --git a/1667_Radiology.txt b/1667_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..99e7adc24d22324443087f069a57853c6002b6bd --- /dev/null +++ b/1667_Radiology.txt @@ -0,0 +1,31 @@ +EXAM: + + CT stone protocol. + +REASON FOR EXAM: + + History of stones, rule out stones. + +TECHNIQUE: + + Noncontrast CT abdomen and pelvis per renal stone protocol. + +FINDINGS: + + Correlation is made with a prior examination dated 01/20/09. + +Again identified are small intrarenal stones bilaterally. These are unchanged. There is no hydronephrosis or significant ureteral dilatation. There is no stone along the expected course of the ureters or within the bladder. There is a calcification in the low left pelvis not in line with ureter, this finding is stable and is compatible with a phlebolith. There is no asymmetric renal enlargement or perinephric stranding. + +The appendix is normal. There is no evidence of a pericolonic inflammatory process or small bowel obstruction. + +Scans through the pelvis disclose no free fluid or adenopathy. + +Lung bases aside from very mild dependent atelectasis appear clear. + +Given the lack of contrast, liver, spleen, adrenal glands, and the pancreas are grossly unremarkable. The gallbladder is present. There is no abdominal free fluid or pathologic adenopathy. + +IMPRESSION: + +1. Bilateral intrarenal stones, no obstruction. + +2. Normal appendix. \ No newline at end of file diff --git a/1668_Radiology.txt b/1668_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..49edc7be82a06121bcd5ae16f5820e6d34963253 --- /dev/null +++ b/1668_Radiology.txt @@ -0,0 +1,12 @@ +REASON FOR EXAMINATION: Face asleep. + +COMPARISON EXAMINATION: None. + +TECHNIQUE: Multiple axial images were obtained of the brain. 5 mm sections were acquired. 2.5-mm sections were acquired without injection of intravenous contrast. Reformatted sagittal and coronal images were obtained. + +DISCUSSION: No acute intracranial abnormalities appreciated. No evidence for hydrocephalus, midline shift, space occupying lesions or abnormal fluid collections. No cortical based abnormalities appreciated. The sinuses are clear. No acute bony abnormalities identified. + +Preliminary report given to emergency room at conclusion of exam by Dr. Xyz. + +IMPRESSION: No acute intracranial abnormalities appreciated. + diff --git a/1672_Radiology.txt b/1672_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..6a9634dacccdb3d476b5dfe61a16823b0fa3d5d3 --- /dev/null +++ b/1672_Radiology.txt @@ -0,0 +1,26 @@ +EXAM: + + Lumbar spine CT without contrast. + +HISTORY: + + Back pain after a fall. + +TECHNIQUE: + + Noncontrast axial images were acquired through the lumbar spine. Coronal and sagittal reconstruction views were also obtained. + +FINDINGS: + + There is no evidence for acute fracture or subluxation. There is no spondylolysis or spondylolisthesis. The central canal and neuroforamen are grossly patent at all levels. There are no abnormal paraspinal masses. There is no wedge/compression deformity. There is intervertebral disk space narrowing to a mild degree at L2-3 and L4-5. + +Soft tissue windows demonstrate atherosclerotic calcification of the abdominal aorta, which is not dilated. There was incompletely visualized probable simple left renal cyst, exophytic at the lower pole. + +IMPRESSION: + +1. No evidence for acute fracture or subluxation. + +2. Mild degenerative changes. + +3. Probable left simple renal cyst. + diff --git a/1675_Radiology.txt b/1675_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..4bf32d8d3e337a5d446f5f3b4b3299d350e7df76 --- /dev/null +++ b/1675_Radiology.txt @@ -0,0 +1,37 @@ +FINDINGS: + +There is a lobulated mass lesion of the epiglottis measuring approximately 22 x 16 x 30 mm (mediolateral x AP x craniocaudal) in size. There is slightly greater involvement on the right side however there is bilateral involvement of the aryepiglottic folds. There is marked enlargement of the bilateral aryepiglottic folds (left greater than right). There is thickening of the glossoepiglottic fold. There is an infiltrative mass like lesion extending into the pre-epiglottic space. + +There is no demonstrated effacement of the piriform sinuses. The mass obliterates the right vallecula. The paraglottic spaces are normal. The true and false cords appear normal. Normal thyroid, cricoid and arytenoid cartilages. + +There is lobulated thickening of the right side of the tongue base, for which invasion of the tongue cannot be excluded. A MRI examination would be of benefit for further evaluation of this finding. + +There is a 14 x 5 x 12 mm node involving the left submental region (Level I). + +There is borderline enlargement of the bilateral jugulodigastric nodes (Level II). The left jugulodigastric node,measures 14 x 11 x 8 mm while the right jugulodigastric node measures 15 x 12 x 8 mm. + +There is an enlarged second left high deep cervical node measuring 19 x 14 x 15 mm also consistent with a left Level II node, with a probable necrotic center. + +There is an enlarged second right high deep cervical node measuring 12 x 10 x 10 mm but no demonstrated central necrosis. + +There is an enlarged left mid level deep cervical node measuring 9 x 16 x 6 mm, located inferior to the hyoid bone but cephalad to the cricoid consistent with a Level III node. + +There are two enlarged matted nodes involving the right mid level deep cervical chain consistent with a right Level III nodal disease, producing a conglomerate nodal mass measuring approximately 26 x 12 x 10 mm. + +There is a left low level deep cervical node lying along the inferior edge of the cricoid cartilage measuring approximately 18 x 11 x 14 mm consistent with left Level IV nodal disease. + +There is no demonstrated pretracheal, prelaryngeal or superior mediastinal nodes. There is no demonstrated retropharyngeal adenopathy. + +There is thickening of the adenoidal pad without a mass lesion of the nasopharynx. The torus tubarius and fossa of Rosenmuller appear normal. + +IMPRESSION: + +Epiglottic mass lesion with probable invasion of the glossoepiglottic fold and pre-epiglottic space with invasion of the bilateral aryepiglottic folds. + +Lobulated tongue base for which tongue invasion cannot be excluded. An MRI may be of benefit for further assessment of this finding. + +Borderline enlargement of a submental node suggesting Level I adenopathy. + +Bilateral deep cervical nodal disease involving bilateral Level II + + Level III and left Level IV. \ No newline at end of file diff --git a/1679_Radiology.txt b/1679_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..df0fd3659b1fb356c5bcbced5df4eceeef648f99 --- /dev/null +++ b/1679_Radiology.txt @@ -0,0 +1,41 @@ +EXAM: + + CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast. + +REASON FOR EXAM: + + A 68-year-old status post fall with multifocal pain. + +COMPARISONS: + + None. + +TECHNIQUE: + + Sequential axial CT images were obtained from the vertex to the thoracic inlet without contrast. Additional high-resolution sagittal and/or coronal reconstructed images were obtained through the facial bones and cervical spine for better visualization of the osseous structures. + +INTERPRETATIONS: + +HEAD: + +There is mild generalized atrophy. Scattered patchy foci of decreased attenuation is seen in the subcortical and periventricular white matter consistent with chronic small vessel ischemic changes. There are subtle areas of increased attenuation seen within the frontal lobes bilaterally. Given the patient's clinical presentation, these likely represent small hemorrhagic contusions. Other differential considerations include cortical calcifications, which are less likely. The brain parenchyma is otherwise normal in attenuation without evidence of mass, midline shift, hydrocephalus, extra-axial fluid, or acute infarction. The visualized paranasal sinuses and mastoid air cells are clear. The bony calvarium and skull base are unremarkable. + +FACIAL BONES: + +The osseous structures about the face are grossly intact without acute fracture or dislocation. The orbits and extra-ocular muscles are within normal limits. There is diffuse mucosal thickening in the ethmoid and right maxillary sinuses. The remaining visualized paranasal sinuses and mastoid air cells are clear. Diffuse soft tissue swelling is noted about the right orbit and right facial bones without underlying fracture. + +CERVICAL SPINE: + +There is mild generalized osteopenia. There are diffuse multilevel degenerative changes identified extending from C4-C7 with disk space narrowing, sclerosis, and marginal osteophyte formation. The remaining cervical vertebral body heights are maintained without acute fracture, dislocation, or spondylolisthesis. The central canal is grossly patent. The pedicles and posterior elements appear intact with multifocal facet degenerative changes. There is no prevertebral or paravertebral soft tissue masses identified. The atlanto-dens interval and dens are maintained. + +IMPRESSION: + +1.Subtle areas of increased attenuation identified within the frontal lobes bilaterally suggesting small hemorrhagic contusions. There is no associated shift or mass effect at this time. Less likely, this finding could be secondary to cortical calcifications. The patient may benefit from a repeat CT scan of the head or MRI for additional evaluation if clinically indicated. + +2.Atrophy and chronic small vessel ischemic changes in the brain. + +3.Ethmoid and right maxillary sinus congestion and diffuse soft tissue swelling over the right side of the face without underlying fracture. + +4.Osteopenia and multilevel degenerative changes in the cervical spine as described above. + +5.Findings were discussed with Dr. X from the emergency department at the time of interpretation. \ No newline at end of file diff --git a/1684_Radiology.txt b/1684_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..895ed9bfe487afaca576ddd614aeb7132960cfc6 --- /dev/null +++ b/1684_Radiology.txt @@ -0,0 +1,11 @@ +TECHNIQUE: + + Sequential axial CT images were obtained from the vertex to the skull base without contrast. + +FINDINGS: + + There is mild generalized atrophy. Scattered patchy foci of decreased attenuation are seen within the sub cortical and periventricular white matter compatible with chronic small vessel ischemic changes. The brain parenchyma is otherwise normal in attenuation with no evidence of mass, hemorrhage, midline shift, hydrocephalus, extra-axial fluid, or acute infarction. The visualized paranasal sinuses and mastoid air cells are clear. The bony calvarium and skull base are within normal limits. + +IMPRESSION: + + No acute abnormalities. \ No newline at end of file diff --git a/1686_Radiology.txt b/1686_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..aa5b581ee4d1f24edc7464b0f65e27fb113e71da --- /dev/null +++ b/1686_Radiology.txt @@ -0,0 +1,29 @@ +EXAM: + +CT KUB. + +REASON FOR EXAM: + + Flank pain. + +TECHNIQUE: + + Noncontrast CT abdomen and pelvis per renal stone protocol. + +Correlation is made with the prior examination dated 01/16/09. + +FINDINGS: + + There is no intrarenal stone or obstruction bilaterally. There is no hydronephrosis, ureteral dilatation. There are calcifications about the pelvis including one in the left upper pelvis, but these are stable from the prior study and there is no upstream ureteral dilatation, the findings therefore are favored to represent phleboliths. The bladder is nearly completely decompressed. There is no asymmetric renal enlargement or perinephric stranding as secondary evidence of obstruction. + +The appendix is normal. There is no evidence for a pericolonic inflammatory process or small bowel obstruction. + +Dedicated scan to the pelvis disclosed the aforementioned presumed phleboliths. There is no pelvic free fluid or adenopathy. + +Lung bases appear clear. Given the lack of contrast, liver, spleen, adrenal glands, and the pancreas appear grossly unremarkable. The gallbladder has been resected. There is no abdominal free fluid or pathologic adenopathy. + +IMPRESSION: + +1. No renal stone or evidence of obstruction. Stable appearing pelvic calcifications likely indicate phleboliths. + +2. Normal appendix. \ No newline at end of file diff --git a/1689_Radiology.txt b/1689_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..fb75a88389b0ba1ce2a7f0acdbafd7bd1bb147d0 --- /dev/null +++ b/1689_Radiology.txt @@ -0,0 +1,23 @@ +EXAM: + + CT cervical spine. + +REASON FOR EXAM: + + MVA + + feeling sleepy, headache, shoulder and rib pain. + +TECHNIQUE: + + Axial images through the cervical spine with coronal and sagittal reconstructions. + +FINDINGS: + + There is reversal of the normal cervical curvature at the vertebral body heights. The intervertebral disk spaces are otherwise maintained. There is no prevertebral soft tissue swelling. The facets are aligned. The tip of the clivus and occiput appear intact. On the coronal reconstructed sequence, there is satisfactory alignment of C1 on C2, no evidence of a base of dens fracture. + +The included portions of the first and second ribs are intact. There is no evidence of a posterior element fracture. Included portions of the mastoid air cells appear clear. There is no CT evidence of a moderate or high-grade stenosis. + +IMPRESSION: + + No acute process, cervical spine. \ No newline at end of file diff --git a/1691_Radiology.txt b/1691_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..a4cf031ddbd14f385e87be09e864934729b8653d --- /dev/null +++ b/1691_Radiology.txt @@ -0,0 +1,37 @@ +CT HEAD WITHOUT CONTRAST AND CT CERVICAL SPINE WITHOUT CONTRAST + +REASON FOR EXAM: + + Motor vehicle collision. + +CT HEAD WITHOUT CONTRAST + +TECHNIQUE: + + Noncontrast axial CT images of the head were obtained. + +FINDINGS: + + There is no acute intracranial hemorrhage, mass effect, midline shift, or extra-axial fluid collection. The ventricles and cortical sulci are normal in shape and configuration. The gray/white matter junctions are well preserved. There is no calvarial fracture. The visualized paranasal sinuses and mastoid air cells are clear. + +IMPRESSION: + + Negative for acute intracranial disease. + +CT CERVICAL SPINE + +TECHNIQUE: + +Noncontrast axial CT images of the cervical spine were obtained. Sagittal and coronal images were obtained. + +FINDINGS: + + Straightening of the normal cervical lordosis is compatible with patient position versus muscle spasms. No fracture or subluxation is seen. Anterior and posterior osteophyte formation is seen at C5-C6. No abnormal anterior cervical soft tissue swelling is seen. No spinal compression is noted. The atlanto-dens interval is normal. There is a large retention cyst versus polyp within the right maxillary sinus. + +IMPRESSION: + +1. Straightening of the normal cervical lordosis compatible with patient positioning versus muscle spasms. + +2. Degenerative disk and joint disease at C5-C6. + +3. Retention cyst versus polyp of the right maxillary sinus. \ No newline at end of file diff --git a/1694_Radiology.txt b/1694_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..5a04782de7a3b88928f7de2c5d1a2df25cd8b327 --- /dev/null +++ b/1694_Radiology.txt @@ -0,0 +1,85 @@ +CC: + + Falls. + +HX: + +This 51y/o RHF fell four times on 1/3/93, because her "legs suddenly gave out." She subsequently noticed weakness involving the right leg, and often required the assistance of her arms to move it. During some of these episodes she appeared mildly pale and felt generally weak; her husband would give her 3 teaspoons of sugar and she would appear to improve, thought not completely. During one episode she held her RUE in an "odd fisted posture." She denied any other focal weakness, sensory change, dysarthria, diplopia, dysphagia or alteration of consciousness. She did not seek medical attention despite her weakness. Then, last night, 1/4/93, she fell again + +and because her weakness did not subsequently improve she came to UIHC for evaluation on 1/5/93. + +MEDS: + +Micronase 5mg qd, HCTZ + + quit ASA 6 months ago (tired of taking it). + +PMH: + + 1)DM type 2, dx 6 months ago. 2)HTN. 3)DJD. 4)s/p Vitrectomy and retinal traction OU for retinal detachment 7/92. 5) s/p Cholecystemomy,1968. 6) Cataract implant, OU + +1992. 7) s/p C-section. + +FHX: + +Grand Aunt (stroke) + + MG (CAD) + + Mother (CAD + + died MI age 63) + + Father (with unknown CA) + + Sisters (HTN) + + No DM in relatives. + +SHX: + +Married, lives with husband, 4 children alive and well. Denied tobacco/ETOH/illicit drug use. + +ROS: + + intermittent diarrhea for 20 years. + +EXAM: + +BP164/82 HR64 RR18 36.0C,MS: A & O to person, place, time. Speech fluent and without dysarthria. Intact naming, comprehension, reading. + +CN: Pupils 4.5 (irregular)/4.0 (irregular) and virtually fixed. Optic disks flat. EOM intact. VFFTC. Right lower facial weakness. The rest of the CN exam was unremarkable. + +Motor: 5/5 BUE with some question of breakaway. LE: HF and HE 4+/5, KF5/5, AF and AE 5/5. Normal muscle bulk and tone. + +Sensory: intact PP/VIB/PROP/LT/T/graphesthesia. + +Coord: slowed FNF and HKS (worse on right). + +Station: no pronator drift or Romberg sign. + +Gait: Unsteady wide-based gait. Unable to heel walk on right. + +Reflexes: 2/2+ throughout (Slightly more brisk on right). Plantar responses were downgoing bilaterally. + +HEENT: N0 Carotid or cranial bruits. + +Gen Exam: unremarkable. + +COURSE: + + CBC + + GS (including glucose) + + PT/PTT + + EKG + + CXR on admission, 1/5/93, were unremarkable. HCT + + 1/5/93, revealed a hypodensity in the left caudate consistent with ischemic change. Carotid Duplex: 0-15%RICA + + 16-49%LICA; antegrade vertebral artery flow, bilaterally. Transthoracic echocardiogram showed borderline LV hypertrophy and normal LV function. No valvular abnormalities or thrombus were seen. + +The patient's history and exam findings of right facial and RLE weakness with sparing of the RUE would invoke a RACA territory stroke with recurrent artery of Heubner involvement causing the facial weakness. \ No newline at end of file diff --git a/1697_Radiology.txt b/1697_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..a43a25385a71ca492568382ddb0e2d306a5015c8 --- /dev/null +++ b/1697_Radiology.txt @@ -0,0 +1,27 @@ +EXAM: + + CT chest with contrast. + +REASON FOR EXAM: + + Pneumonia, chest pain, short of breath, and coughing up blood. + +TECHNIQUE: + + Postcontrast CT chest 100 mL of Isovue-300 contrast. + +FINDINGS: + + This study demonstrates a small region of coalescent infiltrates/consolidation in the anterior right upper lobe. There are linear fibrotic or atelectatic changes associated with this. Recommend followup to ensure resolution. There is left apical scarring. There is no pleural effusion or pneumothorax. There is lingular and right middle lobe mild atelectasis or fibrosis. + +Examination of the mediastinal windows disclosed normal inferior thyroid. Cardiac and aortic contours are unremarkable aside from mild atherosclerosis. The heart is not enlarged. There is no pathologic adenopathy identified in the chest including the bilateral axillary and hilar regions. + +Very limited assessment of the upper abdomen demonstrates no definite abnormalities. + +There are mild degenerative changes in the thoracic spine. + +IMPRESSION: + +1.Anterior small right upper lobe infiltrate/consolidation. Recommend followup to ensure resolution given its consolidated appearance. + +2.Bilateral atelectasis versus fibrosis. \ No newline at end of file diff --git a/1698_Radiology.txt b/1698_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..cd35585437dadcdecb8262cdcf66b3f0c3d39a88 --- /dev/null +++ b/1698_Radiology.txt @@ -0,0 +1,45 @@ +CC: + + Headache,HX: + +This 16 y/o RHF was in good health, until 11:00PM + + the evening of 11/27/87, when she suddenly awoke from sleep with severe headache. Her parents described her as holding her head between her hands. She had no prior history of severe headaches. 30 minutes later she felt nauseated and vomited. The vomiting continued every 30 minutes and she developed neck stiffness. At 2:00AM on 11/28/97, she got up to go to the bathroom and collapsed in her mother's arms. Her mother noted she appeared weak on the left side. Shortly after this she experienced fecal and urinary incontinence. She was taken to a local ER and transferred to UIHC. + +PMH/FHX/SHX: + + completely unremarkable FHx. Has boyfriend and is sexually active. + +Denied drug/ETOH/Tobacco use. + +MEDS: + + Oral Contraceptive pill QD. + +EXAM: + + BP152/82 HR74 RR16 T36.9C,MS: Somnolent and difficult to keep awake. Prefer to lie on right side because of neck pain/stiffness. Answers appropriately though when questioned. + +CN: No papilledema noted. Pupils 4/4 decreasing to 2/2. EOM Intact. Face: ?left facial weakness. The rest of the CN exam was unremarkable. + +Motor: Upper extremities: 5/3 with left pronator drift. Lower extremities: 5/4 with LLE weakness evident throughout. + +Coordination: left sided weakness evident. + +Station: left pronator drift. + +Gait: left hemiparesis. + +Reflexes: 2/2 throughout. No clonus. Plantars were flexor bilaterally. + +Gen Exam: unremarkable. + +COURSE: + +The patient underwent emergent CT Brain. This revealed a perimesencephalic subarachnoid hemorrhage and contrast enhancing structures in the medial aspect of the parietotemporal region. She then underwent a 4-vessel cerebral angiogram. This study was unremarkable except for delayed transit of the contrast material through the vascular system of the brain and poor opacification of the straight sinus. This suggested straight sinus thromboses. MRI Brain was then done; this was unremarkable and did not show sign of central venous thrombosis. CBC/Blood Cx/ESR/PT/PTT/GS/CSF Cx/ANA were negative. + +Lumbar puncture on 12/1/87 revealed an opening pressure of 55cmH20, RBC18550, WBC25, 18neutrophils, 7lymphocytes, Protein25mg/dl, Glucose47mg/dl, Cx negative. + +The patient was assumed to have had a SAH secondary to central venous thrombosis due to oral contraceptive use. She recovered well, but returned to Neurology at age 32 for episodic blurred vision and lightheadedness. EEG was compatible with seizure tendency (right greater than left theta bursts from the mid-temporal regions) + + and she was recommended an anticonvulsant which she refused. \ No newline at end of file diff --git a/1700_Radiology.txt b/1700_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..d4199f25b8a29ea75d4c6ef66a486312e9eab5c2 --- /dev/null +++ b/1700_Radiology.txt @@ -0,0 +1,67 @@ +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. \ No newline at end of file diff --git a/1701_Radiology.txt b/1701_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..44b65d347ea3571249ac4733ecab3ba4593f9d65 --- /dev/null +++ b/1701_Radiology.txt @@ -0,0 +1,97 @@ +CC: + + Episodic mental status change and RUE numbness, and chorea (found on exam). + +HX: + + This 78y/o RHM was referred for an episode of unusual behavior and RUE numbness. In 9/91, he experienced near loss of consciousness, generalized weakness, headache and vomiting. Evaluation at that time revealed an serum glucose of >500mg/dL and he was placed on insulin therapy with subsequent resolution of his signs and symptoms. Since then, he became progressively more forgetful, and at the time of evaluation, 1/17/93, had lost his ability to perform his job repairing lawn mowers. His wife had taken over the family finances. + +He had also been "stumbling," when ambulating, for 2 months prior to presentation. He was noted to be occasionally confused upon awakening for last several months. On 1/15/93, he was lying on a couch when he suddenly began throwing pillows and blankets for no apparent reason. There had been no change in sleep, appetite, or complaint of depression. + +In addition, for two months prior to presentation, he had been experiencing 10-15minute episodes of RUE numbness. There was no face or lower extremity involvement. + +During the last year he had developed unusual movements of his extremities. + +MEDS: + + NPH Humulin 12U qAM and 6U qPM. Advil prn. + +PMH: + + 1) Traumatic amputation of the 4th and 5th digits of his left hand. 2) Hospitalized for an unknown "nervous" condition in the 1940's. + +SHX/FHX: + + Retired small engine mechanic who worked in a poorly ventilated shop. Married with 13 children. No history of ETOH + + Tobacco or illicit drug use. Father had tremors following a stroke. Brother died of brain aneurysm. No history of depression, suicide, or Huntington's disease in family. + +ROS: + + no history of CAD + + Renal or liver disease, SOB + + Chest pain, fevers, chills, night sweats or weight loss. No report of sign of bleeding. + +EXAM: + + BP138/63 HR65 RR15 36.1C,MS: Alert and oriented to self, season; but not date, year, or place. Latent verbal responses and direction following. Intact naming, but able to repeat only simple but not complex phrases. Slowed speech, with mild difficulty with word finding. 2/3 recall at one minute and 0/3 at 3 minutes. Knew the last 3 presidents. 14/27 on MMSE: unable to spell "world" backwards. Unable to read/write for complaint of inability to see without glasses. + +CN: II-XII appeared grossly intact. EOM were full and smooth and without unusual saccadic pursuits. OKN intact. Choreiform movements of the tongue were noted. + +Motor: 5/5 strength throughout with Guggenheim type resistance. there were choreiform type movements of all extremities bilaterally. No motor impersistence noted. + +Sensory: unreliable. + +Cord: "normal" FNF + + HKS + + and RAM + + bilaterally. + +Station: No Romberg sign. + +Gait: unsteady and wide-based. + +Reflexes: BUE 2/2, Patellar 2/2, Ankles Trace/Trace, Plantars were flexor bilaterally. + +Gen Exam: 2/6 Systolic ejection murmur in aortic area. + +COURSE: + + No family history of Huntington's disease could be elicited from relatives. Brain CT + + 1/18/93: bilateral calcification of the globus pallidi and a high attenuation focus in the right occipital lobe thought to represent artifact. Carotid duplex, 1/18/93: RICA 0-15% + + LICA 16-49% stenosis and normal vertebral artery flow bilaterally. Transthoracic Echocardiogram (TTE) + +1/18/93: revealed severe aortic fibrosis or valvular calcification with "severe" aortic stenosis in the face of "normal" LV function. Cardiology felt the patient the patient had asymptomatic aortic stenosis. EEG + + 1/20/93, showed low voltage Delta over the left posterior quadrant and intermittent background slowing over the same region consistent with focal dysfunction in this quadrant. MRI Brain, 1/22/93: multiple focal and more confluent areas of increased T2 signal in the periventricular white matter, more prominent on the left; in addition, there were irregular shaped areas of increased T2 signal and decreased T1 signal in both cerebellar hemispheres; and age related atrophy; incidentally, there is a cavum septum pellucidum et vergae and mucosal thickening of the maxillary sinuses. Impression: diffuse bilateral age related ischemic change, age related atrophy and maxillary sinus disease. There were no masses or areas of abnormal enhancement. TSH + + FT4, Vit B12, VDRL + + Urine drug and heavy metal screens were unremarkable. CSF + +1/19/93: glucose 102 (serum glucose 162mg/dL) + + Protein 45mg/dL, RBC O, WBC O, Cultures negative. SPEP negative. However serum and CSF beta2 microglobulin levels were elevated at 2.5 and 3.1mg/L, respectively. Hematology felt these may have been false positives. CBC + + 1/17/93: Hgb 10.4g/dL (low) + + HCT 31% (low) + + RBC 3/34mil/mm3 (low) + + WBC 5.8K/mm3, Plt 201K/mm3. Retic 30/1K/mm3 (normal). Serum Iron 35mcg/dL (low) + + TIBC 201mcg/dL (low) + + FeSat 17% (low) + + CRP 0.1mg/dL (normal) + + ESR 83mm/hr (high). Bone Marrow Bx: normal with adequate iron stores. Hematology felt the finding were compatible with anemia of chronic disease. Neuropsychologic evaluation on 1/17/93 revealed significant impairments in multiple realms of cognitive function (visuospatial reasoning, verbal and visual memory, visual confrontational naming, impaired arrhythmatic, dysfluent speech marked by use of phrases no longer than 5 words, frequent word finding difficulty and semantic paraphasic errors) most severe for expressive language, attention and memory. The pattern of findings reveals an atypical aphasia suggestive of left temporo-parietal dysfunction. The patient was discharged1/22/93 on ASA 325mg qd. He was given a diagnosis of senile chorea and dementia (unspecified type). 6/18/93 repeat Neuropsychological evaluation revealed moderate decline in all areas tested reflecting severe dementia. \ No newline at end of file diff --git a/1705_Radiology.txt b/1705_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..de3688b9f976be34a2489bedc0c893a1951cb763 --- /dev/null +++ b/1705_Radiology.txt @@ -0,0 +1,29 @@ +CT ABDOMEN WITH AND WITHOUT CONTRAST AND CT PELVIS WITH CONTRAST + +REASON FOR EXAM: + + Generalized abdominal pain, nausea, diarrhea, and recent colonic resection in 11/08. + +TECHNIQUE: + + Axial CT images of the abdomen were obtained without contrast. Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue-300. + +FINDINGS: + + The liver is normal in size and attenuation. + +The gallbladder is normal. + +The spleen is normal in size and attenuation. + +The adrenal glands and pancreas are unremarkable. + +The kidneys are normal in size and attenuation. + +No hydronephrosis is detected. Free fluid is seen within the right upper quadrant within the lower pelvis. A markedly thickened loop of distal small bowel is seen. This segment measures at least 10-cm long. No definite pneumatosis is appreciated. No free air is apparent at this time. Inflammatory changes around this loop of bowel. Mild distention of adjacent small bowel loops measuring up to 3.5 cm is evident. No complete obstruction is suspected, as there is contrast material within the colon. Postsurgical changes compatible with the partial colectomy are noted. Postsurgical changes of the anterior abdominal wall are seen. Mild thickening of the urinary bladder wall is seen. + +IMPRESSION: + +1. Marked thickening of a segment of distal small bowel is seen with free fluid within the abdomen and pelvis. An inflammatory process such as infection or ischemia must be considered. Close interval followup is necessary. + +2. Thickening of the urinary bladder wall is nonspecific and may be due to under distention. However, evaluation for cystitis is advised. \ No newline at end of file diff --git a/1706_Radiology.txt b/1706_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..5c94a1ef9faa87f4d50a6921d388830adb51f607 --- /dev/null +++ b/1706_Radiology.txt @@ -0,0 +1,21 @@ +CT ANGIOGRAPHY CHEST WITH CONTRAST + +REASON FOR EXAM: + + Chest pain, shortness of breath and cough, evaluate for pulmonary arterial embolism. + +TECHNIQUE: + +Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300. + +FINDINGS: + +There is no evidence for pulmonary arterial embolism. + +The lungs are clear of any abnormal airspace consolidation, pleural effusion, or pneumothorax. No abnormal mediastinal or hilar lymphadenopathy is seen. + +Limited images of the upper abdomen are unremarkable. No destructive osseous lesion is detected. + +IMPRESSION: + + Negative for pulmonary arterial embolism. \ No newline at end of file diff --git a/1707_Radiology.txt b/1707_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..fbae7548882bc18a9e9ecababf7b2d6968d49aad --- /dev/null +++ b/1707_Radiology.txt @@ -0,0 +1,27 @@ +EXAM: + + CT abdomen without contrast and pelvis without contrast, reconstruction. + +REASON FOR EXAM: + + Right lower quadrant pain, rule out appendicitis. + +TECHNIQUE: + +Noncontrast CT abdomen and pelvis. An intravenous line could not be obtained for the use of intravenous contrast material. + +FINDINGS: + + The appendix is normal. There is a moderate amount of stool throughout the colon. There is no evidence of a small bowel obstruction or evidence of pericolonic inflammatory process. Examination of the extreme lung bases appear clear, no pleural effusions. The visualized portions of the liver, spleen, adrenal glands, and pancreas appear normal given the lack of contrast. There is a small hiatal hernia. There is no intrarenal stone or evidence of obstruction bilaterally. There is a questionable vague region of low density in the left anterior mid pole region, this may indicate a tiny cyst, but it is not well seen given the lack of contrast. This can be correlated with a followup ultrasound if necessary. The gallbladder has been resected. There is no abdominal free fluid or pathologic adenopathy. There is abdominal atherosclerosis without evidence of an aneurysm. + +Dedicated scans of the pelvis disclosed phleboliths, but no free fluid or adenopathy. There are surgical clips present. There is a tiny airdrop within the bladder. If this patient has not had a recent catheterization, correlate for signs and symptoms of urinary tract infection. + +IMPRESSION: + +1.Normal appendix. + +2.Moderate stool throughout the colon. + +3.No intrarenal stones. + +4.Tiny airdrop within the bladder. If this patient has not had a recent catheterization, correlate for signs and symptoms of urinary tract infection. The report was faxed upon dictation. \ No newline at end of file diff --git a/1709_Radiology.txt b/1709_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..60020371fb167723baac3045fcb48a0a7af402ed --- /dev/null +++ b/1709_Radiology.txt @@ -0,0 +1,23 @@ +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. \ No newline at end of file diff --git a/1710_Radiology.txt b/1710_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..5f4597f40c3698c4db133efd733b06fec6f9b8b7 --- /dev/null +++ b/1710_Radiology.txt @@ -0,0 +1,47 @@ +CC: + + Left-sided weakness. + +HX: + + This 28y/o RHM was admitted to a local hospital on 6/30/95 for a 7 day history of fevers, chills, diaphoresis, anorexia, urinary frequency, myalgias and generalized weakness. He denied foreign travel, IV drug abuse, homosexuality, recent dental work, or open wound. Blood and urine cultures were positive for Staphylococcus Aureus, oxacillin sensitive. He was place on appropriate antibiotic therapy according to sensitivity.. A 7/3/95 transthoracic echocardiogram revealed normal left ventricular function and a damaged mitral valve with regurgitation. Later that day he developed left-sided weakness and severe dysarthria and aphasia. HCT + + on 7/3/95 revealed mild attenuated signal in the right hemisphere. On 7/4/95 he developed first degree AV block, and was transferred to UIHC. + +MEDS: + +Nafcillin 2gm IV q4hrs, Rifampin 600mg q12hrs, Gentamicin 130mg q12hrs. + +PMH: + + 1) Heart murmur dx age 5 years. + +FHX: + + Unremarkable. + +SHX: + + Employed cook. Denied ETOH/Tobacco/illicit drug use. + +EXAM: + + BP 123/54, HR 117, RR 16, 37.0C,MS: Somnolent and arousable only by shaking and repetitive verbal commands. He could follow simple commands only. He nodded appropriately to questioning most of the time. Dysarthric speech with sparse verbal output. + +CN: Pupils 3/3 decreasing to 2/2 on exposure to light. Conjugate gaze preference toward the right. Right hemianopia by visual threat testing. Optic discs flat and no retinal hemorrhages or Roth spots were seen. Left lower facial weakness. Tongue deviated to the left. Weak gag response, bilaterally. Weak left corneal response. + +MOTOR: Dense left flaccid hemiplegia. + +SENSORY: Less responsive to PP on left. + +COORD: Unable to test. + +Station and Gait: Not tested. + +Reflexes: 2/3 throughout (more brisk on the left side). Left ankle clonus and a Left Babinski sign were present. + +GEN EXAM: Holosystolic murmur heard throughout the precordium. Janeway lesions were present in the feet and hands. No Osler's nodes were seen. + +COURSE: + + 7/6/95, HCT showed a large RMCA stroke with mass shift. His neurologic exam worsened and he was intubated, hyperventilated, and given IV Mannitol. He then underwent emergent left craniectomy and duraplasty. He tolerated the procedure well and his brain was allowed to swell. He then underwent mitral valve replacement on 7/11/95 with a St. Judes valve. His post-operative recovery was complicated by pneumonia, pericardial effusion and dysphagia. He required temporary PEG placement for feeding. The 7/27/95, 8/6/95 and 10/18/96 HCT scans show the chronologic neuroradiologic documentation of a large RMCA stroke. His 10/18/96 Neurosurgery Clinic visit noted that he can ambulate without assistance with the use of a leg brace to prevent left foot drop. His proximal LLE strength was rated at a 4. His LUE was plegic. He had a seizure 6 days prior to his 10/18/96 evaluation. This began as a Jacksonian march of shaking in the LUE; then involved the LLE. There was no LOC or tongue-biting. He did have urinary incontinence. He was placed on DPH. His speech was dysarthric but fluent. He appeared bright, alert and oriented in all spheres. \ No newline at end of file diff --git a/1714_Radiology.txt b/1714_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..2cca5bddc48ba76f8eb338680abb17a5c1178273 --- /dev/null +++ b/1714_Radiology.txt @@ -0,0 +1,39 @@ +EXAM: + + CT scan of the abdomen and pelvis without and with intravenous contrast. + +CLINICAL INDICATION: + + Left lower quadrant abdominal pain. + +COMPARISON: + + None. + +FINDINGS: + + CT scan of the abdomen and pelvis was performed without and with intravenous contrast. Total of 100 mL of Isovue was administered intravenously. Oral contrast was also administered. + +The lung bases are clear. The liver is enlarged and decreased in attenuation. There are no focal liver masses. + +There is no intra or extrahepatic ductal dilatation. + +The gallbladder is slightly distended. + +The adrenal glands, pancreas, spleen, and left kidney are normal. + +A 12-mm simple cyst is present in the inferior pole of the right kidney. There is no hydronephrosis or hydroureter. + +The appendix is normal. + +There are multiple diverticula in the rectosigmoid. There is evidence of focal wall thickening in the sigmoid colon (image #69) with adjacent fat stranding in association with a diverticulum. These findings are consistent with diverticulitis. No pneumoperitoneum is identified. There is no ascites or focal fluid collection. + +The aorta is normal in contour and caliber. + +There is no adenopathy. + +Degenerative changes are present in the lumbar spine. + +IMPRESSION: + + Findings consistent with diverticulitis. Please see report above. \ No newline at end of file diff --git a/1717_Radiology.txt b/1717_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..3e3fa43bc537a89331d897a65cb97fada37023d1 --- /dev/null +++ b/1717_Radiology.txt @@ -0,0 +1,35 @@ +EXAM: + + CT Abdomen and Pelvis with contrast + +REASON FOR EXAM: + + Nausea, vomiting, diarrhea for one day. Fever. Right upper quadrant pain for one day. + +COMPARISON: + + None. + +TECHNIQUE: + + CT of the abdomen and pelvis performed without and with approximately 54 ml Isovue 300 contrast enhancement. + +CT ABDOMEN: + + Lung bases are clear. The liver, gallbladder, spleen, pancreas, and bilateral adrenal/kidneys are unremarkable. The aorta is normal in caliber. There is no retroperitoneal lymphadenopathy. + +CT PELVIS: + + The appendix is visualized along its length and is diffusely unremarkable with no surrounding inflammatory change. Per CT + + the colon and small bowel are unremarkable. The bladder is distended. No free fluid/air. Visualized osseous structures demonstrate no definite evidence for acute fracture, malalignment, or dislocation. + +IMPRESSION: + +1. Unremarkable exam; specifically no evidence for acute appendicitis. + +2. No acute nephro-/ureterolithiasis. + +3. No secondary evidence for acute cholecystitis. + +Results were communicated to the ER at the time of dictation. \ No newline at end of file diff --git a/1721_Radiology.txt b/1721_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..9a2a3b8bf812ed1dbcbb134d8d99a39281dfea8d --- /dev/null +++ b/1721_Radiology.txt @@ -0,0 +1,19 @@ +EXAM: + + Coronary artery CTA with calcium scoring and cardiac function. + +HISTORY: + + Chest pain. + +TECHNIQUE AND FINDINGS: + + Coronary artery CTA was performed on a Siemens dual-source CT scanner. Post-processing on a Vitrea workstation. 150 mL Ultravist 370 was utilized as the intravenous contrast agent. Patient did receive nitroglycerin sublingually prior to the contrast. + +HISTORY: + + Significant for high cholesterol, overweight, chest pain, family history,Patient's total calcium score (Agatston) is 10. his places the patient just below the 75th percentile for age. + +The LAD has a moderate area of stenosis in its midportion due to a focal calcified plaque. The distal LAD was unreadable while the proximal was normal. The mid and distal right coronary artery are not well delineated due to beam-hardening artifact. The circumflex is diminutive in size along its proximal portion. Distal is not readable. + +Cardiac wall motion within normal limits. No gross pulmonary artery abnormality however they are not well delineated. A full report was placed on the patient's chart. Report was saved to PACS. \ No newline at end of file diff --git a/1723_Radiology.txt b/1723_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..e1c1a6a45f09ad0562fcf8db0dcbcfbc6ed43a8a --- /dev/null +++ b/1723_Radiology.txt @@ -0,0 +1,85 @@ +COMPARISON: + + None. + +MEDICATIONS: + + Lopressor 5mg IV at 0920 hours. + +HEART RATE: + +Recorded heart rate 55 to 57bpm. + +EXAM: + +Initial unenhanced axial CT imaging of the heart was obtained with ECG gating for the purpose of coronary artery calcium scoring (Agatston Method) and calcium volume determination. + +18 gauge IV Intracath was inserted into the right antecubital vein. + +A 20cc saline bolus was injected intravenously to confirm vein patency and adequacy of venous access. + +Multi-detector CT imaging was performed with a 64 slice MDCT scanner with images obtained from the mid ascending aorta to the diaphragm at 0.5mm slice thickness during breath-holding. + +95 cc of Isovue was administered followed by a 90cc saline “bolus chaser”. Image reconstruction was performed using retrospective cardiac gating. Calcium scoring analysis (Agatston Method and volume determination) was performed. + +FINDINGS: + +CALCIUM SCORE: The patient's total Agatston calcium score is: 115. The Agatston score for the individual vessels are: LM: 49. RCA: 1. LAD: 2. CX: 2. Other: 62. The Agatston calcium score places the patient in the 90th percentile, which means 10 percent of the male population in this age group would have a higher calcium score. + +QUALITY ASSESSMENT: + + Examination is of good quality with good bolus timing and good demonstration of coronary arteries. + +LEFT MAIN CORONARY ARTERY: + + The left main coronary artery has a posteriorly positioned take-off from the valve cusp, with a patent ostium, and it has an extramural (non-malignant) course. The vessel is of moderate size. There is an apparent second ostium, in a more normal anatomic location, but quite small. This has an extramural (non-malignant) course. There is mixed calcific/atheromatous plaque within the distal vessel, as well as positive remodeling. There is no high grade stenosis but a flow-limiting lesion can not be excluded. The vessel trifurcates into a left anterior descending artery, a ramus intermedius and a left circumflex artery. + +LEFT ANTERIOR DESCENDING CORONARY ARTERY: + + The left anterior descending artery is a moderate-size vessel, with ostial calcific plaque and soft plaque without a high-grade stenosis, but there may be a flow-limiting lesion here. There is a moderate size bifurcating first diagonal branch with ostial calcification, but no flow-limiting lesion. LAD continues as a moderate-size vessel to the posterior apex of the left ventricle. + +Ramus intermedius branch is a moderate to large-size vessel with extensive calcific plaque, but no ostial stenosis. The dense calcific plaque limits evaluation of the vessel lumen, and a flow-limiting lesion within the proximal vessel cannot be excluded. The vessel continues as a small vessel on the left lateral ventricular wall. + +LEFT CIRCUMFLEX CORONARY ARTERY: + + The left circumflex artery is a moderate-size vessel with a normal ostium giving rise to a small OM1 branch and a large OM2 branch supplying much of the posterolateral wall of the left ventricular. The AV-groove branch tapers at the base of the heart. There is minimal calcific plaque within the mid vessel, but there is no flow-limiting stenosis. + +RIGHT CORONARY ARTERY: + + The right coronary artery is a large vessel with a normal ostium giving rise to a moderate-size acute marginal branch and continuing as a large vessel to the crux of the heart supplying a left posterior descending artery and small posterolateral ventricular branches. There is minimal calcific plaque within the mid vessel, but there is no flow-limiting lesion. + +Coronary circulation is right dominant. + +FUNCTIONAL ANALYSIS: + + End diastolic volume: 106ml End systolic volume: 44ml Ejection fraction: 58 percent,ANATOMIC ANALYSIS: + +Normal heart size with no demonstrated ventricular wall abnormalities. There are no demonstrated myocardial,bridges. Normal left atrial appendage with no evidence of thrombosis. + +Cardiac valves are normal. + +The aortic diameter measures 33mm just distal to the sino-tubular junction. The visualized thoracic aorta appears normal in size. + +Normal pericardium without pericardial thickening or effusion. + +There is no demonstrated mediastinal or hilar adenopathy. The visualized lung parenchyma is unremarkable. + +There are two left and two right pulmonary veins. + +IMPRESSION: + +Ventricular function: Normal. + +Single vessel coronary artery analysis: + +LM: There is a posterior origin from the valve cusp. There is mixed calcific/atheromatous plaque and positive remodeling plaque within the LM + + and although there is no high grade stenosis, a flow-limiting lesion can not be excluded. In addition, there is an apparent second ostium of indeterminate significance, but both ostia have extramural (non-malignant) courses. + +LAD: Dense calcific plaque within the proximal vessel with ostial calcification and possible flow-limiting proximal lesion. There is a ramus branch with dense calcific plaque limiting evaluation of the vessel lumen, but a flow-limiting lesion cannot be excluded here. + +CX: Minimal calcific plaque with no flow-limiting lesion. + +RCA: Minimal calcific plaque with no flow-limiting lesion. + +Coronary artery dominance: Right. \ No newline at end of file diff --git a/1727_Radiology.txt b/1727_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..fa15817c38dbe3aa79a0c4bc6c5e94af95f48632 --- /dev/null +++ b/1727_Radiology.txt @@ -0,0 +1,59 @@ +CC: + + Intermittent binocular horizontal, vertical, and torsional diplopia. + +HX: + +70y/o RHM referred by Neuro-ophthalmology for evaluation of neuromuscular disease. In 7/91, he began experiencing intermittent binocular horizontal, vertical and torsional diplopia which was worse and frequent at the end of the day, and was eliminated when closing one either eye. An MRI Brain scan at that time was unremarkable. He was seen at UIHC Strabismus Clinic in 5/93 for these symptoms. On exam, he was found to have intermittent right hypertropia in primary gaze, and consistent diplopia in downward and rightward gaze. This was felt to possibly represent Grave's disease. Thyroid function studies were unremarkable, but orbital echography suggested Graves orbitopathy. The patient was then seen in the Neuro-ophthalmology clinic on 12/23/92. His exam remained unchanged. He underwent Tensilon testing which was unremarkable. On 1/13/93, he was seen again in Neuro-ophthalmology. His exam remained relatively unchanged and repeat Tensilon testing was unremarkable. He then underwent a partial superior rectus resection, OD + + with only mild improvement of his diplopia. During his 8/27/96 Neuro-ophthalmology clinic visit he was noted to have hypertropia OD with left pseudogaze palsy and a right ptosis. The ptosis improved upon administration of Tensilon and he was placed on Mestinon 30mg tid. His diplopia subsequently improved, but did not resolve. The dosage was increased to 60mg tid and his diplopia worsened and the dose decreased back to 30mg tid. At present he denied any fatigue on repetitive movement. He denied dysphagia, SOB + + dysarthria, facial weakness, fevers, chills, night sweats, weight loss or muscle atrophy. + +MEDS: + + Viokase, Probenecid, Mestinon 30mg tid. + +PMH: + + 1) Gastric ulcer 30 years ago, 2) Cholecystectomy, 3) Pancreatic insufficiency, 4) Gout, 5) Diplopia. + +FHX: + + Mother died age 89 of "old age." Father died age 89 of stroke. Brother, age 74 with CAD + + Sister died age 30 of cancer. + +SHX: + + Retired insurance salesman and denies history of tobacco or illicit drug us. He has no h/o ETOH abuse and does not drink at present. + +EXAM: + +BP 155/104. HR 92. RR 12. Temp 34.6C. WT 76.2kg. + +MS: Unremarkable. Normal speech with no dysarthria. + +CN: Right hypertropia (worse on rightward gaze and less on leftward gaze). Minimal to no ptosis, OD. No ptosis, OS. VFFTC. No complaint of diplopia. The rest of the CN exam was unremarkable. + +MOTOR: 5/5 strength throughout with normal muscle bulk and tone. + +SENSORY: No deficits appreciated on PP/VIB/LT/PROP/TEMP testing. + +Coordination/Station/Gait: Unremarkable. + +Reflexes: 2/2 throughout. Plantar responses were flexor on the right and withdrawal on the left. + +HEENT and GEN EXAM: Unremarkable. + +COURSE: + + EMG/NCV + + 9/26/96: Repetitive stimulation studies of the median, facial, and spinal accessory nerves showed no evidence of decrement at baseline, and at intervals up to 3 minutes following exercise. The patient had been off Mestinon for 8 hours prior to testing. Chest CT with contrast, 9/26/96, revealed a 4x2.5x4cm centrally calcified soft tissue anterior mediastinal mass adjacent to the aortic arch. This was highly suggestive of a thymoma. There were diffuse emphysematous disease with scarring in the lung bases. A few nodules suggestive of granulomas and few calcified perihilar lymph nodes. He underwent thoracotomy and resection of the mass. Pathologic analysis was consistent with a thymoma, lymphocyte predominant type, with capsular and pleural invasion, and extension to the phrenic nerve resection margin. Acetylcholine Receptor-binding antibody titer 12.8nmol/L (normal<0.7) + + Acetylcholine receptor blocking antibody <10% (normal) + + Acetylcholine receptor modulating antibody 42% (normal<19) + + Striated muscle antibody 1:320 (normal<1:10). Striated muscle antibody titers tend to be elevated in myasthenia gravis associated with thymoma. He was subsequently treated with XRT and continued to complain of fatigue at his 4/18/97 Oncology visit. \ No newline at end of file diff --git a/1731_Radiology.txt b/1731_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..154e62d6fa058d7c339ff4a7eb988c92e98bd411 --- /dev/null +++ b/1731_Radiology.txt @@ -0,0 +1,5 @@ +CONCOMITANT CHEMORADIOTHERAPY FOR CURATIVE INTENT PATIENTS + +This patient is receiving combined radiotherapy and chemotherapy in an effort to maximize the chance of control of this cancer. The chemotherapy is given in addition to the radiotherapy, not only to act as a cytotoxic agent on its own, but also to potentiate and enhance the effect of radiotherapy on tumor cells. It has been shown in the literature that this will maximize the chance of control. + +During the course of the treatment, the patient's therapy must be closely monitored by the attending physician to be sure that the proper chemotherapy drugs are given at the proper time during the radiotherapy course. It is also important to closely monitor the patient to know when treatment with either chemotherapy or radiotherapy needs to be held. This combined treatment usually produces greater side effects than either treatment alone, and these need to be constantly monitored and treatment initiated on a timely basis to minimize these effects. In accordance, this requires more frequency consultation and coordination with the medical oncologist. Therefore, this becomes a very time intensive treatment and justifies CPT Code 77470. \ No newline at end of file diff --git a/1734_Radiology.txt b/1734_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..4619340aa07528538277bf6e98fc7cc92ad87e32 --- /dev/null +++ b/1734_Radiology.txt @@ -0,0 +1,27 @@ +CARDIOLITE TREADMILL EXERCISE STRESS TEST + +CLINICAL DATA: + + This is a 72-year-old female with history of diabetes mellitus, hypertension, and right bundle branch block. + +PROCEDURE: + + The patient was exercised on the treadmill to maximum tolerance achieving after 5 minutes a peak heart rate of 137 beats per minute with a workload of 2.3 METS. There was a normal blood pressure response. The patient did not complain of any symptoms during the test and other than the right bundle branch block that was present at rest, no other significant electrographic abnormalities were observed. + +Myocardial perfusion imaging was performed at rest following the injection of 10 mCi Tc-99 Cardiolite. At peak pharmacological effect, the patient was injected with 30 mCi Tc-99 Cardiolite. + +Gating poststress tomographic imaging was performed 30 minutes after the stress. + +FINDINGS: + +1. The overall quality of the study is fair. + +2. The left ventricular cavity appears to be normal on the rest and stress studies. + +3. SPECT images demonstrate fairly homogeneous tracer distribution throughout the myocardium with no overt evidences of fixed and/or reperfusion defect. + +4. The left ventricular ejection fraction was normal and estimated to be 78%. + +IMPRESSION: + + Myocardial perfusion imaging is normal. Result of this test suggests low probability for significant coronary artery disease. \ No newline at end of file diff --git a/1735_Radiology.txt b/1735_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..79bea75aa307048de0b7bb4cbb0ffd1c0e9dc39a --- /dev/null +++ b/1735_Radiology.txt @@ -0,0 +1,63 @@ +CC: + +Headache (HA) + +HX: + + 10 y/o RHM awoke with a bilateral parieto-occipital HA associated with single episode of nausea and vomiting, 2 weeks prior to presentation. The nausea and vomiting resolved and did not recur. However, he continued to experience similar HA 3-4 times per week during the early morning upon awakening. He never felt the HA awakened him from sleep. The HA were partially relieved by Tylenol or Advil, and he distracted himself from the pain by remaining active. One week prior to presentation, he started to experience short episodes of blurred vision and diplopia. He also became fatigued, less active, and frequently yawned. + +He had no prior history of HA and he and his family denied any sign or symptom of focal weakness or numbness, dysphagia, dysarthria, or loss of consciousness. + +The patient underwent an MRI brain scan prior to transfer to UIHC. This revealed a mass in the left frontal region adjacent to the left temporal horn. The mass was an inhomogeneous blend of signals on T1 and T2 images giving a suggestion of acute bleeding, hemosiderin deposition and multiple vessels within the mass. + +MEDS: + + None. + +PMH: + + 1) He was a 7# 15oz. product of a full term, uncomplicated pregnancy and spontaneous vaginal delivery. His post-partum course was unremarkable. 2)Developmental milestones were reached at the appropriate times; though he was diagnosed with dyslexia 4 years ago. 3) No significant illnesses or hospitalizations. + +FHX: + + MGF (meningioma). PGF (lymphoma). Mother (migraine HA). Father and 22yr old brother are alive and well. + +SHX: + +lives with parents and attends mainstream 5th grade classes. + +EXAM: + + BP124/93 HR96 RR20 37.9C (tympanic) + +MS: A & O to person, place, time. Cooperative and interactive. Speech fluent and without dysarthria. + +CN: EOM intact. VFFTC + + Pupils 3/3 decreasing to 2/2 on exposure to light. Fundoscopy: optic disks flat, no evidence of hemorrhage. The rest of the CN exam was unremarkable. + +MOTOR: full strength throughout all 4 extremities. Normal muscle tone and bulk. + +Sensory: unremarkable. + +Coord: unremarkable. + +Station: no pronator drift or Romberg sign,Gait: unremarkable. + +Reflexes: 2+ in RUE and RLE. 3 in LUE and LLE. Plantar responses were flexor, bilaterally. + +HEENT: no meningismus. no cranial bruits. no skull defects palpated. + +GEN EXAM: unremarkable. + +COURSE: + + GS + + PT/PTT + + CBC were unremarkable. The MRI finding above lead to a differential diagnosis of Venous Angioma, Arteriovenous Malformation, Ependymoma, Neurocytoma, Glioma: all with associated hemorrhage. + +He underwent cerebral angiography on 1/25/93. Upon injection of the RCCA an avascular mass was identified in the right temporal lobe displacing the anterior choroidal artery, and temporal branches of the middle cerebral arteries. The internal cerebral vein is displaced to the left suggesting mass effect. There is a hypoplastic A1 segment and fetal origin of the LPCA. The mass was felt by neuroradiology to represent a hematoma. + +He underwent a right frontal craniotomy, 1/28/93. Pathological evaluation of the resected tissue was consistent with a vascular malformation with inclusive reactive glial tissue and evidence of recurrent and remote hemorrhage. There were dilated vascular channels having walls of variable thickness, but without evidence of elastic lamina by elastic staining. This was consistent with venous angioma/malformation. \ No newline at end of file diff --git a/1738_Radiology.txt b/1738_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..57e19039509830a036c7550d7361f007fdbe38d7 --- /dev/null +++ b/1738_Radiology.txt @@ -0,0 +1,39 @@ +EXAM: + + Mammographic screening FFDM + +HISTORY: + + 40-year-old female who is on oral contraceptive pills. She has no present symptomatic complaints. No prior history of breast surgery nor family history of breast CA. + +TECHNIQUE: + + Standard CC and MLO views of the breasts. + +COMPARISON: + + This is the patient's baseline study. + +FINDINGS: + + The breasts are composed of moderately to significantly dense fibroglandular tissue. The overlying skin is unremarkable. + +There are a tiny cluster of calcifications in the right breast, near the central position associated with 11:30 on a clock. + +There are benign-appearing calcifications in both breasts as well as unremarkable axillary lymph nodes. + +There are no spiculated masses or architectural distortion. + +IMPRESSION: + + Tiny cluster of calcifications at the 11:30 position of the right breast. Recommend additional views; spot magnification in the MLO and CC views of the right breast. + +BIRADS Classification 0 - Incomplete,MAMMOGRAPHY INFORMATION: + +1. A certain percentage of cancers, probably 10% to 15% + + will not be identified by mammography. + +2. Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present. + +3. These images were obtained with FDA-approved digital mammography equipment, and iCAD Second Look Software Version 7.2 was utilized. \ No newline at end of file diff --git a/1739_Radiology.txt b/1739_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..da6e411c9530d343ecf52de33a49e832c39b499a --- /dev/null +++ b/1739_Radiology.txt @@ -0,0 +1,49 @@ +PROCEDURE PERFORMED: + +1. Selective ascending aortic arch angiogram. + +2. Selective left common carotid artery angiogram. + +3. Selective right common carotid artery angiogram. + +4. Selective left subclavian artery angiogram. + +5. Right iliac angio with runoff. + +6. Bilateral cerebral angiograms were performed as well via right and left common carotid artery injections. + +INDICATIONS FOR PROCEDURE: + + TIA + + aortic stenosis, postoperative procedure. Moderate carotid artery stenosis. + +ESTIMATED BLOOD LOSS: + + 400 ml. + +SPECIMENS REMOVED: + + Not applicable. + +TECHNIQUE OF PROCEDURE: + + After obtaining informed consent, the patient was brought to the cardiac catheterization suite in postabsorptive and nonsedated state. The right groin was prepped and draped in the usual sterile fashion. Lidocaine 2% was used for infiltration anesthesia. Using modified Seldinger technique, a 6-French sheath was placed into the right common femoral artery and vein without complication. Using injection through the side port of the sheath, a right iliac angiogram with runoff was performed. Following this, straight pigtail catheter was used to advance the aortic arch and aortic arch angiogram under digital subtraction was performed. Following this, selective engagement in left common carotid artery, right common carotid artery, and left subclavian artery angiograms were performed with a V-Tech catheter over an 0.035-inch wire. + +ANGIOGRAPHIC FINDINGS: + +1. Type 2 aortic arch. + +2. Left subclavian artery was patent. + +3 Left vertebral artery was patent. + +4. Left internal carotid artery had a 40% to 50% lesion with ulceration, not treated and there was no cerebral cross over. + +5. Right common carotid artery had a 60% to 70% lesion which was heavily calcified and was not treated with the summed left-to-right cross over flow. + +6. Closure was with a 6-French Angio-Seal of the artery, and the venous sheath was sutured in. + +PLAN: + + Continue aspirin, Plavix, and Coumadin to an INR of 2 with a carotid duplex followup. \ No newline at end of file diff --git a/1740_Radiology.txt b/1740_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..fe24ef4a238add85f2415871f072990cd9350fde --- /dev/null +++ b/1740_Radiology.txt @@ -0,0 +1,13 @@ +HISTORY: + + Advanced maternal age and hypertension. + +FINDINGS: + + There is a single live intrauterine pregnancy with a vertex lie, posterior placenta, and adequate amniotic fluid. The amniotic fluid index is 23.2 cm. Estimated gestational age based on prior ultrasound is 36 weeks 4 four days with an estimated date of delivery of 03/28/08. Based on fetal measurements obtained today, estimated fetal weight is 3249 plus or minus 396 g, 7 pounds 3 ounces plus or minus 14 ounces, which places the fetus in the 66th percentile for the estimated gestational age. Fetal heart motion at a rate of 156 beats per minute is documented. The cord Doppler ratio is normal at 2.2. The biophysical profile score, assessing fetal breathing movement, gross body movement, fetal tone, and qualitative amniotic fluid volume is 8/8. + +IMPRESSION: + +1. Single live intrauterine pregnancy in vertex presentation with an estimated gestational age of 36 weeks 4 days and established due date of 03/28/08. + +2. Biophysical profile (BPP) score 8/8. \ No newline at end of file diff --git a/1748_Radiology.txt b/1748_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..e3eb457237eb6f363ef9404c3b2146799ff0aad0 --- /dev/null +++ b/1748_Radiology.txt @@ -0,0 +1,33 @@ +CC: + + Seizures. + +HX: + +The patient was initially evaluated at UIHC at 7 years of age. He had been well until 7 months prior to evaluation when he started having spells which were described as "dizzy spells" lasting from several seconds to one minute in duration. They occurred quite infrequently and he was able to resume activity immediately following the episodes. The spell became more frequent and prolonged, and by the time of initial evaluation were occurring 2-3 times per day and lasting 2-3 minutes in duration. In addition, in the 3 months prior to evaluation, the right upper extremity would become tonic and flexed during the episodes, and he began to experience post ictal fatigue. + +BIRTH HX: + + 32 weeks gestation to a G4 mother and weighed 4#11oz. He was placed in an incubator for 3 weeks. He was jaundiced, but there was no report that he required treatment. + +PMH: + +Single febrile convulsion lasting "3 hours" at age 2 years. + +MEDS: + +none. + +EXAM: + + Appears healthy and in no acute distress. Unremarkable general and neurologic exam. + +Impression: Psychomotor seizures. + +Studies: Skull X-Rays were unremarkable. + +EEG showed "minimal spike activity during hyperventilation, as well as random sharp delta activity over the left temporal area, in drowsiness and sleep. This record also showed moderate amplitude asymmetry ( left greater than right) over the frontal central and temporal areas, which is a peculiar finding." + +COURSE: + + The patient was initially treated with Phenobarbital; then Dilantin was added (early 1970's); then Depakene was added ( early 1980's) due to poor seizure control. An EEG on 8/22/66 showed "Left mid-temporal spike focus with surrounding slow abnormality, especially posterior to the anterior temporal areas (sparing the parasagittal region). In addition, the right lateral anterior hemisphere voltage is relatively depressed. ...this suggests two separate areas of cerebral pathology." He underwent his first HCT scan in Sioux City in 1981, and this revealed an right temporal arachnoid cyst. The patient had behavioral problems throughout elementary/junior high/high school. He underwent several neurosurgical evaluations at UIHC and Mayo Clinic and was told that surgery was unwarranted. He was placed on numerous antiepileptic medication combinations including Tegretol, Dilantin, Phenobarbital, Depakote, Acetazolamide, and Mysoline. Despite this he averaged 2-3 spells a month. He was last seen, 6/19/95, and was taking Dilantin and Tegretol. His typical spells were described as sudden in onset and without aura. He frequently becomes tonic or undergoes tonic-clonic movement and falls with associated loss of consciousness. He usually has rapid recovery and can return to work in 20 minutes. He works at a Turkey packing plant. Serial HCT scans showed growth in the arachnoid cyst until 1991, when growth arrest appeared to have occurred. \ No newline at end of file diff --git a/1749_Radiology.txt b/1749_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..3f925418b1661f9f56cb66ec29bfc47e69d5a0b9 --- /dev/null +++ b/1749_Radiology.txt @@ -0,0 +1,29 @@ +INDICATION: + + Chest pain. + +TYPE OF TEST: + + Adenosine with nuclear scan as the patient unable to walk on a treadmill. + +INTERPRETATION: + + Resting heart rate of 67, blood pressure of 129/86. EKG + + normal sinus rhythm. Post-Lexiscan 0.4 mg, heart rate was 83, blood pressure 142/74. EKG remained the same. No symptoms were noted. + +SUMMARY: + +1. Nondiagnostic adenosine stress test. + +2. Nuclear interpretation as below. + +NUCLEAR INTERPRETATION: + + Resting and stress images were obtained with 10.4, 33.1 mCi of tetrofosmin injected intravenously by standard protocol. Nuclear myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake without any evidence of reversible or fixed defect. Gated SPECT revealed normal wall motion, ejection fraction of 58%. End-diastolic volume of 74, end-systolic volume of 31. + +IMPRESSION: + +1. Normal nuclear myocardial perfusion scan. + +2. Ejection fraction 58% by gated SPECT. \ No newline at end of file diff --git a/1750_Radiology.txt b/1750_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..976a871c0c04892db9b3a6a324b12f2c8a7585a7 --- /dev/null +++ b/1750_Radiology.txt @@ -0,0 +1,77 @@ +CC: + +Left hand numbness on presentation; then developed lethargy later that day. + +HX: + +On the day of presentation, this 72 y/o RHM suddenly developed generalized weakness and lightheadedness, and could not rise from a chair. Four hours later he experienced sudden left hand numbness lasting two hours. There were no other associated symptoms except for the generalized weakness and lightheadedness. He denied vertigo. + +He had been experiencing falling spells without associated LOC up to several times a month for the past year. + +MEDS: + + procardia SR + + Lasix, Ecotrin, KCL + + Digoxin, Colace, Coumadin. + +PMH: + +1)8/92 evaluation for presyncope (Echocardiogram showed: AV fibrosis/calcification, AV stenosis/insufficiency, MV stenosis with annular calcification and regurgitation, moderate TR + + Decreased LV systolic function, severe LAE. MRI brain: focal areas of increased T2 signal in the left cerebellum and in the brainstem probably representing microvascular ischemic disease. IVG (MUGA scan)revealed: global hypokinesis of the LV and biventricular dysfunction, RV ejection Fx 45% and LV ejection Fx 39%. He was subsequently placed on coumadin severe valvular heart disease) + + 2)HTN + + 3)Rheumatic fever and heart disease, 4)COPD + + 5)ETOH abuse, 6)colonic polyps, 7)CAD + + 8)CHF + + 9)Appendectomy, 10)Junctional tachycardia. + +FHX: + + stroke, bone cancer, dementia. + +SHX: + +2ppd smoker since his teens; quit 2 years ago. 6-pack beer plus 2 drinks per day for many years: now claims he has been dry for 2 years. Denies illicit drug use. + +EXAM: + +36.8C, 90BPM + + BP138/56. + +MS: Alert and oriented to person, place, but not date. Hypophonic and dysarthric speech. 2/3 recall. Followed commands. + +CN: Left homonymous hemianopia and left CN7 nerve palsy (old). + +MOTOR: full strength throughout. + +SENSORY: unremarkable. + +COORDINATION: dysmetric FNF and HKS movements (left worse than right). + +STATION: RUE pronator drift and Romberg sign present. + +GAIT: shuffling and bradykinetic. + +REFLEXES: 1+/1+ to 2+/2+ and symmetric throughout. Plantar responses were flexor bilaterally. + +HEENT: Neck supple and no carotid bruits. + +CV: RRR with 3/6 SEM and diastolic murmurs throughout the precordium. + +Lungs: bibasilar crackles. + +LABS: + + PT 19 (elevated) and PTT 46 (elevated). + +COURSE: + + Coumadin was discontinued on admission as he was felt to have suffered a right hemispheric stroke. The initial HCT revealed a subtle low density area in the right occipital lobe and no evidence of hemorrhage. He was scheduled to undergo an MRI Brain scan the same day, and shortly before the procedure became lethargic. By the time the scan was complete he was stuporous. MRI Scan then revealed a hypointense area of T1 signal in the right temporal lobe with a small foci of hyperintensity within it. The hyperintense area seen on T1 weighted images appeared hypointense on T2 weighted images. There was edema surrounding the lesion The findings were consistent with a hematoma. A CT scan performed 4 hours later confirmed a large hematoma with surrounding edema involving the right temporal/parietal/occipital lobes. The patient subsequently died. \ No newline at end of file diff --git a/1756_Radiology.txt b/1756_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..b4923ec07fcd646d3cd21382071cde671422cbb9 --- /dev/null +++ b/1756_Radiology.txt @@ -0,0 +1,28 @@ +DESCRIPTION: + +1. Normal cardiac chambers size. + +2. Normal left ventricular size. + +3. Normal LV systolic function. Ejection fraction estimated around 60%. + +4. Aortic valve seen with good motion. + +5. Mitral valve seen with good motion. + +6. Tricuspid valve seen with good motion. + +7. No pericardial effusion or intracardiac masses. + +DOPPLER: + +1. Trace mitral regurgitation. + +2. Trace tricuspid regurgitation. + +IMPRESSION: + +1. Normal LV systolic function. + +2. Ejection fraction estimated around 60%. + diff --git a/1758_Radiology.txt b/1758_Radiology.txt new file mode 100644 index 0000000000000000000000000000000000000000..0cd1183dd30fe000de722952a48378f0b242cb48 --- /dev/null +++ b/1758_Radiology.txt @@ -0,0 +1,25 @@ +2-D M-MODE: + + + +1. Left atrial enlargement with left atrial diameter of 4.7 cm. + +2. Normal size right and left ventricle. + +3. Normal LV systolic function with left ventricular ejection fraction of 51%. + +4. Normal LV diastolic function. + +5. No pericardial effusion. + +6. Normal morphology of aortic valve, mitral valve, tricuspid valve, and pulmonary valve. + +7. PA systolic pressure is 36 mmHg. + +DOPPLER: + + + +1. Mild mitral and tricuspid regurgitation. + +2. Trace aortic and pulmonary regurgitation. \ No newline at end of file diff --git a/19_General Medicine.txt b/19_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..84add1847f32667bb14a3e247c648bf3ca15b61d --- /dev/null +++ b/19_General Medicine.txt @@ -0,0 +1,35 @@ +HISTORY OF PRESENT ILLNESS: + + The patient is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room. She was intubated and fishbone. + +PAST MEDICAL HISTORY: + + Significant for diabetes, hypertension, asthma, cholecystectomy, and total hysterectomy and cataract. + +ALLERGIES: + +No known drug allergies. + +CURRENT MEDICATIONS: + + Prevacid, Humulin, Diprivan, Proventil, Unasyn, and Solu-Medrol. + +FAMILY HISTORY: + + Noncontributory. + +SOCIAL HISTORY: + + Negative for illicit drugs, alcohol, and tobacco. + +PHYSICAL EXAMINATION: + +Please see the hospital chart. + +LABORATORY DATA: + + Please see the hospital chart. + +HOSPITAL COURSE: + + The patient was taken to the operating room by Dr. X who is covering for ENT and noted that she had airway compromise and a rather large fishbone noted and that was removed. The patient was intubated and it was felt that she should be observed to see if the airway would improve upon which she could be extubated. If not she would require tracheostomy. The patient was treated with IV antibiotics and ventilatory support and at the time of this dictation, she has recently been taken to the operating room where it was felt that the airway sufficient and she was extubated. She was doing well with good p.o.s, good airway, good voice, and desiring to be discharged home. So, the patient is being prepared for discharge at this point. We will have Dr. X evaluate her before she leaves to make sure I do not have any problem with her going home. Dr. Y feels she could be discharged today and will have her return to see him in a week. \ No newline at end of file diff --git a/2756_Neurology.txt b/2756_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..46e9f4993f66f758b1af6a436a39ef6b0ba46f72 --- /dev/null +++ b/2756_Neurology.txt @@ -0,0 +1,11 @@ +Doctor's Address,Dear Doctor: + +This letter is an introduction to my patient, A, who you will be seeing in the near future. He is a pleasant gentleman with a history of Wilson's disease. It has been treated with penicillamine. He was diagnosed with this at age 14. He was on his way to South Carolina for a trip when he developed shortness of breath, palpitations, and chest discomfort. He went to the closest hospital that they were near in Randolph, North Carolina and he was found to be in atrial fibrillation with rapid rate. He was admitted there and observed. He converted to normal sinus rhythm spontaneously and so he required no further interventions. He was started on Lopressor, which he has tolerated well. An echocardiogram was performed, which revealed mild-to-moderate left atrial enlargement. Normal ejection fraction. No other significant valvular abnormality. He reported to physicians there that he had cirrhosis related to his Wilson's disease. Therefore hepatologist was consulted. There was a recommendation to avoid Coumadin secondary to his questionable significant liver disease, therefore he was placed on aspirin 325 mg once a day. + +In discussion with Mr. A and review of his chart that I have available, it is unclear as to the status of his liver disease, however, he has never had a liver biopsy, so his diagnosis of cirrhosis that they were concerned about in North Carolina is in doubt. His LFTs have remained normal and his copper level has been undetectable on his current dose of penicillamine. + +I would appreciate your input into the long term management of his anticoagulation and also any recommendations you would have about rhythm control. He is in normal sinus rhythm as of my evaluation of him on 06/12/2008. He is tolerating his metoprolol and aspirin without any difficulty. I guess the big question remains is what level of risk that is entailed by placing him on Coumadin therapy due to his potentially paroxysmal atrial fibrillation and evidence of left atrial enlargement that would place him in increased risk of recurrent episodes. + +I appreciate your input regarding this friendly gentleman. His current medicines include penicillamine 250 mg p.o. four times a day, metoprolol 12.5 mg twice a day, and aspirin 325 mg a day. + +If you have any questions regarding his care, please feel free to call me to discuss his case. Otherwise, I will look forward to hearing back from you regarding his evaluation. Thank you as always for your care of our patient. \ No newline at end of file diff --git a/2758_Neurology.txt b/2758_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..8c149948f3756a158c219436eddc416b5808ad9f --- /dev/null +++ b/2758_Neurology.txt @@ -0,0 +1,31 @@ +DATE OF EXAMINATION: + + Start: 12/29/2008 at 1859 hours. End: 12/30/2008 at 0728 hours. + +TOTAL RECORDING TIME: + + 12 hours, 29 minutes. + +PATIENT HISTORY: + + This is a 46-year-old female with a history of events concerning for seizures. The patient has a history of epilepsy and has also had non-epileptic events in the past. Video EEG monitoring is performed to assess whether it is epileptic seizures or non-epileptic events. + +VIDEO EEG DIAGNOSES + +1. Awake: Normal. + +2. Sleep: Activation of a single left temporal spike seen maximally at T3. + +3. Clinical events: None. + +DESCRIPTION: + +Approximately 12 hours of continuous 21-channel digital video EEG monitoring was performed. During the waking state, there is a 9-Hz dominant posterior rhythm. The background of the record consists primarily of alpha frequency activity. At times, during the waking portion of the record, there appears to be excessive faster frequency activity. No activation procedures were performed. + +Approximately four hours of intermittent sleep was obtained. A single left temporal, T3, spike is seen in sleep. Vertex waves and sleep spindles were present and symmetric. + +The patient had no clinical events during the recording. + +CLINICAL INTERPRETATION: + +This is abnormal video EEG monitoring for a patient of this age due to the presence of a single left temporal spike seen during sleep. The patient had no clinical events during the recording period. Clinical correlation is required. \ No newline at end of file diff --git a/2760_Neurology.txt b/2760_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..f56239d1f3fb2c5716d4aa1c6baa0f11ad8505a5 --- /dev/null +++ b/2760_Neurology.txt @@ -0,0 +1,27 @@ +PREOPERATIVE DIAGNOSIS: + + Chronic venous hypertension with painful varicosities, lower extremities, bilaterally. + +POSTOPERATIVE DIAGNOSIS: + + Chronic venous hypertension with painful varicosities, lower extremities, bilaterally. + +PROCEDURES + +1. Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, right leg. + +2. Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, left leg. + +PROCEDURE DETAIL: + + After obtaining the informed consent, the patient was taken to the operating room where she underwent a general endotracheal anesthesia. A time-out process was followed and antibiotics were given. + +Then, both legs were prepped and draped in the usual fashion with the patient was in the supine position. An incision was made in the right groin and the greater saphenous vein at its junction with the femoral vein was dissected out and all branches were ligated and divided. Then, an incision was made just below the knee where the greater saphenous vein was also found and connection to varices from the calf were seen. A third incision was made in the distal third of the right thigh in the area where there was a communication with large branch varicosities. Then, a vein stripper was passed from the right calf up to the groin and the greater saphenous vein, which was divided, was stripped without any difficultly. Several minutes of compression was used for hemostasis. Then, the exposed branch varicosities both in the lower third of the thigh and in the calf were dissected out and then many stabs were performed to do stab phlebectomies at the level of the thigh and the level of the calf as much as the position would allow us to do. + +Then in the left thigh, a groin incision was made and the greater saphenous vein was dissected out in the same way as was on the other side. Also, an incision was made in the level of the knee and the saphenous vein was isolated there. The saphenous vein was stripped and a several minutes of local compression was performed for hemostasis. Then, a number of stabs to perform phlebectomy were performed at the level of the calf to excise branch varicosities to the extent that the patient's position would allow us. Then, all incisions were closed in layers with Vicryl and staples. + +Then, the patient was placed in the prone position and the stab phlebectomies of the right thigh and calf and left thigh and calf were performed using 10 to 20 stabs in each leg. The stab phlebectomies were performed with a hook and they were very satisfactory. Hemostasis achieved with compression and then staples were applied to the skin. + +Then, the patient was rolled onto a stretcher where both legs were wrapped with the Kerlix, fluffs, and Ace bandages. + +Estimated blood loss probably was about 150 mL. The patient tolerated the procedure well and was sent to recovery room in satisfactory condition. The patient is to be observed, so a decision will be made whether she needs to stay overnight or be able to go home. \ No newline at end of file diff --git a/2765_Neurology.txt b/2765_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..6fb6a3b30d45b249c4f1cc5c621707e4c9d11048 --- /dev/null +++ b/2765_Neurology.txt @@ -0,0 +1,23 @@ +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. \ No newline at end of file diff --git a/2766_Neurology.txt b/2766_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..86cafea707f1665f4a59f0c83512901bc73ee41d --- /dev/null +++ b/2766_Neurology.txt @@ -0,0 +1,27 @@ +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. \ No newline at end of file diff --git a/2767_Neurology.txt b/2767_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..13512525a7ea01b9cdbedc2b36b1f71b85e169bf --- /dev/null +++ b/2767_Neurology.txt @@ -0,0 +1,21 @@ +REASON FOR VISIT: + + The patient referred by Dr. X for evaluation of her possible tethered cord. + +HISTORY OF PRESENT ILLNESS: + + Briefly, she is a 14-year-old right handed female who is in 9th grade, who underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age. The last surgery was in 03/95. She did well; however, in the past several months has had some leg pain in both legs out laterally, worsening at night and requiring Advil, Motrin as well as Tylenol PM. + +Denies any new bowel or bladder dysfunction or increased sensory loss. She had some patchy sensory loss from L4 to S1. + +MEDICATIONS: + + Singulair for occasional asthma. + +FINDINGS: + + She is awake, alert, and oriented x 3. Pupils equal and reactive. EOMs are full. Motor is 5 out of 5. She was able to toe and heel walk without any difficulties as well as tendon reflexes were 2 plus. There is no evidence of clonus. There is diminished sensation from L4 to S1, having proprioception. + +ASSESSMENT AND PLAN: + + Possible tethered cord. I had a thorough discussion with the patient and her parents. I have recommended a repeat MRI scan. The prescription was given today. MRI of the lumbar spine was just completed. I would like to see her back in clinic. We did discuss the possible symptoms of this tethering. \ No newline at end of file diff --git a/2768_Neurology.txt b/2768_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..66bc2e98ca0b4ed249d2f7a0be6e49d9059e050d --- /dev/null +++ b/2768_Neurology.txt @@ -0,0 +1,23 @@ +TITLE OF OPERATION: + + Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty. + +INDICATION FOR SURGERY: + + The patient with a large 3.5 cm acoustic neuroma. The patient is having surgery for resection. There was significant cerebellar peduncle compression. The tumor was very difficult due to its size as well as its adherence to the brainstem and the nerve complex. The case took 12 hours. This was more difficult and took longer than the usual acoustic neuroma. + +PREOP DIAGNOSIS: + + Right acoustic neuroma. + +POSTOP DIAGNOSIS: + + Right acoustic neuroma. + +PROCEDURE: + + The patient was brought to the operating room. General anesthesia was induced in the usual fashion. After appropriate lines were placed, the patient was placed in Mayfield 3-point head fixation, hold into a right park bench position to expose the right suboccipital area. A time-out was settled with nursing and anesthesia, and the head was shaved, prescrubbed with chlorhexidine, prepped and draped in the usual fashion. The incision was made and cautery was used to expose the suboccipital bone. Once the suboccipital bone was exposed under the foramen magnum, the high speed drill was used to thin out the suboccipital bone and the craniectomy carried out with Leksell and insertion with Kerrison punches down to the rim of the foramen magnum as well as laterally to the edge of the sigmoid sinus and superiorly to the edge of the transverse sinus. The dura was then opened in a cruciate fashion, the cisterna magna was drained, which nicely relaxed the cerebellum. The dura leaves were held back with the 4-0 Nurolon. The microscope was then brought into the field, and under the microscope, the cerebellar hemisphere was elevated. Laterally, the arachnoid was very thick. This was opened with bipolar and microscissors and this allowed for the cerebellum to be further mobilized until the tumor was identified. The tumor was quite large and filled up the entire lateral aspect of the right posterior fossa. Initially two retractors were used, one on the tentorium and one inferiorly. The arachnoid was taken down off the tumor. There were multiple blood vessels on the surface, which were bipolared. The tumor surface was then opened with microscissors and the Cavitron was used to began debulking the lesion. This was a very difficult resection due to the extreme stickiness and adherence to the cerebellar peduncle and the lateral cerebellum; however, as the tumor was able to be debulked, the edge began to be mobilized. The redundant capsule was bipolared and cut out to get further access to the center of the tumor. Working inferiorly and then superiorly, the tumor was taken down off the tentorium as well as out the 9th, 10th or 11th nerve complex. It was very difficult to identify the 7th nerve complex. The brainstem was identified above the complex. Similarly, inferiorly the brainstem was able to be identified and cotton balls were placed to maintain this plain. Attention was then taken to try identify the 7th nerve complex. There were multitude of veins including the lateral pontine vein, which were coming right into this area. The lateral pontine vein was maintained. Microscissors and bipolar were used to develop the plain, and then working inferiorly, the 7th nerve was identified coming off the brainstem. A number 1 and number 2 microinstruments were then used to began to develop the plane. This then allowed for the further appropriate plane medially to be identified and cotton balls were then placed. A number 11 and number 1 microinstrument continued to be used to free up the tumor from the widely spread out 7th nerve. Cavitron was used to debulk the lesion and then further dissection was carried out. The nerve stimulated beautifully at the brainstem level throughout this. The tumor continued to be mobilized off the lateral pontine vein until it was completely off. The Cavitron was used to debulk the lesion out back laterally towards the area of the porus. The tumor was debulked and the capsule continued to be separated with number 11microinstrument as well as the number 1 microinstrument to roll the tumor laterally up towards the porus. At this point, the capsule was so redundant, it was felt to isolate the nerve in the porus. There was minimal bulk remaining intracranially. All the cotton balls were removed and the nerve again stimulated beautifully at the brainstem. Dr. X then came in and scrubbed into the case to drill out the porus and remove the piece of the tumor that was left in the porus and coming out of the porus. + +I then scrubbed back into case once Dr. X had completed removing this portion of the tumor. There was no tumor remaining at this point. I placed some Norian in the porus to seal any air cells, although there were no palpated. An intradural space was then irrigated thoroughly. There was no bleeding. The nerve was attempted to be stimulated at the brainstem level, but it did not stimulate at this time. The dura was then closed with 4-0 Nurolons in interrupted fashion. A muscle plug was used over one area. Duragen was laid and strips over the suture line followed by Hemaseel. Gelfoam was set over this and then a titanium cranioplasty was carried out. The wound was then irrigated thoroughly. O Vicryls were used to close the deep muscle and fascia, 3-0 Vicryl for subcutaneous tissue, and 3-0 nylon on the skin. + +The patient was extubated and taken to the ICU in stable condition. \ No newline at end of file diff --git a/2770_Neurology.txt b/2770_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..bdcfffb4071a4d4b6d47d317f3587a9853b6d808 --- /dev/null +++ b/2770_Neurology.txt @@ -0,0 +1,11 @@ +SUBJECTIVE: + + The patient is a 55-year-old African-American male that was last seen in clinic on 07/29/2008 with diagnosis of new onset seizures and an MRI scan, which demonstrated right contrast-enhancing temporal mass. Given the characteristics of this mass and his new onset seizures, it is significantly concerning for a high-grade glioma. + +OBJECTIVE: + + The patient is alert and oriented times three, GCS of 15. Cranial nerves II to XII are grossly intact. Motor exam demonstrates 5/5 strength in all four extremities. Sensation is intact to light touch, pain, temperature, and proprioception. Cerebellar exam is intact. Gait is normal and tandem on heels and toes. Speech is appropriate. Judgment is intact. Pupils are equal and reactive to light. + +ASSESSMENT AND PLAN: + + The patient is a 55-year-old African-American male with a new diagnosis of rim-enhancing right temporal mass. Given the characteristics of the MRI scan, it is highly likely that he demonstrates high-grade glioma and concerning for glioblastoma multiforme. We have discussed in length the possible benefits of biopsy, surgical resection, medical management, as well as chemotherapy, radiation treatments, and doing nothing. Given the high probability that the mass represents a high-grade glioma, the patient, after weighing the risks and the benefits of surgery, has agreed to undergo a surgical biopsy and resection of the mass as well as concomitant chemotherapy and radiation as the diagnosis demonstrates a high-grade glioma. The patient has signed consent for his right temporal craniotomy for biopsy and likely resection of right temporal brain tumor. He agrees that he will be n.p.o. after mid night on Wednesday night. He is sent for preoperative assessment with the Anesthesiology tomorrow morning. He has undergone vocational rehab assessment. \ No newline at end of file diff --git a/2772_Neurology.txt b/2772_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..9f257c421b393111f62b51ef6ece9eade1a9b042 --- /dev/null +++ b/2772_Neurology.txt @@ -0,0 +1,51 @@ +PROCEDURE: + + Sleep study. + +CLINICAL INFORMATION: + + This patient is a 56-year-old gentleman who had symptoms of obstructive sleep apnea with snoring, hypertension. The test was done 01/24/06. The patient weighed 191 pounds, five feet, seven inches tall. + +SLEEP QUESTIONNAIRE: + + According to the patient's own estimate, the patient took about 15 minutes to fall asleep, slept for six and a half hours, did have some dreams. Did not wake up and the sleep was less refreshing. He was sleepy in the morning. + +STUDY PROTOCOL: + + An all night polysomnogram was recorded with a Compumedics E Series digital polysomnograph. After the scalp was prepared, Ag/AgCl electrodes were applied to the scalp according to the International 10-20 System. EEG was monitored from C4-A1, C3-A2, O2-A1 and O2-A1. EOG and EMG were continuously monitored by electrodes placed at the outer canthi and chin respectively. Nasal and oral airflow were monitored using a triple port Thermistor. Respiratory effort was measured by piezoelectric technology employing an abdominal and thoracic belt. Blood oxygen saturation was continuously monitored by pulse oximetry. Heart rate and rhythm were monitored by surface electrocardiography. Anterior tibialis EMG was studied by using surface mounted electrodes placed 5 cm apart on both legs. Body position and snoring level were also monitored. + +TECHNICAL QUALITY OF STUDY: + + Good. + +ELECTROPHYSIOLOGIC MEASUREMENTS: + + Total recording time 406 minutes, total sleep time 365 minutes, sleep latency 25.5 minutes, REM latency 49 minutes, _____ 90% + + sleep latency measured 86%. _____ period was obtained. The patient spent 10% of the time awake in bed. + +Stage I: 3.8,Stage II: 50.5,Stage III: 14% + +Stage REM: 21.7% + +The patient had relatively good sleep architecture, except for excessive waking. + +RESPIRATORY MEASUREMENTS: + + Total apnea/hypopnea 75, age index 12.3 per hour. REM age index 15 per hour. Total arousal 101, arousal index 15.6 per hour. Oxygen desaturation was down to 88%. Longest event 35 second hypopnea with an FiO2 of 94%. Total limb movements 92, PRM index 15.1 per hour. PRM arousal index 8.9 per hour. + +ELECTROCARDIOGRAPHIC OBSERVATIONS: + + Heart rate while asleep 60 to 64 per minute, while awake 70 to 78 per minute. + +CONCLUSIONS: + + Obstructive sleep apnea syndrome with moderately loud snoring and significant apnea/hypopnea index. + +RECOMMENDATIONS: + +AXIS B: Overnight polysomnography. + +AXIS C: Hypertension. + +The patient should return for nasal CPAP titration. Sleep apnea if not treated, may lead to chronic hypertension, which may have cardiovascular consequences. Excessive daytime sleepiness, dysfunction and memory loss may also occur. \ No newline at end of file diff --git a/2773_Neurology.txt b/2773_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..dcf6d8a5f8fc47346b9ca85f8def2f4efbc61c63 --- /dev/null +++ b/2773_Neurology.txt @@ -0,0 +1,61 @@ +CC: + +Headache. + +HX: + + This 51 y/o RHM was moving furniture several days prior to presentation when he struck his head (vertex) against a door panel. He then stepped back and struck his back on a trailer hitch. There was no associated LOC but he felt "dazed." He complained a HA since the accident. The following day he began experiencing episodic vertigo lasting several minutes with associated nausea and vomiting. He has been lying in bed most of the time since the accident. He also complained of transient left lower extremity weakness. The night before admission he went to his bedroom and his girlfriend heard a loud noise. She found him on the floor unable to speak or move his left side well. He was taken to a local ER. In the ER experienced a spell in which he stared to the right for approximately one minute. During this time he was unable to speak and did not seem to comprehend verbal questions. This resolved. ER staff noted decreased left sided movement and a left Babinski sign. + +He was given valium 5 mg, and DPH 1.0g. A HCT was performed and he was transferred to UIHC. + +PMH: + + DM + + Coronary Artery Disease, Left femoral neuropathy of unknown etiology. Multiple head trauma in past (?falls/fights). + +MEDS: + + unknown oral med for DM. + +SHX: + + 10+pack-year h/o Tobacco use; quit 2 years ago. 6-pack beer/week. No h/o illicit drug use. + +FHX: + + unknown. + +EXAM: + +70BPM + + BP144/83, 16RPM + + 36.0C,MS: Alert and oriented to person, place, time. Fluent speech. + +CN: left lower facial weakness with right gaze preference. Pupils 3/3 decreasing to 2/2 on exposure to light. Optic disks flat. + +MOTOR: decreased spontaneous movement of left-sided extremities. 5/4 strength in both upper and lower extremities. Normal muscle tone and bulk. + +SENSORY: withdrew equally to noxious stimulation in all four extremities. GAIT/STATION/COORDINATION: not tested. + +The general physical exam was unremarkable. + +During the exam the patient experienced a spell during which his head turned and eyes deviated to the leftward, and his right hand twitched. The entire spell lasted one minute. + +During the episode he was verbally unresponsive. He appeared groggy and lethargic after the event. + +HCT without contrast: 11/18/92: right frontal skull fracture with associated minimal epidural hematoma and small subdural hematoma, as well as some adjacent subarachnoid blood and brain contusion. + +LABS: + + CBC + + GS + + PT/PTT were all WNL. + +COURSE: + + The patient was diagnosed with a right frontal SAH/contusion and post traumatic seizures. DPH was continued and he was given a Librium taper for possible alcoholic withdrawal. A neurosurgical consult was obtained. He did not receive surgical intervention and was discharged 12/1/92. Neuropsychological testing on 11/25/92 revealed: poor orientation to time or place and poor attention. Anterograde verbal and visual memory was severely impaired. Speech became mildly dysarthric when fatigued. Defective word finding. Difficulty copying 2 of 3 three dimensional figures. Recent head injury as well as a history of ETOH abuse and multiple prior head injuries probably contribute to his deficits. \ No newline at end of file diff --git a/2774_Neurology.txt b/2774_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..44a04506eea3ea3c54eb623993bb3c52d6c3e0fa --- /dev/null +++ b/2774_Neurology.txt @@ -0,0 +1,61 @@ +CHIEF COMPLAINT: + + Status epilepticus. + +HISTORY OF PRESENT ILLNESS: + +The patient is a 6-year-old male who is a former 27-week premature infant who suffered an intraventricular hemorrhage requiring shunt placement, and as a result, has developmental delay and left hemiparesis. At baseline, he can put about 2 to 4 words together in brief sentences. His speech is not always easily understood; however, he is in a special education classroom in kindergarten. He ambulates independently, but falls often. He has difficulty with his left side compared to the right, and prefers to use the right upper extremity more than the left. Mother reports he postures the left upper extremity when running. He is being followed by Medical Therapy Unit and has also been seen in the past by Dr. X. He has not received Botox or any other interventions with regard to his cerebral palsy. + +The patient did require one shunt revision, but since then his shunt has done well. + +The patient developed seizures about 2 years ago. These occurred periodically, but they are always in the same and with the involvement of the left side more than right and he had an eye deviation forcefully to the left side. His events, however, always tend to be prolonged. He has had seizures as long as an hour and a half. He tends to require multiple medications to stop them. He has been followed by Dr. Y and was started on Trileptal. At one point, The patient was taken off his medication for presumed failure to prevent his seizures. He was more recently placed on Topamax since March 2007. His last seizures were in March and May respectively. He is worked up to a dose of 25 mg capsules, 2 capsules twice a day or about 5 mg/kg/day at this point. + +The patient was in his usual state of health until early this morning and was noted to be in seizure. His seizure this morning was similar to the previous seizures with forced deviation of his head and eyes to the left side and convulsion more on the left side than the right. Family administered Diastat 7.5 mg x1 dose. They did not know they could repeat this dose. EMS was called and he received lorazepam 2 mg and then in the emergency department, 15 mg/kg of fosphenytoin. His seizures stopped thereafter, since that time, he had gradually become more alert and is eating, and is nearly back to baseline. He is a bit off balance and tends to be a bit weaker on the left side compared to baseline postictally. + +REVIEW OF SYSTEMS: + + At this time, he is positive for a low-grade fever, he has had no signs of illness otherwise. He does have some fevers after his prolonged seizures. He denies any respiratory or cardiovascular complaints. There is no numbness or loss of skills. He has no rashes, arthritis or arthralgias. He has no oropharyngeal complaints. Visual or auditory complaints. + +PAST MEDICAL HISTORY: + + Also positive for some mild scoliosis. + +SOCIAL HISTORY: + + The patient lives at home with mother, father, and 2 other siblings. There are no ill contacts. + +FAMILY HISTORY: + + Noncontributory. + +PHYSICAL EXAMINATION: + +GENERAL: The patient is a well-nourished, well-hydrated male, in no acute distress. + +VITAL SIGNS: His vital signs are stable and he is currently afebrile. + +HEENT: Atraumatic and normocephalic. Oropharynx shows no lesions. + +NECK: Supple without adenopathy. + +CHEST: Clear to auscultation. + +CARDIOVASCULAR: Regular rate and rhythm, no murmurs. + +ABDOMEN: Benign without organomegaly. + +EXTREMITIES: No clubbing, cyanosis or edema. + +NEUROLOGIC: The patient is alert and will follow instructions. His speech is very dysarthric and he tends to run his words together. He is about 50% understandable at best. He does put words and sentences together. His cranial nerves reveal his pupils are equal, round, and reactive to light. His extraocular movements are intact. His visual fields are full. Disks are sharp bilaterally. His face shows left facial weakness postictally. His palate elevates midline. Vision is intact bilaterally. Tongue protrudes midline. + +Motor exam reveals clearly decreased strength on the left side at baseline. His left thigh is abducted at the hip at rest with the right thigh and leg straight. He has difficulty using the left arm and while reaching for objects, shows exaggerated tremor/dysmetria. Right upper extremity is much more on target. His sensations are intact to light touch bilaterally. Deep tendon reflexes are 2+ and symmetric. When sitting up, he shows some truncal instability and tendency towards decreased truncal tone and kyphosis. He also shows some scoliotic curve of the spine, which is mild at this point. Gait was not tested today. + +IMPRESSION: + + This is a 6-year-old male with recurrent status epilepticus, left hemiparesis, history of prematurity, and intraventricular hemorrhage. He is on Topamax, which is at a moderate dose of 5 mg/kg a day or 50 mg twice a day. At this point, it is not clear whether this medication will protect him or not, but the dose is clearly not at maximum, and he is tolerating the dose currently. The plan will be to increase him up to 50 mg in the morning, and 75 mg at night for 2 weeks, and then 75 mg twice daily. Reviewed the possible side effects of higher doses of Topamax, they will monitor him for language issues, cognitive problems or excessive somnolence. I also discussed his imaging studies, which showed significant destruction of the cerebellum compared to other areas and despite this, the patient at baseline has a reasonable balance. The plan from CT standpoint is to continue stretching program, continue with medical therapy unit. He may benefit from Botox. + +In addition, I reviewed the Diastat protocol with parents and given the patient tends to go into status epilepticus each time, they can administer Diastat immediately and not wait the standard 2 minutes or even 5 minutes that they were waiting before. They are going to repeat the dose within 10 minutes and they can call EMS at any point during that time. Hopefully at home, they need to start to abort these seizures or the higher dose of Topamax will prevent them. Other medication options would include Keppra, Zonegran or Lamictal. + +FOLLOWUP: + + Followup has already been scheduled with Dr. Y in February and they will continue to keep that date for followup. \ No newline at end of file diff --git a/2775_Neurology.txt b/2775_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..1a780af333877bc1db620cd6433d2a4fdc0c47ec --- /dev/null +++ b/2775_Neurology.txt @@ -0,0 +1,25 @@ +City, State,Dear Dr. Y: + +I had the pleasure of seeing ABC today back in Neurology Clinic where he has been followed previously by Dr. Z. His last visit was in June 2006, and he carries a diagnosis of benign rolandic epilepsy. To review, his birth was unremarkable. He is a second child born to a G3, P1 to 2 female. He has had normal development, and is a bright child in 7th grade. He began having seizures, however, at 9 years of age. It is manifested typically as generalized tonic-clonic seizures upon awakening or falling into sleep. He also had smaller spells with more focal convulsion and facial twitching. His EEGs have shown a pattern consistent with benign rolandic epilepsy (central temporal sharp waves both of the right and left hemisphere). Most recent EEG in May 2006 shows the same abnormalities. + +ABC initially was placed on Tegretol, but developed symptoms of toxicity (hallucinations) on this medication, he was switched to Trileptal. He has done very well taking 300 mg twice a day without any further seizures. His last event was the day of his last EEG when he was sleep deprived and was off medication. That was a convulsion lasting 5 minutes. He has done well otherwise. Parents deny that he has any problems with concentration. He has not had any behavior issues. He is an active child and participates in sports and some motocross activities. He has one older sibling and he lives with his parents. Father manages Turkey farm with foster farms. Mother is an 8th grade teacher. + +Family history is positive for a 3rd cousin, who has seizures, but the specific seizure type is not known. There is no other relevant family history. + +Review of systems is positive for right heel swelling and tenderness to palpation. This is perhaps due to sports injury. He has not sprained his ankle and does not have any specific acute injury around the time that this was noted. He does also have some discomfort in the knees and ankles in the general sense with activities. He has no rashes or any numbness, weakness or loss of skills. He has no respiratory or cardiovascular complaints. He has no nausea, vomiting, diarrhea or abdominal complaints. + +Past medical history is otherwise unremarkable. + +Other workup includes CT scan and MRI scan of the brain, which are both normal. + +PHYSICAL EXAMINATION: + +GENERAL: The patient is a well-nourished, well-hydrated male in no acute distress. VITAL SIGNS: His weight today is 80.6 pounds. Height is 58-1/4 inches. Blood pressure 113/66. Head circumference 36.3 cm. HEENT: Atraumatic, normocephalic. Oropharynx shows no lesions. NECK: Supple without adenopathy. CHEST: Clear auscultation. + +CARDIOVASCULAR: Regular rate and rhythm. No murmurs. ABDOMEN: Benign without organomegaly. EXTREMITIES: No clubbing, cyanosis or edema. NEUROLOGIC: The patient is alert and oriented. His cognitive skills appear normal for his age. His speech is fluent and goal-directed. He follows instructions well. His cranial nerves reveal his pupils equal, round, and reactive to light. Extraocular movements are intact. Visual fields are full. Disks are sharp bilaterally. Face moves symmetrically with normal sensation. Palate elevates midline. Tongue protrudes midline. Hearing is intact bilaterally. Motor exam reveals normal strength and tone. Sensation intact to light touch and vibration. His gait is nonataxic with normal heel-toe and tandem. Finger-to-nose, finger-nose-finger, rapid altering movements are normal. Deep tendon reflexes are 2+ and symmetric. + +IMPRESSION: + +This is an 11-year-old male with benign rolandic epilepsy, who is followed over the past 2 years in our clinic. Most recent electroencephalogram still shows abnormalities, but it has not been done since May 2006. The plan at this time is to repeat his electroencephalogram, follow his electroencephalogram annually until it reveres to normal. At that time, he will be tapered off of medication. I anticipate at some point in the near future, within about a year or so, he will actually be taken off medication. For now, I will continue on Trileptal 300 mg twice a day, which is a low starting dose for him. There is no indication that his dose needs to be increased. Family understands the plan. We will try to obtain an electroencephalogram in the near future in Modesto and followup is scheduled for 6 months. Parents will contact us after the electroencephalogram is done so they can get the results. + +Thank you very much for allowing me to access ABC for further management. \ No newline at end of file diff --git a/2777_Neurology.txt b/2777_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..89d23cffda9a8f4be8207576240611f2c5f7172b --- /dev/null +++ b/2777_Neurology.txt @@ -0,0 +1,31 @@ +REASON FOR VISIT: + + Followup left-sided rotator cuff tear and cervical spinal stenosis. + +HISTORY OF PRESENT ILLNESS: + + Ms. ABC returns today for followup regarding her left shoulder pain and left upper extremity C6 radiculopathy. I had last seen her on 06/21/07. + +At that time, she had been referred to me Dr. X and Dr. Y for evaluation of her left-sided C6 radiculopathy. She also had a significant rotator cuff tear and is currently being evaluated for left-sided rotator cuff repair surgery, I believe on, approximately 07/20/07. At our last visit, I only had a report of her prior cervical spine MRI. I did not have any recent images. I referred her for cervical spine MRI and she returns today. + +She states that her symptoms are unchanged. She continues to have significant left-sided shoulder pain for which she is being evaluated and is scheduled for surgery with Dr. Y. + +She also has a second component of pain, which radiates down the left arm in a C6 distribution to the level of the wrist. She has some associated minimal weakness described in detail in our prior office note. No significant right upper extremity symptoms. No bowel, bladder dysfunction. No difficulty with ambulation. + +FINDINGS: + + On examination, she has 4 plus over 5 strength in the left biceps and triceps muscle groups, 4 out of 5 left deltoid, 5 out of 5 otherwise in both muscle groups and all muscle groups of upper extremities. Light touch sensation is minimally decreased in the left C6 distribution; otherwise, intact. Biceps and brachioradialis reflexes are 1 plus. Hoffmann sign normal bilaterally. Motor strength is 5 out of 5 in all muscle groups in lower extremities. Hawkins and Neer impingement signs are positive at the left shoulder. + +An EMG study performed on 06/08/07 demonstrates no evidence of radiculopathy or plexopathy or nerve entrapment to the left upper extremity. + +Cervical spine MRI dated 06/28/07 is reviewed. It is relatively limited study due to artifact. He does demonstrate evidence of minimal-to-moderate stenosis at the C5-C6 level but without evidence of cord impingement or cord signal change. There appears to be left paracentral disc herniation at the C5-C6 level, although axial T2-weighted images are quite limited. + +ASSESSMENT AND PLAN: + + Ms. ABC's history, physical examination and radiographic findings are compatible with left shoulder pain and left upper extremity pain, which is due to a combination of left-sided rotator cuff tear and moderate cervical spinal stenosis. + +I agree with the plan to go ahead and continue with rotator cuff surgery. With regard to the radiculopathy, I believe this can be treated non-operatively to begin with. I am referring her for consideration of cervical epidural steroid injections. The improvement in her pain may help her recover better from the shoulder surgery. + +I will see her back in followup in 3 months, at which time she will be recovering from a shoulder surgery and we will see if she needs any further intervention with regard to the cervical spine. + +I will also be in touch with Dr. Y to let him know this information prior to the surgery in several weeks. \ No newline at end of file diff --git a/2781_Neurology.txt b/2781_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..8b10257943b5d423298108a1616e6a22c027d5c1 --- /dev/null +++ b/2781_Neurology.txt @@ -0,0 +1,69 @@ +DIAGNOSIS: + + Status post brain tumor removal. + +HISTORY: + + The patient is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. The patient reports that on 10/24/08 she had a brain tumor removed and had left-sided weakness. The patient was being seen in physical therapy from 11/05/08 to 11/14/08 then she began having complications. The patient reports that she was admitted to Hospital on 12/05/08. At that time, they found massive swelling on the brain and a second surgery was performed. The patient then remained in acute rehab until she was discharged to home on 01/05/09. The patient's husband, Al, is also present and he reports that during rehabilitation the patient did have a DVT in the left calf that has since been resolved. + +PAST MEDICAL HISTORY: + + Unremarkable. + +MEDICATIONS: + +Coumadin, Keppra, Decadron, and Glucophage. + +SUBJECTIVE: + + The patient reports that the pain is not an issue at this time. The patient states that her primary concern is her left-sided weakness as related to her balance and her walking and her left arm weakness. + +PATIENT GOAL: + +To increase strength in her left leg for better balance and walking. + +OBJECTIVE: + +RANGE OF MOTION: Bilateral lower extremities are within normal limits. + +STRENGTH: Bilateral lower extremities are grossly 5/5 with one repetition, except left hip reflexion 4+/5. + +BALANCE: The patient's balance was assessed with a Berg balance test. The patient has got 46/56 points, which places her at moderate risk for falls. + +GAIT: The patient ambulates with contact guard assist. The patient ambulates with a reciprocal gait pattern with good bilateral foot clearance. However, the patient has been reports that with increased fatigue, left footdrop tends to occur. A 6-minute walk test will be performed at the next visit due to time constraints. + +ASSESSMENT: + + The patient is a 64-year-old female referred to Physical Therapy status post brain surgery. Examination indicates deficits in strength, balance, and ambulation. The patient will benefit from skilled physical therapy to address these impairments. + +TREATMENT PLAN: + + The patient will be seen three times per week for 4 weeks and then reduce it to two times per week for 4 additional weeks. Interventions include: + +1. Therapeutic exercise. + +2. Balance training. + +3. Gait training. + +4. Functional mobility training. + +SHORT TERM GOAL TO BE COMPLETED IN 4 WEEKS: + +1. The patient is to tolerate 30 repetitions of all lower extremity exercises. + +2. The patient is to improve balance with a score of 50/56 points. + +3. The patient is to ambulate 1000 feet in a 6-minute walk test with standby assist. + +LONG TERM GOAL TO BE ACHIEVED IN 8 WEEKS: + +1. The patient is to ambulate independently within her home and standby to general supervision within the community. + +2. Berg balance test to be 52/56. + +3. The patient is to ambulate a 6-minute walk test for 1500 feet independently including safe negotiation of corners and busy areas. + +4. The patient is to demonstrate safely stepping over and around objects without loss of balance. + +Prognosis for the above-stated goals is good. The above treatment plan has been discussed with the patient and her husband. They are in agreement. \ No newline at end of file diff --git a/2783_Neurology.txt b/2783_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..4749054f7f5bf401b80ec81f2e9e74839c65ff3d --- /dev/null +++ b/2783_Neurology.txt @@ -0,0 +1,37 @@ +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. \ No newline at end of file diff --git a/2784_Neurology.txt b/2784_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..30d482125b12359e079ffd3babef92a71b48ebfe --- /dev/null +++ b/2784_Neurology.txt @@ -0,0 +1,29 @@ +PROCEDURES PERFORMED: + + Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves. Botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors. + +PROCEDURE CODES: + + 64640 times three, 64614 times four, 95873 times four. + +PREOPERATIVE DIAGNOSIS: + + Spastic quadriparesis secondary to traumatic brain injury, 907.0. + +POSTOPERATIVE DIAGNOSIS: + + Spastic quadriparesis secondary to traumatic brain injury, 907.0. + +ANESTHESIA: + + MAC. + +COMPLICATIONS: + + None. + +DESCRIPTION OF TECHNIQUE: + + Informed consent was obtained from the patient's brother. The patient was brought to the minor procedure area and sedated per their protocol. The patient was positioned lying supine. Skin overlying all areas injected was prepped with chlorhexidine. The obturator nerves were identified lateral to the adductor longus tendon origin and below the femoral pulse using active EMG stimulation. Approximately 7 mL was injected on the right side and 5 mL on the left side. At all sites of phenol injections in this area injections were done at the site of maximum hip adduction contraction with least amount of stimulus. Negative drawback for blood was done prior to each injection of phenol. The musculocutaneous nerve was identified in the left upper extremity above the brachial pulse using active EMG stimulation. Approximately 5 mL of 5% phenol was injected in this location. Injections in this area were done at the site of maximum elbow flexion contraction with least amount of stimulus. Negative drawback for blood was done prior to each injection of phenol. + +Muscles injected with botulinum toxin were identified using active EMG stimulation. Approximately 150 units was injected in the knee extensors bilaterally, 100 units in the left pectoralis major, and 50 units in the left wrist flexors. Total amount of botulinum toxin injected was 450 units diluted 25 units to 1 mL. The patient tolerated the procedure well and no complications were encountered. \ No newline at end of file diff --git a/2786_Neurology.txt b/2786_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..c636f85a5689eb39697776565bf61643329e594d --- /dev/null +++ b/2786_Neurology.txt @@ -0,0 +1,15 @@ +EXAM: + + Cervical, lumbosacral, thoracic spine flexion and extension. + +HISTORY: + + Back and neck pain. + +CERVICAL SPINE + +FINDINGS: + +AP + + lateral with flexion and extension, and both oblique projections of the cervical spine demonstrate alignment and soft tissue structures to be unremarkable. \ No newline at end of file diff --git a/2789_Neurology.txt b/2789_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..84c0cc93dd8403ff4d418b35b0907abb8529bb66 --- /dev/null +++ b/2789_Neurology.txt @@ -0,0 +1,77 @@ +REASON FOR REFERRAL: + + The patient is a 76-year-old Caucasian gentleman who works full-time as a tax attorney. He was referred for a neuropsychological evaluation by Dr. X after a recent hospitalization for possible transient ischemic aphasia. Two years ago, a similar prolonged confusional spell was reported as well. A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning. + +RELEVANT BACKGROUND INFORMATION: + + Historical information was obtained from a review of available medical records and clinical interview with the patient. A summary of pertinent information is presented below. Please refer to the patient's medical chart for a more complete history. + +HISTORY OF PRESENTING PROBLEM: + + The patient was brought to the Hospital Emergency Department on 09/30/09 after experiencing an episode of confusion for which he has no recall the previous day. He has no recollection of the event. The following information is obtained from his medical record. On 09/29/09, he reportedly went to a five-hour meeting and stated several times "I do not feel well" and looked "glazed." He does not remember anything from midmorning until the middle of the night and when his wife came home, she found him in bed at 6 p.m. + + which is reportedly unusual. She thought he was warm and had chills. He later returned to his baseline. He was seen by Dr. X in the hospital on 09/30/09 and reported to him at that time that he felt that he had returned entirely to baseline. His neurological exam at that time was unremarkable aside from missing one of three items on recall for the Mini-Mental Status Examination. Due to mild memory complaints from himself and his wife, he was referred for more extensive neuropsychological testing. Note that reportedly when his wife found him in bed, he was shaking and feeling nauseated, somewhat clammy and kept saying that he could not remember anything and he was repeating himself, asking the same questions in an agitated way, so she brought him to the emergency room. The patient had an episode two years ago of transient loss of memory during which he was staring blankly while sitting at his desk at work and the episode lasted approximately two hours. He was hospitalized at Hospital at that time as well and evaluation included negative EEG + + MRI showing mild atrophy, and a neurological consultation, which did not result in a specific diagnosis, but during this episode he was also reportedly nauseous. He was also reportedly amnestic for this episode. + +In 2004, he had a sense of a funny feeling in his neck and electrodes in his head and had an MRI at that time which showed some small vessel changes. + +During this interview, the patient reported that other than a coworker noticing a few careless errors in his completion of some documents and his wife reporting some mild memory changes that he had not noticed any significant decline. He thought that his memory abilities were similar to those of his peers of his same age. When I asked about this episode, he said he had no recall of it at all and that he "felt fine the whole time." He appeared to be somewhat questioning of the validity of reports that he was amnestic and confused at that time. So, The patient reported some age related "memory lapses" such as going into a room and forgetting why, sometimes putting something down and forgetting where he had put it. However, he reported that these were entirely within normal expectations and he denied any type of impairment in his ability to continue to work full-time as a tax attorney other than his wife and one coworker, he had not received any feedback from his children or friends of any problems. He denied any missed appointments, any difficulty scheduling and maintaining appointments. He does not have to recheck information for errors. He is able to complete tasks in the same amount of time as he always has. He reported that he has not made additional errors in tasks that he completed. He said he does write everything down, but has always done things that way. He reported that he works in a position that requires a high level of attentiveness and knowledge and that will become obvious very quickly if he was having difficulties or making mistakes. He did report some age related changes in attention as well, although very mild and he thought these were normal and not more than he would expect for his age. He remains completely independent in his ADLs. He denied any difficulty with driving or maintaining any activities that he had always participated in. He is also able to handle their finances. He did report significant stress recently particularly in relation to his work environment. + +PAST MEDICAL HISTORY: + + Includes coronary artery disease, status post CABG in 1991, radical prostate cancer, status post radical prostatectomy, nephrectomy for the same cancer, hypertension, lumbar surgery done twice previously, lumbar stenosis many years ago in the 1960s and 1970s, now followed by Dr. Y with another lumbar surgery scheduled to be done shortly after this evaluation, and hyperlipidemia. Note that due to back pain, he had been taking Percocet daily prior to his hospitalization. + +CURRENT MEDICATIONS: + + Celebrex 200 mg, levothyroxine 0.025 mg, Vytorin 10/40 mg, lisinopril 10 mg, Coreg 10 mg, glucosamine with chondroitin, prostate 2.2, aspirin 81 mg, and laxative stimulant or stool softener. Note that medical records say that he was supposed to be taking Lipitor 40 mg, but it is not clear if he was doing so and also there was no specific reason found for why he was taking the levothyroxine. + +OTHER MEDICAL HISTORY: + + Surgical history is significant for hernia repair in 2007 as well. The patient reported drinking an occasional glass of wine approximately two days of the week. He quit smoking cigarettes 25 to 30 years ago and he was diagnosed with cancer. He denied any illicit drug use. Please add that his prostatectomy was done in 1993 and nephrectomy in 1983 for carcinoma. He also had right carpal tunnel surgery in 2005 and has cholelithiasis. Upon discharge from the hospital, the patient's sleep deprived EEG was recommended. + +MRI completed on 09/30/09 showed "mild cerebral and cerebellar atrophy with no significant interval change from a prior study dated June 15, 2007. No evidence of acute intracranial processes identified. CT scan was also unremarkable showing only mild cerebral and cerebellar atrophy. EEG was negative. Deferential diagnosis was transient global amnesia versus possible seizure disorder. Note that he also reportedly has some hearing changes, but has not followed up with an evaluation for hearing aid. + +FAMILY MEDICAL HISTORY: + + Reportedly significant for TIAs in his mother, although the patient did not report this during our evaluation and so that she had no memory problems or dementia when she passed away of old age at the age of 85. In addition, his father had a history of heart disease and passed away at the age of 75. He has one sister with diabetes and thought his mom might have had diabetes as well. + +SOCIAL HISTORY: + + The patient obtained a law degree from the University of Baltimore. He did not complete his undergraduate degree from the University of Maryland because he was able to transfer his credits in order to attend law school at that time. He reported that he did not obtain very good grades until he reached law school, at which point he graduated in the top 10 of his class and had no problem passing the Bar. He thought that effort and motivation were important to his success in his school and he had not felt very motivated previously. He reported that he repeated math classes "every year of school" and attended summer school every year due to that. He has worked as a tax attorney for the past 48 years and reported having a thriving practice with clients all across the country. He served also in the U.S. Coast Guard between 1951 and 1953. He has been married for the past 36 years to his wife, Linda, who is a homemaker. They have four children and he reported having good relationship with them. He described being very active. He goes for dancing four to five times a week, swims daily, plays golf regularly and spends significant amounts of time socializing with friends. + +PSYCHIATRIC HISTORY: + + The patient denied any history of psychological or psychiatric treatment. He reported that some stressors occasionally contribute to mildly low mood at this time, but that these are transient. + +TASKS ADMINISTERED: + +Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR) + +Mini Mental Status Exam (MMSE) + +Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX) + +Mattis Dementia Rating Scale, 2nd Edition (DRS-2) + +Neuropsychological Assessment Battery (NAB) + +Wechsler Adult Intelligence Scale, Third Edition (WAIS-III) + +Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV) + +Wechsler Abbreviated Scale of Intelligence (WASI) + +Test of Variables of Attention (TOVA) + +Auditory Consonant Trigrams (ACT) + +Paced Auditory Serial Addition Test (PASAT) + +Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT) + +Multilingual Aphasia Examination, Second Edition (MAE-II) + + Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test, Second Edition (BNT-2) + +Animal Naming Test \ No newline at end of file diff --git a/2791_Neurology.txt b/2791_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..caa32c3ecb4717233d66a92957fc196d7c6cd198 --- /dev/null +++ b/2791_Neurology.txt @@ -0,0 +1,45 @@ +REASON FOR REFERRAL: + +The patient was referred for a neuropsychological evaluation by Dr. X. A comprehensive evaluation was requested to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope. + +BRIEF SUMMARY & IMPRESSIONS: + +RELEVANT HISTORY: + +Historical information was obtained from a review of available medical records and an interview with + +the patient. + +The patient presented to Dr. X on August 05, 2008 as she had been recently hospitalized for prolonged episodes of syncope. She was referred to Dr. X for diagnostic differentiation for possible seizures or other causes of syncope. The patient reports an extensive neurological history. Her mother used alcohol during her pregnancy with the patient. In spite of exposure to alcohol in utero, the patient reported that she achieved "honors in school" and "looked smart." She reported that she began to experience migraines at 11 years of age. At 15 years of age, she reported that she was thought to have hydrocephalus. She reported that she will frequently "bang her head against the wall" to relieve the pain. The patient gave birth to her daughter at 17 years of age. At 18 years of age, she received a spinal tap as a procedure to determine the cause of her severe headaches. She reported, in 1995 to 1996 she experienced a severe head injury, as she was struck by a car as a pedestrian and "thrown two and a half city blocks." The patient reported that she could recall before being hit, but could not recall the activities of that same day or the following day. She reported that she had difficulty walking following this head injury, but received rehabilitation for approximately one month. Her migraines became more severe following the head injury. In 1998, she reportedly was experiencing episodes of syncope where she would experience a headache with photophobia, phonophobia, and flashing lights. Following the syncope episode, she would experience some confusion. These episodes reportedly were related to her donating plasma. + +The patient also reported that her ex-husband stated that she frequently jerked and would shake in her sleep. She reported that upon awakening, she would feel off balanced and somewhat confused. These episodes diminished from 2002 to June 2008. When making dinner, she suddenly dropped and hit the back of her head on refrigerator. She reported that she was unconscious for five to six minutes. A second episode occurred on July 20th when she lost consciousness for may be a full day. She was admitted to Sinai Hospital and assessed by a neurologist. Her EEG and head CT were considered to be completely normal. She did not report any typical episodes during the time of her 36-hour EEG. She reported that her last episode of syncope occurred prior to her being hospitalized. She stated that she had an aura of her ears ringing, vision being darker and "tunnel vision" (vision goes smaller to a pinpoint) + + and she was "spazzing out" on the floor. During these episodes, she reports that she cannot talk and has difficulty understanding. + +The patient also reports that she has experienced some insomnia since she was 6 years old. She reported that she was a heavy drinker until about 1998 or 1999 and that she would drink a gallon daily of Jack Daniel. She stopped the use of alcohol and that time she experienced a suicide attempt. In 2002, she was diagnosed with bipolar disorder and was started on medication. At the time of the neuropsychological evaluation, she had stopped taking her medicine as she felt that she was now in remission and could manage her symptoms herself. The patient's medical history is also significant for postpartum depression. + +The patient reported that she has been experiencing difficulty with cognitive abilities of attention/concentration, spelling, tangential and slow thinking, poor sequencing memory for events, and variable verbal memory. She reported that she sometimes has difficulty understanding what people say, specifically she has difficulty understanding jokes. She finds that she often has difficulty with expressing her thoughts, as she is very tangential. She experiences episodes of not recalling what she was speaking of or remembering what activities she was trying to perform. She reported that she had a photographic memory for directions. She said that she experienced a great deal of emotional lability, but in general her personality has become more subdued. At the present time, her daughter has now moved on to college. The patient is living with her biological mother. Although she is going through divorce, she reported that it was not really stressful. She reported that she spends her day driving other people around and trying to be helpful to them. + +At the time of the neuropsychological evaluation, the patient's medication included Ativan, Imitrex, Levoxyl, vitamin B12, albuterol metered dose inhaler as needed, and Zofran as needed. (It should be noted that The patient by the time of the feedback on September 19, 2008 had resumed taking her Trileptal for bipolar disorder.). The patient's familial medical history is significant for alcohol abuse, diabetes, hypertension, and high cholesterol. + +TESTS ADMINISTERED: + +Clinical Interview,Cognistat,Mattis Dementia Rating Scale,Wechsler Adult Intelligence Scale - III (WAIS-III) + +Wechsler Abbreviated Scale of Intelligence (WASI) + +Selected Subtests from the Delis Kaplan Executive Function System (DKEFS) + + Trail Making Test, Verbal Fluency (Letter Fluency & Category Fluency) + + Design Fluency, Color-Word Interference Test, Tower,Wisconsin Card Sorting Test (WCST) + +Stroop Test,Color Trails,Trails A & B,Test of Variables of Attention,Multilingual Aphasia Examination II + + Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test-2 (BNT-2) + +Animal Naming Test,The Beery-Buktenica Developmental Test of Visual-Motor Integration (VMI) + +The Beery-Buktenica Developmental Test of Motor Coordination,The Beery-Buktenica Developmental Test of Visual Perception,Judgment Line Orientation,Grooved Pegboard,Purdue Pegboard,Finger Tapping Test,Rey Complex Figure,Wechsler Memory Scale -III (WMS-III) + +California Verbal Learning Test \ No newline at end of file diff --git a/2792_Neurology.txt b/2792_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..9db95f4a6995350f75e9eaeb4f3331206fbe6d59 --- /dev/null +++ b/2792_Neurology.txt @@ -0,0 +1,29 @@ +PRELIMINARY DIAGNOSES: + +1. Contusion of the frontal lobe of the brain. + +2. Closed head injury and history of fall. + +3. Headache, probably secondary to contusion. + +FINAL DIAGNOSES: + +1. Contusion of the orbital surface of the frontal lobes bilaterally. + +2. Closed head injury. + +3. History of fall. + +COURSE IN THE HOSPITAL: + + This is a 29-year-old male, who fell at home. He was seen in the emergency room due to headache. CT of the brain revealed contusion of the frontal lobe near the falx. The patient did not have any focal signs. He was admitted to ABCD. Neurology consultation was obtained. Neuro checks were done. The patient continued to remain stable, although he had some frontal headache. He underwent an MRI to rule out extension of the contusion or the possibility of a bleed and the MRI of the brain without contrast revealed findings consistent with contusion of the orbital surface of the frontal lobes bilaterally near the interhemispheric fissure. The patient remained clinically stable and his headache resolved. He was discharged home on 11/6/2008. + +PLAN: + + Discharge the patient to home. + +ACTIVITY: + +As tolerated. + +The patient has been advised to call if the headache is recurrent and Tylenol 650 mg 1 p.o. q.6 h. p.r.n. headache. The patient has been advised to follow up with me as well as the neurologist in about 1 week. \ No newline at end of file diff --git a/2802_Neurology.txt b/2802_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..51f3d8b5f8ed12fa98ad161a6d6f99754ed330e1 --- /dev/null +++ b/2802_Neurology.txt @@ -0,0 +1,95 @@ +REASON FOR VISIT: + +The patient is a 76-year-old man referred for neurological consultation by Dr. X. The patient is companied to clinic today by his wife and daughter. He provides a small portion of his history; however, his family provides virtually all of it. + +HISTORY OF PRESENT ILLNESS: + + He has trouble with walking and balance, with bladder control, and with thinking and memory. When I asked him to provide me detail, he could not tell me much more than the fact that he has trouble with his walking and that he has trouble with his bladder. He is vaguely aware that he has trouble with his memory. + +According to his family, he has had difficulty with his gait for at least three or four years. At first, they thought it was weakness and because of he was on the ground (for example, gardening) he was not able to get up by himself. They did try stopping the statin that he was taking at that time, but because there was no improvement over two weeks, they resumed the statin. As time progressed, he developed more and more difficulty. He started to shuffle. He started using a cane about two and a half years ago and has used a walker with wheels in the front since July of 2006. At this point, he frequently if not always has trouble getting in or out of the seat. He frequently tends to lean backwards or sideways when sitting. He frequently if not always has trouble getting in or out a car, always shuffles or scuffs his feet, always has trouble turning or changing direction, always has trouble with uneven surfaces or curbs, and always has to hold on to someone or something when walking. He has not fallen in the last month. He did fall earlier, but there seemed to be fewer opportunities for him to fall. His family has recently purchased a lightweight wheelchair to use if he is traveling long distances. He has no stairs in his home, however, his family indicates that he would not be able to take stairs. His handwriting has become smaller and shakier. + +In regard to the bladder, he states, "I wet the bed." In talking with his family, it seems as if he has no warning that he needs to empty his bladder. He was diagnosed with a small bladder tumor in 2005. This was treated by Dr. Y. Dr. X does not think that the bladder tumor has anything to do with the patient's urinary incontinence. The patient has worn a pad or undergarment for at least one to one and a half years. His wife states that they go through two or three of them per day. He has been placed on medications; however, they have not helped. + +He has no headaches or sensation of head fullness. + +In regard to the thinking and memory, at first he seemed forgetful and had trouble with dates. Now he seems less spontaneous and his family states he seems to have trouble expressing himself. His wife took over his medications about two years ago. She stopped his driving about three years ago. She discovered that his license had been expired for about a year and she was concerned enough at that time that she told him he could drive no more. Apparently, he did not object. At this point, he frequently has trouble with memory, orientation, and everyday problems solving at home. He needs coaching for his daily activities such as reminders to brush his teeth, put on his clothes, and so forth. He is a retired office machine repairman. He is currently up and active about 12 hours a day and sleeping or lying down about 12 hours per day. + +He has not had PT or OT and has not been treated with medications for Parkinson's disease or Alzheimer's disease. He has been treated for the bladder. He has not had lumbar puncture. + +Past medical history and review of all 14 systems from the form they completed for this visit that I reviewed with them is negative with the exception that he has had hypertension since 1985, hypercholesterolemia since 1997, and diabetes since 1998. The bladder tumor was discovered in 2005 and was treated noninvasively. He has lost weight from about 200 pounds to 180 pounds over the last two or three years. He had a period of depression in 1999 and was on Prozac for a while, but this was then stopped. He used to drink a significant amount of alcohol. This was problematic enough that his wife was concerned. She states he stopped when she retired and she was at home all day. + +SOCIAL HISTORY: + +He quit smoking in 1968. His current weight is 183 pounds. His tallest height is 5 feet 10 inches. + +FAMILY HISTORY: + +His grandfather had arthritis. His father had Parkinson's disease. His mother had heart disease and a sister has diabetes. + +He does not have a Living Will and indicates he would wish his wife to make decisions for him if he could not make them for himself. + +REVIEW OF HYDROCEPHALUS RISK FACTORS: + + None. + +ALLERGIES: + + None. + +MEDICATIONS: + + Metformin 500 mg three times a day, Lipitor 10 mg per day, lisinopril 20 mg per day, metoprolol 50 mg per day, Uroxatral 10 mg per day, Detrol LA 4 mg per day, and aspirin 81 mg per day. + +PHYSICAL EXAM: + + On examination today, this is a pleasant 76-year-old man who is guided back from the clinic waiting area walking with his walker. He is well developed, well nourished, and kempt. + +Vital Signs: His weight is 180 pounds. + +Head: The head is normocephalic and atraumatic. The head circumference is 59 cm, which is the + +75-90th percentile for an adult man whose height is 178 cm. + +Spine: The spine is straight and not tender. I can easily palpate the spinous processes. There is no scoliosis. + +Skin: No neurocutaneous stigmata. + +Cardiovascular Examination: No carotid or vertebral bruits. + +Mental Status: Assessed for orientation, recent and remote memory, attention span, concentration, language, and fund of knowledge. The Mini-Mental State Exam score was 17/30. He did not know the year, season, or day of the week nor did he know the building or specialty or the floor. There was a tendency for perseveration during the evaluation. He could not copy the diagram of intersecting pentagons. + +Cranial Nerve Exam: No evidence of papilledema. The pupillary light reflex is intact as are extraocular movements without nystagmus, facial expression and sensation, hearing, head turning, tongue, and palate movement. + +Motor Exam: Normal bulk and strength, but the tone is marked by significant paratonia. There is no atrophy, fasciculations, or drift. There is tremulousness of the outstretched hands. + +Sensory Exam: Is difficult to interpret. Either he does not understand the test or he is mostly guessing. + +Cerebellar Exam: Is intact for finger-to-nose, heel-to-knee, and rapid alternating movement tests. There is no dysarthria. + +Reflexes: Trace in the arms, 2+ at the knees, and 0 at the ankles. It is not certain whether there is a Babinski sign or simply withdrawal. + +Gait: Assessed using the Tinetti assessment tool that shows a balance score of 7-10/16 and a gait score of 2-5/12 for a total score of 9-15/28, which is significantly impaired. + +REVIEW OF X-RAYS: + + I personally reviewed the MRI scan of the brain from December 11, 2007 at Advanced Radiology. It shows the ventricles are enlarged with a frontal horn span of 5.0 cm. The 3rd ventricle contour is flat. The span is enlarged at 12 mm. The sylvian aqueduct is patent. There is a pulsation artifact. The corpus callosum is effaced. There are extensive T2 signal abnormalities that are confluent in the corona radiata. There are also scattered T2 abnormalities in the basal ganglia. There is a suggestion of hippocampal atrophy. There is also a suggestion of vermian atrophy. + +ASSESSMENT: + + The patient has a clinical syndrome that raises the question of idiopathic normal pressure hydrocephalus. His examination today is notable for moderate-to-severe dementia and moderate-to-severe gait impairment. His MRI scan raises the question of hydrocephalus, however, is also consistent with cerebral small vessel disease. + +PROBLEMS/DIAGNOSES: + +1. Possible idiopathic normal pressure hydrocephalus (331.5). + +2. Probable cerebral small-vessel disease (290.40 & 438). + +3. Gait impairment (781.2). + +4. Urinary urgency and incontinence (788.33). + +5. Dementia. + +6. Hypertension. + +7. Hypercholesterolemia. \ No newline at end of file diff --git a/2803_Neurology.txt b/2803_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..66e5ff8b5da71fbb961e70be2680b0c644b5f538 --- /dev/null +++ b/2803_Neurology.txt @@ -0,0 +1,49 @@ +HISTORY OF PRESENT ILLNESS: + + The patient is a 55-year-old gentleman who presents for further evaluation of right leg weakness. He has difficulty recollecting the exact details and chronology of his problem. To the best of his recollection, he thinks that about six months ago he developed weakness of his right leg. He describes that he is reaching to get something from a cabinet and he noticed that he was unable to stand on his right toe. Since that time, he has had difficulty pushing off when he walks. He has mild tingling and numbness in his toes, but this has been a chronic problem and nothing new since he has developed the weakness. He has chronic mild back pain, but this has been persistent for many years and has not changed. He has experienced cramps in both calves for the past year. This dissipated about two months ago. He does not think that his left leg is weak. He does not have any bowel or bladder incontinence. There is no radicular pain. He does not think that the problem is progressive, meaning that the weakness that he perceives in his right leg is no different than when it was six months ago. + +He first sought medical attention for this problem in October. He then saw you a couple of months later. He has undergone an EMG and nerve conduction studies. Unfortunately, he cannot undergo an MRI of his spine because he has an ear implant. He has had a CT scan that shows degenerative changes, but nothing obviously abnormal. + +In addition, the patient has hyperCKemia. He tells me that he has had an elevated CK prior to starting taking stat medications, although this is not entirely clear to me. He thinks that he is not taking Lipitor for about 15 months and thought that his CK was in the 500 or 600s prior to starting it. Once it was started, it increased to about 800 and then came down to about 500 when it was stopped. He then had a recent bump again up to the 1000 and since Lipitor has been stopped, his CK apparently has returned to about the 500 or 600s. I do no have any laboratory data to support these statements by the patient, but he seems to be up to speed on this. More recently, he has been started taking Zetia. He does not have any proximal weakness. He denies any myalgias. + + + +PAST MEDICAL HISTORY: + + He has coronary artery disease and has received five stents. He has hypertension and hypercholesterolemia. He states that he was diagnosed with diabetes based on the results of an abnormal oral glucose tolerance test. He believes that his glucose shot up to over 300 with this testing. He does not take any medications for this and his blood glucoses are generally normal when he checks it. He has had plastic surgery on his face from an orbital injury. He also had an ear graft when he developed an ear infection during his honeymoon. + + + +CURRENT MEDICATIONS: + + He takes amlodipine, Diovan, Zetia, hydrochlorothiazide, Lovaza (fish oil) + + Niaspan, aspirin, and Chantix. + + + +ALLERGIES: + + He has no known drug allergies. + + + +SOCIAL HISTORY: + + He lives with his wife. He works at Shepherd Pratt doing network engineering. He smokes a pack of cigarettes a day and is working on quitting. He drinks four alcoholic beverages per night. Prior to that, he drank significantly more. He denies illicit drug use. He was athletic growing up. + + + +FAMILY HISTORY: + + His mother died of complications from heart disease. His father died of heart disease in his 40s. He has two living brothers. One of them he does not speak too much with and does not know about his medical history. The other is apparently healthy. He has one healthy child. His maternal uncles apparently had polio. When I asked him to tell me further details about this, he states that one of them had to wear crutches due to severe leg deformans and then the other had leg deformities in only one leg. He is fairly certain that they had polio. He is unaware of any other family members with neurological conditions. + +REVIEW OF SYSTEMS: + + He has occasional tinnitus. He has difficulty sleeping. Otherwise, a complete review of systems was obtained and was negative except for as mentioned above. This is documented in the handwritten notes from today's visit. + +PHYSICAL EXAMINATION: + + + +Vital Signs: \ No newline at end of file diff --git a/2805_Neurology.txt b/2805_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..36a7482e74c76ad823d24fa72d40dd871f6ecad7 --- /dev/null +++ b/2805_Neurology.txt @@ -0,0 +1,29 @@ +DIAGNOSES: + +1. Juvenile myoclonic epilepsy. + +2. Recent generalized tonic-clonic seizure. + +MEDICATIONS: + +1. Lamictal 250 mg b.i.d. + +2. Depo-Provera. + +INTERIM HISTORY: + + The patient returns for followup. Since last consultation she has tolerated Lamictal well, but she has had a recurrence of her myoclonic jerking. She has not had a generalized seizure. She is very concerned that this will occur. Most of the myoclonus is in the mornings. Recent EEG did show polyspike and slow wave complexes bilaterally, more prominent on the left. She states that she has been very compliant with the medications and is getting a good amount of sleep. She continues to drive. + +Social history and review of systems are discussed above and documented on the chart. + +PHYSICAL EXAMINATION: + + Vital signs are normal. Pupils are equal and reactive to light. Extraocular movements are intact. There is no nystagmus. Visual fields are full. Demeanor is normal. Facial sensation and symmetry is normal. No myoclonic jerks noted during this examination. No myoclonic jerks provoked by tapping on her upper extremity muscles. Negative orbit. Deep tendon reflexes are 2 and symmetric. Gait is normal. Tandem gait is normal. Romberg negative. + +IMPRESSION AND PLAN: + + Recurrence of early morning myoclonus despite high levels of Lamictal. She is tolerating the medication well and has not had a generalized tonic-clonic seizure. She is concerned that this is a precursor for another generalized seizure. She states that she is compliant with her medications and has had a normal sleep-wake cycle. + +Looking back through her notes, she initially responded very well to Keppra, but did have a breakthrough seizure on Keppra. This was thought secondary to severe insomnia when her baby was very young. Because she tolerated the medication well and it was at least partially affective, I have recommended adding Keppra 500 mg b.i.d. Side effect profile of this medication was discussed with the patient. + +I will see in followup in three months. \ No newline at end of file diff --git a/2806_Neurology.txt b/2806_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..bc78d296b7a376cdbe68045f0112eef90fb473b4 --- /dev/null +++ b/2806_Neurology.txt @@ -0,0 +1,21 @@ +SOCIAL HISTORY + + FAMILY HISTORY + + AND PAST MEDICAL HISTORY: + + Reviewed. There are no changes, otherwise. + +REVIEW OF SYSTEMS: + + Fatigue, pain, difficulty with sleep, mood fluctuations, low stamina, mild urgency frequency and hesitancy, preponderance of lack of stamina, preponderance of pain particularly in the left shoulder. + +EXAMINATION: + + The patient is alert and oriented. Extraocular movements are full. The face is symmetric. The uvula is midline. Speech has normal prosody. Today there is much less guarding of the left shoulder. In the lower extremities, iliopsoas, quadriceps, femoris and tibialis anterior are full. The gait is narrow based and noncircumductive. Rapid alternating movements are slightly off bilaterally. The gait does not have significant slapping characteristics. Sensory examination is largely unremarkable. Heart, lungs, and abdomen are within normal limits. + +IMPRESSION: + + Mr. ABC is doing about the same. We discussed the issue of adherence to Copaxone. In order to facilitate this, I would like him to take Copaxone every other day, but on a regular rhythm. His wife continues to inject him. He has not been able to start himself on the injections. + +Greater than 50% of this 40-minute appointment was devoted to counseling. \ No newline at end of file diff --git a/2807_Neurology.txt b/2807_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..471912de380302ddf6bc9ec8f9edb632eaaac361 --- /dev/null +++ b/2807_Neurology.txt @@ -0,0 +1,47 @@ +Subsequently, the patient developed a moderately severe depression. She was tried on various medications, which caused sweating, nightmares and perhaps other side effects. She was finally put on Effexor 25 mg two tablets h.s. and trazodone 100 mg h.s. + + and has done fairly well, although she still has significant depression. + +Her daughter brought her in today to be sure that she does not have dementia. There is no history of memory loss. There is no history of focal neurologic symptoms or significant headaches. + +The patient's complaints, according to the daughter, include not wanted to go out in public, shamed regarding her appearance (25-pound weight loss over the past year) + + eating poorly, not doing things unless asked, hiding food to prevent having to eat it, nervousness, and not taking a shower. She has no focal neurologic deficits. She does complain of constipation. She has severe sleep maintenance insomnia and often sleeps only 2 hours before awakening frequently for the rest of the night. + +The patient was apparently visiting her daughter in northern California in December 2003. She was taken to her daughter's primary care physician. She underwent vitamin B12 level, RPR + + T4 and TSH + + all of which were normal. + +On 05/15/04, the patient underwent MRI scan of the brain. I reviewed the scan in the office today. This shows moderate cortical and central atrophy and also shows mild-to-moderate deep white matter ischemic changes. + +PAST MEDICAL HISTORY: + + The patient has generally been in reasonably good physical health. She did have a "nervous breakdown" in 1975 after the death of her husband. She was hospitalized for several weeks and was treated with ECT. This occurred while she was living in Korea. + +She does not smoke or drink alcoholic beverages. She has had no prior surgeries. There is a past history of hypertension, but this is no longer present. + +FAMILY HISTORY: + + Negative for dementia. Her mother died of a stroke at the age of 62. + +PHYSICAL EXAMINATION: + +Vital Signs: Blood pressure 128/80, pulse 84, temperature 97.4 F, and weight 105 lbs (dressed). + +General: Well-developed, well-nourished Korean female in no acute distress. + +Head: Normocephalic, without evidence of trauma or bruits. + +Neck: Supple, with full range of motion. No spasm or tenderness. Carotid pulsations are of normal volume and contour bilaterally without bruits. No thyromegaly or adenopathy. + +Extremities: No clubbing, cyanosis, edema, or deformity. Range of motion full throughout. + +NEUROLOGICAL EXAMINATION: + +Mental Status: The patient is awake, alert and oriented to time, place, and person and generally appropriate. She exhibits mild psychomotor retardation and has a flat or depressed affect. She knows the current president of Korea and the current president of the United States. She can recall 3 out of 3 objects after 5 minutes. Calculations are performed fairly well with occasional errors. There is no right-left confusion, finger agnosia, dysnomia or aphasia. + +Cranial Nerves: + +II: \ No newline at end of file diff --git a/2808_Neurology.txt b/2808_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..4c503b0cd681717b22b04c1184369a2cb4449600 --- /dev/null +++ b/2808_Neurology.txt @@ -0,0 +1,101 @@ +HISTORY OF PRESENT ILLNESS: + + The patient is a 63-year-old left-handed gentleman who presents for further evaluation of multiple neurological symptoms. I asked him to discuss each symptom individually as he had a very hard time describing the nature of his problems. He first mentioned that he has neck pain. He states that he has had this for at least 15 years. It is worse with movement. It has progressed very slowly over the course of 15 years. It is localized to the base of his neck and is sharp in quality. He also endorses a history of gait instability. This has been present for a few years and has been slightly progressively worsening. He describes that he feels unsteady on his feet and "walks like a duck." He has fallen about three or four times over the past year and a half. + +He also describes that he has numbness in his feet. When I asked him to describe this in more detail, the numbness is actually restricted to his toes. Left is slightly more affected than the right. He denies any tingling or paresthesias. He also described that he is slowly losing control of his hands. He thinks that he is dropping objects due to weakness or incoordination in his hands. This has also been occurring for the past one to two years. He has noticed that buttoning his clothes is more difficult for him. He also does not have any numbness or tingling in the hands. He does have a history of chronic low back pain. + +At the end of the visit, when I asked him which symptom was most bothersome to him, he actually stated that his fatigue was most troublesome. He did not even mention this on the initial part of my history taking. When I asked him to describe this further, he states that he experiences a general exhaustion. He basically lays in bed all day everyday. I asked him if he was depressed, he states that he is treated for depression. He is unsure if this is optimally treated. As I just mentioned, he stays in bed almost all day long and does not engage in any social activities. He does not think that he is necessarily sad. His appetite is good. He has never undergone any psychotherapy for depression. + +When I took his history, I noticed that he is very slow in responding to my questions and also had a lot of difficulty recalling details of his history as well as names of physicians who he had seen in the past. I asked if he had ever been evaluated for cognitive difficulties and he states that he did undergo testing at Johns Hopkins a couple of years ago. He states that the results were normal and that specifically he did not have any dementia. + +When I asked him when he was first evaluated for his current symptoms, he states that he saw Dr. X several years ago. He believes that he was told that he had neuropathy but that it was unclear if it was due to his diabetes. He told me that more recently he was evaluated by you after Dr. Y referred him for this evaluation. He also saw Dr. Z for neurosurgical consultation a couple of weeks ago. He reports that she did not think there was any surgical indication in his neck or back at this point in time. + +PAST MEDICAL HISTORY: + + He has had diabetes for five years. He also has had hypercholesterolemia. He has had Crohn's disease for 25 or 30 years. He has had a colostomy for four years. He has arthritis, which is reportedly related to the Crohn's disease. He has hypertension and coronary artery disease and is status post stent placement. He has depression. He had a kidney stone removed about 25 years ago. + +CURRENT MEDICATIONS: + + He takes Actos, Ambien, baby aspirin, Coreg, Entocort, folic acid, Flomax, iron, Lexapro 20 mg q.h.s. + + Lipitor, Pentasa, Plavix, Protonix, Toprol, Celebrex and Zetia. + +ALLERGIES: + + He states that Imuran caused him to develop tachycardia. + +SOCIAL HISTORY: + + He previously worked with pipeline work, but has been on disability for five years. He is unsure which symptoms led him to go on disability. He has previously smoked about two packs of cigarettes daily for 20 years, but quit about 20 years ago. He denies alcohol or illicit drug use. He lives with his wife. He does not really have any hobbies. + +FAMILY HISTORY: + + His father died of a cerebral hemorrhage at age 49. His mother died in her 70s from complications of congestive heart failure. He has one sister who died during a cardiac surgery two years ago. He has another sister with diabetes. He has one daughter with hypercholesterolemia. He is unaware of any family members with neurological disorders. + +REVIEW OF SYSTEMS: + + He has dyspnea on exertion. He states that he was evaluated by a pulmonologist and had a normal evaluation. He has occasional night sweats. His hearing is poor. He occasionally develops bloody stools, which he attributes to his Crohn's disease. He also was diagnosed with sleep apnea. He does not wear his CPAP machine on a regular basis. He has a history of anemia. Otherwise, a complete review of systems was obtained and was negative except for as mentioned above. This is documented in the handwritten notes from today's visit. + +PHYSICAL EXAMINATION: + +Vital Signs: Blood pressure 160/86 HR 100 RR 16 Wt 211 pounds Pain 3/10,General Appearance: He is well appearing in no acute distress. He has somewhat of a flat affect. + +Cardiovascular: He has a regular rhythm without murmurs, gallops, or rubs. There are no carotid bruits. + +Chest: The lungs are clear to auscultation bilaterally. + +Skin: There are no rashes or lesions. + +Musculoskeletal: He has no joint deformities or scoliosis. + +NEUROLOGICAL EXAMINATION: + +Mental Status: His speech is fluent without dysarthria or aphasia. He is alert and oriented to name, place, and date. Attention, concentration, and fund of knowledge are intact. He has 3/3 object registration and 1/3 recall in 5 minutes. + +Cranial Nerves: Pupils are equal, round, and reactive to light and accommodation. Visual fields are full. Optic discs are normal. Extraocular movements are intact without nystagmus. Facial sensation is normal. There is no facial, jaw, palate, or tongue weakness. Hearing is grossly intact. Shoulder shrug is full. + +Motor: He has normal muscle bulk and tone. There is no atrophy. He has few fasciculations in his calf muscles bilaterally. Manual muscle testing reveals MRC grade 5/5 strength in all proximal and distal muscles of the upper and lower extremities. There is no action or percussion myotonia or paramyotonia. + +Sensory: He has absent vibratory sensation at the left toe. This is diminished at the right toe. Joint position sense is intact. There is diminished sensation to light touch and temperature at the feet to the knees bilaterally. Pinprick is intact. Romberg is absent. There is no spinal sensory level. + +Coordination: This is intact by finger-nose-finger or heel-to-shin testing. He does have a slight tremor of the head and outstretched arms. + +Deep Tendon Reflexes: They are 2+ at the biceps, triceps, brachioradialis, patellas, and ankles. Plantar reflexes are flexor. There is no ankle clonus, finger flexors, or Hoffman's signs. He has crossed adductors bilaterally. + +Gait and Stance: He has a slightly wide-based gait. He has some difficulty with toe walking, but he is able to walk on his heels and tandem walk. He has difficulty with toe raises on the left. + +RADIOLOGIC DATA: + + MRI of the cervical spine, 09/30/08: Chronic spondylosis at C5-C6 causing severe bilateral neuroforamining and borderline-to-mold cord compression with normal cord signal. Spondylosis of C6-C7 causing mild bilateral neuroforamining and left paracentral disc herniation causing borderline cord compression. + +Thoracic MRI spine without contrast: Minor degenerative changes without stenosis. + +I do not have the MRI of the lumbar spine available to review. + +LABORATORY DATA: + + 10/07/08: Vitamin B1 210 (87-280) + + vitamin B6 6, ESR 6, AST 25, ALT 17, vitamin B12 905, CPK 226 (0-200) + + T4 0.85, TSH 3.94, magnesium 1.7, RPR nonreactive, CRP 4, Lyme antibody negative, SPEP abnormal (serum protein electrophoresis) + + but no paraprotein by manifestation, hemoglobin A1c 6.0, aldolase 3.9 and homocystine 9.0. + +ASSESSMENT: + + The patient is a 63-year-old gentleman with multiple neurologic and nonneurologic symptoms including numbness, gait instability, decreased dexterity of his arms and general fatigue. His neurological examination is notable for sensory loss in a length-dependent fashion in his feet and legs with scant fasciculations in his calves. He has fairly normal or very mild increased reflexes including notably the presence of normal ankle jerks. + +I think that the etiology of his symptoms is multifactorial. He probably does have a mild peripheral neuropathy, but the sparing of ankle jerks suggested either the neuropathy is mild or that there is a superimposed myelopathic process such as a cervical or lumbosacral myelopathy. He really is most concerned about the fatigue and I think it is possible due to suboptimally treated depression and suboptimally treated sleep apnea. Whether he has another underlying muscular disorder such as a primary myopathy remains to be seen. + +RECOMMENDATIONS: + +1. I scheduled him for repeat EMG and nerve conduction studies to evaluate for evidence of neuropathy or myopathy. + +2. I will review his films at our spine conference tomorrow although I am confident in Dr. Z's opinion that there is no surgical indication. + +3. I gave him a prescription for physical therapy to help with gait imbalance training as well as treatment for his neck pain. + +4. I believe that he needs to undergo psychotherapy for his depression. It may also be worthwhile to adjust his medications, but I will defer to his primary care physician for managing this or for referring him to a therapist. The patient is very open about proceeding with this suggestion. + +5. He does need to have his sleep apnea better controlled. He states that he is not compliant because the face mask that he uses does not fit him well. This should also be addressed. \ No newline at end of file diff --git a/2810_Neurology.txt b/2810_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..ae95c498353be21d7f187232d278731b9814bdd2 --- /dev/null +++ b/2810_Neurology.txt @@ -0,0 +1,11 @@ +CHIEF COMPLAINT: + + Neck and lower back pain. + +VEHICULAR TRAUMA HISTORY: + + Date of incident: 1/15/2001. The patient was the driver of a small sports utility vehicle and was wearing a seatbelt. The patient’s vehicle was proceeding through an intersection and was struck by another vehicle from the left side and forced off the road into a utility pole. The other vehicle had reportedly been driven by a drunk driver and ran a traffic signal. Estimated impact speed was 80 m.p.h. The driver of the other vehicle was reportedly cited by police. The patient was transiently unconscious and came to the scene. There was immediate onset of headaches, neck and lower back pain. The patient was able to exit the vehicle and was subsequently transported by Rescue Squad to St. Thomas Memorial Hospital, evaluated in the emergency room and released. + +NECK AND LOWER BACK PAIN HISTORY: + + The patient relates the persistence of pain since the motor vehicle accident. Symptoms began immediately following the MVA. Because of persistent symptoms, the patient subsequently sought chiropractic treatment. Neck pain is described as severe. Neck pain remains localized and is non-radiating. There are no associated paresthesias. Back pain originates in the lumbar region and radiates down both lower extremities. Back pain is characterized as worse than the neck pain. There are no associated paresthesias. \ No newline at end of file diff --git a/2812_Neurology.txt b/2812_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..9528a74bd7557338a5c8b4664bdd8c286d1d3dcc --- /dev/null +++ b/2812_Neurology.txt @@ -0,0 +1,69 @@ +CC: + +BLE weakness and numbness. + +HX: + + This 59 y/o RHM was seen and released from an ER 1 week prior to this presentation for a 3 week history of progressive sensory and motor deficits in both lower extremities. He reported numbness beginning about his trunk and slowly progressing to involve his lower extremities over a 4 week period. On presentation, he felt numb from the nipple line down. In addition, he began experiencing progressive weakness in his lower extremities for the past week. He started using a cane 5 days before being seen and had been having difficulty walking and traversing stairs. He claimed he could not stand. He denied loss of bowel or bladder control. However, he had not had a bowel movement in 3 days and he had not urinated 24 hours. His lower extremities had been feeling cold for a day. He denied any associated back or neck pain. He has chronic shortness of breath, but felt it had become worse. He had also been experiencing lightheadedness upon standing more readily than usual for 2 days prior to presentation. + +PMH: + + 1)CAD with chronic CP + + 2)NQWMI 1994, S/P Coronary Angioplasty, 3)COPD (previous FEV 11.48, and FVC 2.13) + + 4)Anxiety D/O, 5)DJD + + 6)Developed confusion with metoprolol use, 7)HTN. + +MEDS: + + Benadryl, ECASA + + Diltiazem, Isordil, Enalapril, Indomethacin, Terbutaline MDI + + Ipratropium MDI + + Folic Acid, Thiamine. + +SHX: + + 120pk-yr smoking, ETOH abuse in past, Retired Dock Hand,FHX: + +unremarkable except for ETOH abuse,EXAM: + + T98.2 96bpm 140/74mmHg R18,Thin cachetic male in moderate distress. + +MS: A&O to person, place and time. Speech was fluent and without dysarthria. Comprehension, naming and reading were intact. + +CN: unremarkable. + +Motor: Full strength in both upper extremities. + +HF HE HAdd HAbd KF KE AF AE + +RLE 3 3 4 4 3 4 1 1,LLE 4 4 4+ 4+ 4+ 4 4 4,There was mild spastic muscle tone in the lower extremities. There was normal muscle bulk throughout. + +SENSORY: Decreased PP in the LLE from the foot to nipple line, and in the RLE from the knee to nipple line. Decreased Temperature sensation from the feet to the umbilicus, bilaterally. No loss of Vibration or Proprioception. Decreased light touch from the feet to nipple line, bilaterally. + +Gait: unable to walk. Stands with support only. + +Station: no pronator drift or truncal ataxia. + +Reflexes: 2+/2+ in BUE + + 3+/3+ patellae, 0/1 ankles. Babinski signs were present, bilaterally. The abdominal reflexes were absent. + +CV: RRR with a 2/6 systolic ejection murmur at the left sternal border. Lungs: CTA with mildly labored breathing. Abdomen: NT + + ND + + NBS + + but bladder distended. Extremities were cool to touch. Peripheral pulses were intact and capillary refill was brisk. Rectal: decreased rectal tone and absent anal reflex. Right prostate nodule at the inferior pole. + +COURSE: + +Admission Labs: FEV1=1.17, FVC 2.19, ABG 7.39/42/79 on room air. WBC 10/5, Hgb 13, Hct 39, Electrolytes were normal. PT & PTT were normal. Straight catheterization revealed a residual volume of 400cc of urine. + +He underwent emergent T-spine MRI. This revealed a T3-4 vertebral body lesion which had invaded the spinal canal was compressing the spinal cord. He was treated with Decadron and underwent emergent spinal cord decompression on 5/7/95. He recovered some lower extremity strength following surgery. Pathological analysis of the tumor was consistent with adenocarcinoma. His primary tumor was not located despite chest-abdominal-pelvic CT scans, and a GI and GU workup which included cystoscopy and endoscopy. He received 3000cGy of XRT and died 5 months after presentation. \ No newline at end of file diff --git a/2813_Neurology.txt b/2813_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..544a88883ec94b89537f30f31d81351c1884a4c4 --- /dev/null +++ b/2813_Neurology.txt @@ -0,0 +1,73 @@ +CC: + +Paraplegia. + +HX: + + This 32 y/o RHF had been performing missionary work in Jos, Nigeria for several years and delivered her 4th child by vaginal delivery on 4/10/97. The delivery was induced with Pitocin, but was otherwise uncomplicated. For the first 4 days post-partum she noted clear liquid diarrhea without blood and minor abdominal discomfort. This spontaneous resolved without medical treatment. The second week post-partum she had 4-5 days of sinusitis, purulent nasal discharge and facial pain. She was otherwise well until 5/4/97 when stationed in a more rural area of Nigeria, she noted a dull ache in both knees (lateral to the patellae) and proximal tibia, bilaterally. The pain was not relieved by massage and seemed more bothersome when seated or supine. She had no sensory loss at the time. + +On 5/6/97, she awakened to pain radiating down her knees to her anterior tibia. Over the next few hours the pain radiated circumferentially around both calves, and involved the soles of her feet and posterior BLE to her buttocks. Rising from bed became a laborious task and she required assistance to walk to the bathroom. Ibuprofen provided minimal analgesia. By evening the sole of one foot was numb. + +She awoke the next morning, 5/9/97, with "pins & needles" sensation in BLE up to her buttocks. She was given Darvocet for analgesia and took an airplane back to the larger city she was based in. During the one hour flight her BLE weakness progressed to a non-weight bearing state (i.e. she could not stand). Local evaluation revealed 3/3 proximal and 4/4 distal BLE weakness. She had a sensory level to her waist on PP and LT testing. She also had mild lumbar back pain. Local laboratory evaluation: WBC 12.7, ESR 10. She was presumed to have Guillain-Barre syndrome and was placed on Solu-Cortef 1000mg qd and Sandimmune IV IgG 12.0 g. + +On 5/10/97, she was airlifted to Geneva, Switzerland. Upon arrival there she had total anesthesia from the feet up to the inguinal region, bilaterally. There was flaccid areflexic paralysis of BLE and she was unable to void or defecate. Straight catheterization of the bladder revealed a residual volume of 1000cc. On 5/12/ CSF analysis revealed: Protein 1.5g/l, Glucose 2.2mmol/l, WBC 92 (O PMNS + + 100% Lymphocytes) + + RBC 70, Clear CSF + + bacterial-fungal-AFB-cultures were negative. Broad spectrum antibiotics and Solu-Medrol 1g IV qd were started. MRI T-L-spine, 5/12/97 revealed an intradural T12-L1 lesion that enhanced minimally with gadolinium and was associated with spinal cord edema in the affected area. MRI Brain, 5/12/97, was unremarkable and showed no evidence of demyelinating disease. HIV + + HTLV-1, HSV + + Lyme, EBV + + Malaria and CMV serological titers were negative. On 5/15/97 the Schistosomiasis Mekongi IFAT serological titer returned positive at 1:320 (normal<1:80). 5/12/97 CSF Schistosomiasis Mekongi IFAT and ELISA were negative. She was then given a one day course of Praziquantel 3.6g total in 3 doses; and started on Prednisone 60 mg po qd; the broad spectrum antibiotics and Solu-Medrol were discontinued. + +On 5/22/97, a rectal biopsy was performed to evaluate parasite eradication. The result came back positive for ova and granulomata after she had left for UIHC. The organism was not speciated. 5/22/97 CSF schistosomiasis ELISA and IFAT titers were positive at 1.09 and 1:160, respectively. These titers were not known when she initially arrived at UIHC. + +Following administration of Praziquantel, she regained some sensation in BLE but the paraplegia, and urinary retention remained. + +MEDS: + + On 5/24/97 UIHC arrival: Prednisone 60mg qd, Zantac 50 IV qd, Propulsid 20mg tid, Enoxaparin 20mg qd. + +PMH: + + 1)G4P4. + +FHX: + + unremarkable. + +SHX: + +Missionary. Married. 4 children ( ages 7,5,3,6 weeks). + +EXAM: + + BP110/70, HR72, RR16, 35.6C,MS: A&O to person, place and time. Speech fluent and without dysarthria. Lucid thought process. + +CN: unremarkable. + +Motor: 5/5 BUE strength. Lower extremities: 1/1 quads and hamstrings, 0/0 distally. + +Sensory: Decreased PP/LT/VIB from feet to inguinal regions, bilaterally. T12 sensory level to temperature (ice glove). + +Coord: normal FNF. + +Station/Gait: not done. + +Reflexes: 2/2 BUE. 0/0 BLE. No plantar responses, bilaterally. + +Rectal: decreased to no rectal tone. Guaiac negative. + +Other: No Lhermitte's sign. No paraspinal hypertonicity noted. No vertebral tenderness. + +Gen exam: Unremarkable. + +COURSE: + + MRI T-L-spine, 5/24/97, revealed a 6 x 8 x 25 soft tissue mass at the L1 level posterior to the tip of the conus medullaris and extending into the canal below that level. This appeared to be intradural. There was mild enhancement. There was more enhancement along the distal cord surface and cauda equina. The distal cord had sign of diffuse edema. She underwent exploratory and decompressive laminectomy on 5/27/97, and was retreated with a one day course of Praziquantel 40mg/kg/day. Praziquantel is reportedly only 80% effective at parasite eradication. + +She continued to reside on the Neurology/Neurosurgical service on 5/31/97 and remained paraplegic. \ No newline at end of file diff --git a/2815_Neurology.txt b/2815_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..abe421ab2bd06808779abac70c905d4711903ae8 --- /dev/null +++ b/2815_Neurology.txt @@ -0,0 +1,33 @@ +EXAM: + + MRI of lumbar spine without contrast. + +HISTORY: + + A 24-year-old female with chronic back pain. + +TECHNIQUE: + + Noncontrast axial and sagittal images were acquired through the lumbar spine in varying degrees of fat and water weighting. + +FINDINGS: + + The visualized cord is normal in signal intensity and morphology with conus terminating in proper position. Visualized osseous structures are normal in marrow signal intensity and morphology without evidence for fracture/contusion, compression deformity, or marrow replacement process. There are no paraspinal masses. + +Disc heights, signal, and vertebral body heights are maintained throughout the lumbar spine. + +L5-S1: Central canal, neural foramina are patent. + +L4-L5: Central canal, neural foramina are patent. + +L3-L4: Central canal, neural foramen is patent. + +L2-L3: Central canal, neural foramina are patent. + +L1-L2: Central canal, neural foramina are patent. + +The visualized abdominal aorta is normal in caliber. Incidental note has been made of multiple left-sided ovarian, probable physiologic follicular cysts. + +IMPRESSION: + + No acute disease in the lumbar spine. \ No newline at end of file diff --git a/2818_Neurology.txt b/2818_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..a8ddf8b502aec968af0a2411b73ae39a125a1244 --- /dev/null +++ b/2818_Neurology.txt @@ -0,0 +1,81 @@ +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. \ No newline at end of file diff --git a/2819_Neurology.txt b/2819_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..5806536e53164805ddedcd6551e31d62d8468318 --- /dev/null +++ b/2819_Neurology.txt @@ -0,0 +1,87 @@ +CC: + +Low Back Pain (LBP) with associated BLE weakness. + +HX: + + This 75y/o RHM presented with a 10 day h/o progressively worsening LBP. The LBP started on 12/3/95; began radiating down the RLE + + on 12/6/95; then down the LLE + + on 12/9/95. By 12/10/95, he found it difficult to walk. On 12/11/95, he drove himself to his local physician, but no diagnosis was rendered. He was given some NSAID and drove home. By the time he got home he had great difficulty walking due to LBP and weakness in BLE + + but managed to feed his pets and himself. On 12/12/95 he went to see a local orthopedist, but on the way to his car he crumpled to the ground due to BLE weakness and LBP pain. He also had had BLE numbness since 12/11/95. He was evaluated locally and an L-S-Spine CT scan and L-S Spine X-rays were "negative." He was then referred to UIHC. + +MEDS: + +SLNTC + + Coumadin 4mg qd, Propranolol, Procardia XL + + Altace, Zaroxolyn. + +PMH: + +1) MI 11/9/78, 2) Cholecystectomy, 3) TURP for BPH 1980's, 4) HTN + + 5) Amaurosis Fugax, OD + + 8/95 (Mayo Clinic evaluation--TEE (-) + + but Carotid Doppler (+) but "non-surgical" so placed on Coumadin). + +FHX: + + Father died age 59 of valvular heart disease. Mother died of DM. Brother had CABG 8/95. + +SHX: + + retired school teacher. 0.5-1.0 pack cigarettes per day for 60 years. + +EXAM: + + BP130.56, HR68, RR16, Afebrile. + +MS: A&O to person, place, time. Speech fluent without dysarthria. Lucid. Appeared uncomfortable. + +CN: Unremarkable. + +MOTOR: 5/5 strength in BUE. Lower extremity strength: Hip flexors & extensors 4-/4- + + Hip abductors 3+/3+ + + Hip adductors 5/5, Knee flexors & extensors 4/4- + + Ankle flexion 4-/4- + + Tibialis Anterior 2/2- + + Peronei 3-/3-. Mild atrophy in 4 extremities. Questionable fasciculations in BLE. Spasms illicited on striking quadriceps with reflex hammer (? percussion myotonia). No rigidity and essential normal muscle tone on passive motion. + +SENSORY: Decreased vibratory sense in stocking distribution from toes to knees in BLE (worse on right). No sensory level. PP/LT/TEMP testing unremarkable. + +COORD: Normal FNF-RAM. Slowed HKS due to weakness. + +Station: No pronator drift. Romberg testing not done. + +Gait: Unable to stand. + +Reflexes: 2/2 BUE. 1/trace patellae, 0/0 Achilles. Plantar responses were flexor, bilaterally. Abdominal reflex was present in all four quadrants. Anal reflex was illicited from all four quadrants. No jaw jerk or palmomental reflexes illicited. + +Rectal: normal rectal tone, guaiac negative stool. + +GEN EXAM: Bilateral Carotid Bruits, No lymphadenopathy, right inguinal hernia, rhonchi and inspiratory wheeze in both lung fields. + +COURSE: + +WBC 11.6, Hgb 13.4, Hct 38% + + Plt 295. ESR 40 (normal 0-14) + + CRP 1.4 (normal <0.4) + + INR 1.5, PTT 35 (normal) + + Creatinine 2.1, CK 346. EKG normal. The differential diagnosis included Amyotrophy, Polymyositis, Epidural hematoma, Disc Herniation and Guillain-Barre syndrome. An MRI of the lumbar spine was obtained, 12/13/95. This revealed an L3-4 disc herniation extending inferiorly and behind the L4 vertebral body. This disc was located more on the right than on the left + + compromised the right neural foramen, and narrowed the spinal canal. The patient underwent a L3-4 laminectomy and diskectomy and subsequently improved. He was never seen in follow-up at UIHC. \ No newline at end of file diff --git a/2823_Neurology.txt b/2823_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..61b0a23c0ed4d66726a4aa2b927ea9869db8a2a0 --- /dev/null +++ b/2823_Neurology.txt @@ -0,0 +1,73 @@ +CC: + + Left hemibody numbness. + +HX: + + This 44y/o RHF awoke on 7/29/93 with left hemibody numbness without tingling, weakness, ataxia, visual or mental status change. She had no progression of her symptoms until 7/7/93 when she notices her right hand was stiff and clumsy. She coincidentally began listing to the right when walking. She denied any recent colds/flu-like illness or history of multiple sclerosis. She denied symptoms of Lhermitte's or Uhthoff's phenomena. + +MEDS: + + none. + +PMH: + + 1)Bronchitis twice in past year (last 2 months ago). + +FHX: + + Father with HTN and h/o strokes at ages 45 and 80; now 82 years old. Mother has DM and is age 80. + +SHX: + + Denies Tobacco/ETOH/illicit drug use. + +EXAM: + + BP112/76 HR52 RR16 36.8C,MS: unremarkable. + +CN: unremarkable. + +Motor: 5/5 strength throughout except for slowing of right hand fine motor movement. There was mildly increased muscle tone in the RUE and RLE. + +Sensory: decreased PP below T2 level on left and some dysesthesias below L1 on the left. + +Coord: positive rebound in RUE. + +Station/Gait: unremarkable. + +Reflexes: 3+/3 throughout all four extremities. Plantar responses were flexor, bilaterally. + +Rectal exam not done. + +Gen exam reportedly "normal." + +COURSE: + + GS + + CBC + + PT + + PTT + + ESR + + Serum SSA/SSB/dsDNA + + B12 were all normal. MRI C-spine, 7/145/93, showed an area of decreased T1 and increased T2 signal at the C4-6 levels within the right lateral spinal cord. The lesion appeared intramedullary and eccentric, and peripherally enhanced with gadolinium. Lumbar puncture, 7/16/93, revealed the following CSF analysis results: RBC 0, WBC 1 (lymphocyte) + + Protein 28mg/dl, Glucose 62mg/dl, CSF Albumin 16 (normal 14-20) + + Serum Albumin 4520 (normal 3150-4500) + + CSF IgG 4.1mg/dl (normal 0-6.2) + + CSF IgG, % total CSF protein 15% (normal 1-14%) + + CSF IgG index 1.1 (normal 0-0.7) + + Oligoclonal bands were present. She was discharged home. + +The patient claimed her symptoms resolved within one month. She did not return for a scheduled follow-up MRI C-spine. \ No newline at end of file diff --git a/2825_Neurology.txt b/2825_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..5589579e323cfe73e4e214bbf8a8fe919202f042 --- /dev/null +++ b/2825_Neurology.txt @@ -0,0 +1,49 @@ +CC: + + Right shoulder pain. + +HX: + +This 46 y/o RHF presented with a 4 month history of right neck and shoulder stiffness and pain. The symptoms progressively worsened over the 4 month course. 2 weeks prior to presentation she began to develop numbness in the first and second fingers of her right hand and RUE pain. The later was described as a throbbing pain. She also experienced numbness in both lower extremities and pain in the coccygeal region. The pains worsened at night and impaired sleep. She denied any visual change, bowel or bladder difficulties and symptoms involving the LUE. She occasionally experienced an electric shock like sensation shooting down her spine when flexing her neck (Lhermitte's phenomena). She denied any history of neck/back/head trauma. + +She had been taking Naprosyn with little relief. + +PMH: + +1) Catamenial Headaches. 2) Allergy to Macrodantin. + +SHX/FHX: + + Smokes 2ppd cigarettes. + +EXAM: + +Vital signs were unremarkable. + +CN: unremarkable. + +Motor: full strength throughout. Normal tone and muscle bulk. + +Sensory: No deficits on LT/PP/VIB/TEMP/PROP testing. + +Coord/Gait/Station: Unremarkable. + +Reflexes: 2/2 in BUE except 2+ at left biceps. 1+/1+BLE except an absent right ankle reflex. + +Plantar responses were flexor bilaterally. Rectal exam: normal tone. + +IMPRESSION: + + C-spine lesion. + +COURSE: + +MRI C-spine revealed a central C5-6 disk herniation with compression of the spinal cord at that level. EMG/NCV showed normal NCV + + but 1+ sharps and fibrillations in the right biceps (C5-6) + + brachioradialis (C5-6) + + triceps (C7-8) and teres major; and 2+ sharps and fibrillations in the right pronator terres. There was increased insertional activity in all muscles tested on the right side. The findings were consistent with a C6-7 radiculopathy. + +The patient subsequently underwent C5-6 laminectomy and her symptoms resolved. \ No newline at end of file diff --git a/2826_Neurology.txt b/2826_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..528534cb419c7bfc8b0135557486c1e7e16a7484 --- /dev/null +++ b/2826_Neurology.txt @@ -0,0 +1,33 @@ +FINDINGS: + +Normal foramen magnum. + +Normal brainstem-cervical cord junction. There is no tonsillar ectopia. Normal clivus and craniovertebral junction. Normal anterior atlantoaxial articulation. + +C2-3: There is disc desiccation but no loss of disc space height, disc displacement, endplate spondylosis or uncovertebral joint arthrosis. Normal central canal and intervertebral neural foramina. + +C3-4: There is disc desiccation with a posterior central disc herniation of the protrusion type. The small posterior central disc protrusion measures 3 x 6mm (AP x transverse) in size and is producing ventral thecal sac flattening. CSF remains present surrounding the cord. The residual AP diameter of the central canal measures 9mm. There is minimal right-sided uncovertebral joint arthrosis but no substantial foraminal compromise. + +C4-5: There is disc desiccation, slight loss of disc space height with a right posterior lateral pre-foraminal disc osteophyte complex with right-sided uncovertebral and apophyseal joint arthrosis. The disc osteophyte complex measures approximately 5mm in its AP dimension. There is minimal posterior annular bulging measuring approximately 2mm. The AP diameter of the central canal has been narrowed to 9mm. CSF remains present surrounding the cord. There is probable radicular impingement upon the exiting right C5 nerve root. + +C5-6: There is disc desiccation, moderate loss of disc space height with a posterior central disc herniation of the protrusion type. The disc protrusion measures approximately 3 x 8mm (AP x transverse) in size. There is ventral thecal sac flattening with effacement of the circumferential CSF cleft. The residual AP diameter of the central canal has been narrowed to 7mm. Findings indicate a loss of the functional reserve of the central canal but there is no cord edema. There is bilateral uncovertebral and apophyseal joint arthrosis with moderate foraminal compromise. + +C6-7: There is disc desiccation, mild loss of disc space height with 2mm of posterior annular bulging. There is bilateral uncovertebral and apophyseal joint arthrosis (left greater than right) with probable radicular impingement upon the bilateral exiting C7 nerve roots. + +C7-T1, T1-2: There is disc desiccation with no disc displacement. Normal central canal and intervertebral neural foramina. + +T3-4: There is disc desiccation with minimal 2mm posterior annular bulging but normal central canal and CSF surrounding the cord. + +IMPRESSION: + +Multilevel degenerative disc disease with uncovertebral joint arthrosis with foraminal compromise as described above. + +C3-4 posterior central disc herniation of the protrusion type but no cord impingement. + +C4-5 right posterior lateral disc osteophyte complex with right-sided uncovertebral and apophyseal joint arthrosis with probable radicular impingement upon the right C5 nerve root. + +C5-6 degenerative disc disease with a posterior central disc herniation of the protrusion type producing borderline central canal stenosis with effacement of the circumferential CSF cleft indicating a limited functional reserve of the central canal. + +C6-7 degenerative disc disease with annular bulging and osseous foraminal compromise with probable impingement upon the bilateral exiting C7 nerve roots. + +T3-4 degenerative disc disease with posterior annular bulging. \ No newline at end of file diff --git a/2828_Neurology.txt b/2828_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..a372deb5693c2e0cfcdb6ba253bb842fbcd3244f --- /dev/null +++ b/2828_Neurology.txt @@ -0,0 +1,57 @@ +CC: + + Weakness. + +HX: + + This 30 y/o RHM was in good health until 7/93, when he began experiencing RUE weakness and neck pain. He was initially treated by a chiropractor and, after an unspecified length of time, developed atrophy and contractures of his right hand. He then went to a local neurosurgeon and a cervical spine CT scan, 9/25/92, revealed an intramedullary lesion at C2-3 and an extramedullary lesion at C6-7. He underwent a C6-T1 laminectomy with exploration and decompression of the spinal cord. His clinical condition improved over a 3 month post-operative period, and then progressively worsened. He developed left sided paresthesia and upper extremity weakness (right worse than left). He then developed ataxia, nausea, vomiting, and hyperreflexia. On 8/31/93, MRI C-spine showed diffuse enlargement of the cervical and thoracic spine and multiple enhancing nodules in the posterior fossa. On 9/1/93, he underwent suboccipital craniotomy with tumor excision, decompression, and biopsy which was consistent with hemangioblastoma. His symptoms stabilized and he underwent 5040 cGy in 28 fractions to his brain and 3600 cGy in 20 fractions to his cervical and thoracic spinal cord from 9/93 through 1/19/94. + +He was evaluated in the NeuroOncology clinic on 10/26/95 for consideration of chemotherapy. He complained of progressive proximal weakness of all four extremities and dysphagia. He had difficulty putting on his shirt and raising his arms, and he had been having increasing difficulty with manual dexterity (e.g. unable to feed himself with utensils). He had difficulty going down stairs, but could climb stairs. He had no bowel or bladder incontinence or retention. + +MEDS: + + none. + +PMH: + + see above. + +FHX: + + Father with Von Hippel-Lindau Disease. + +SHX: + + retired truck driver. smokes 1-3 packs of cigarettes per day, but denied alcohol use. He is divorced and has two sons who are healthy. He lives with his mother. + +ROS: + + noncontributory. + +EXAM: + + Vital signs were unremarkable. + +MS: A&O to person, place and time. Speech fluent and without dysarthria. Thought process lucid and appropriate. + +CN: unremarkable exept for 4+/4+ strength of the trapezeii. No retinal hemangioblastoma were seen. + +MOTOR: 4-/4- strength in proximal and distal upper extremities. There is diffuse atrophy and claw-hands, bilaterally. He is unable to manipulate hads to any great extent. 4+/4+ strength throughout BLE. There is also diffuse atrophy throughout the lower extremities though not as pronounced as in the upper extremities. + +SENSORY: There was a right T3 and left T8 cord levels to PP on the posterior thorax. Decreased LT in throughout the 4 extremities. + +COORD: difficult to assess due to weakness. + +Station: BUE pronator drift. + +Gait: stands without assistance, but can only manage to walk a few steps. Spastic gait. + +Reflexes: Hyperreflexic on left (3+) and Hyporeflexic on right (1). Babinski signs were present bilaterally. + +Gen exam: unremarkable. + +COURSE: + +9/8/95, GS normal. By 11/14/95, he required NGT feeding due to dysphagia and aspiration risk confirmed on cookie swallow studies.MRI Brain, 2/19/96, revealed several lesions (hemangioblastoma) in the cerebellum and brain stem. There were postoperative changes and a cyst in the medulla. + +On 10/25/96, he presented with a 1.5 week h/o numbness in BLE from the mid- thighs to his toes, and worsening BLE weakness. He developed decubitus ulcers on his buttocks. He also had had intermittent urinary retention for month, chronic SOB and dysphagia. He had been sitting all day long as he could not move well and had no daytime assistance. His exam findings were consistent with his complaints. He had had no episodes of diaphoresis, headache, or elevated blood pressures. An MRI of the C-T spine, 10/26/96, revealed a prominent cervicothoracic syrinx extending down to T10. There was evidence of prior cervical laminectomy of C6-T1 with expansion of the cord in the thecalsac at that region. Multiple intradural extra spinal nodular lesions (hyperintense on T2, isointense on T1, enhanced gadolinium) were seen in the cervical spine and cisterna magna. The largest of which measures 1.1 x 1.0 x 2.0cm. There are also several large ring enhancing lesions in cerebellum. The lesions were felt to be consistent with hemangioblastoma. No surgical or medical intervention was initiated. Visiting nursing was provided. He has since been followed by his local physician \ No newline at end of file diff --git a/2835_Neurology.txt b/2835_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..e2701f4102d5f6653a1f21ede50b3b46d766a5d7 --- /dev/null +++ b/2835_Neurology.txt @@ -0,0 +1,45 @@ +CC: + +Motor vehicle-bicycle collision. + +HX: + + A 5 y/o boy admitted 10/17/92. He was struck while riding his bicycle by a motor vehicle traveling at a high rate of speed. First responders found him unconscious with left pupil 6 mm and unreactive and the right pupil 3 mm and reactive. He had bilateral decorticate posturing and was bleeding profusely from his nose and mouth. He was intubated and ventilated in the field, and then transferred to UIHC. + +PMH/FHX/SHX: + + unremarkable. + +MEDS: + + none,EXAM: + + BP 127/91 HR69 RR30,MS: unconscious and intubated,Glasgow coma scale=4,CN: Pupils 6/6 fixed. Corneal reflex: trace OD + + absent OS. Gag present on manipulation of endotracheal tube. + +MOTOR/SENSORY: bilateral decorticate posturing to noxious stimulation (chest). + +Reflexes: bilaterally. + +Laceration of mid forehead exposing calvarium. + +COURSE: + + Emergent Brain CT scan revealed: Displaced fracture of left calvarium. Left frontoparietal intraparenchymal hemorrhage. Right ventricular collection of blood. Right cerebral intraparenchymal hemorrhage. Significant mass effect with deviation of the midline structures to right. The left ventricle was compressed with obliteration of the suprasellar cistern. Air within the soft tissues in the left infra temporal region. C-spine XR + + Abdominal/Chest CT were unremarkable. + +Patient was taken to the OR emergently and underwent bifrontal craniotomy, evacuation of a small epidural and subdural hematomas, and duraplasty. He was given mannitol enroute to the OR and hyperventilated during and after the procedure. Postoperatively he continued to manifest decerebrate posturing . On 11/16/92 he underwent VP shunting with little subsequent change in his neurological status. On 11/23/92 he underwent tracheostomy. On 12/11/92 he underwent bifrontal acrylic prosthesis implantation for repair of the bifrontal craniectomy. By the time of discharge, 1/14/93, he tracked relatively well OD + + but had a CN3 palsy OS. He had relatively severe extensor rigidity in all extremities (R>L). His tracheotomy was closed prior to discharge. A 11/16/92 Brain MRI demonstrated infarction in the upper brain stem (particularly in the Pons) + + left cerebellum, right basil ganglia and thalamus. + +He was initially treated for seizure prophylaxis with DPH + + but developed neutropenia, so it was discontinued. He developed seizures within several months of discharge and was placed on VPA (Depakene). This decreased seizure frequency but his liver enzymes became elevated and he changed over to Tegretol. 10/8/93 Brain MRI (one year after MVA) revealed interval appearance of hydrocephalus, abnormal increased T2 signal (in the medulla, right pons, both basal ganglia, right frontal and left occipital regions) + + a small mid-brain, and a right subdural fluid collection. These findings were consistent with diffuse axonal injury of the white matter and gray matter contusion, and signs of a previous right subdural hematoma. + +He was last seen 10/30/96 in the pediatric neurology clinic--age 9 years. He was averaging 2-3 seizures per day---characterized by extension of BUE with tremor and audible cry or laughter---on Tegretol and Diazepam. In addition he experiences 24-48hour periods of "startle response (myoclonic movement of the shoulders)" with or without stimulation every 6 weeks. He had limited communication skills (sparse speech). On exam he had disconjugate gaze, dilated/fixed left pupil, spastic quadriplegia. \ No newline at end of file diff --git a/2837_Neurology.txt b/2837_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..5a36302db43a4e53fe90802e7cf9e24761176a2c --- /dev/null +++ b/2837_Neurology.txt @@ -0,0 +1,63 @@ +CC: + + Falling. + +HX: + + This 67y/o RHF was diagnosed with Parkinson's Disease in 9/1/95, by a local physician. For one year prior to the diagnosis, the patient experienced staggering gait, falls and episodes of lightheadedness. She also noticed that she was slowly "losing" her voice, and that her handwriting was becoming smaller and smaller. Two months prior to diagnosis, she began experienced bradykinesia, but denied any tremor. She noted no improvement on Sinemet, which was started in 9/95. At the time of presentation, 2/13/96, she continued to have problems with coordination and staggering gait. She felt weak in the morning and worse as the day progressed. She denied any fever, chills, nausea, vomiting, HA + + change in vision, seizures or stroke like events, or problems with upper extremity coordination. + +MEDS: + + Sinemet CR 25/100 1tab TID + + Lopressor 25mg qhs, Vitamin E 1tab TID + + Premarin 1.25mg qd, Synthroid 0.75mg qd, Oxybutynin 2.5mg has, isocyamine 0.125mg qd. + +PMH: + + 1) Hysterectomy 1965. 2) Appendectomy 1950's. 3) Left CTR 1975 and Right CTR 1978. 4) Right oophorectomy 1949 for "tumor." 5) Bladder repair 1980 for unknown reason. 6) Hypothyroidism dx 4/94. 7) HTN since 1973. + +FHX: + +Father died of MI + + age 80. Mother died of MI + + age73. Brother died of Brain tumor, age 9. + +SHX: + +Retired employee of Champion Automotive Co. + +Denies use of TOB/ETOH/Illicit drugs. + +EXAM: + +BP (supine)182/113 HR (supine)94. BP (standing)161/91 HR (standing)79. RR16 36.4C. + +MS: A&O to person, place and time. Speech fluent and without dysarthria. No comment regarding hypophonia. + +CN: Pupils 5/5 decreasing to 2/2 on exposure to light. Disks flat. Remainder of CN exam unremarkable. + +Motor: 5/5 strength throughout. NO tremor noted at rest or elicited upon movement or distraction,Sensory: Unremarkable PP/VIB testing. + +Coord: Did not show sign of dysmetria, dyssynergia, or dysdiadochokinesia. There was mild decrement on finger tapping and clasping/unclasping hands (right worse than left). + +Gait: Slow gait with difficulty turning on point. Difficulty initiating gait. There was reduced BUE swing on walking (right worse than left). + +Station: 3-4step retropulsion. + +Reflexes: 2/2 and symmetric throughout BUE and patellae. 1/1 Achilles. Plantar responses were flexor. + +Gen Exam: Inremarkable. HEENT: unremarkable. + +COURSE: + + The patient continued Sinemet CR 25/100 1tab TID and was told to monitor orthostatic BP at home. The evaluating Neurologist became concerned that she may have Parkinsonism plus dysautonomia. + +She was seen again on 5/28/96 and reported no improvement in her condition. In addition she complained of worsening lightheadedness upon standing and had an episode, 1 week prior to 5/28/96, in which she was at her kitchen table and became unable to move. There were no involuntary movements or alteration in sensorium/mental status. During the episode she recalled wanting to turn, but could not. Two weeks prior to 5/28/96 she had an episode of orthostatic syncope in which she struck her head during a fall. She discontinued Sinemet 5 days prior to 5/28/96 and felt better. She felt she was moving slower and that her micrographia had worsened. She had had recent difficulty rolling over in bed and has occasional falls when turning. She denied hypophonia, dysphagia or diplopia. + +On EXAM: BP (supine)153/110 with HR 88. BP (standing)110/80 with HR 96. (+) Myerson's sign and mild hypomimia, but no hypophonia. There was normal blinking and EOM. Motor strength was full throughout. No resting tremor, but mild postural tremor present. No rigidity noted. Mild decrement on finger tapping noted. Reflexes were symmetric. No Babinski signs and no clonus. Gait was short stepped with mild anteroflexed posture. She was unable to turn on point. 3-4 step Retropulsion noted. The Parkinsonism had been unresponsive to Sinemet and she had autonomic dysfunction suggestive of Shy-Drager syndrome. It was recommended that she liberalize dietary salt use and lie with head of the bed elevate at 20-30 degrees at night. Indomethacin was suggested to improve BP in future. \ No newline at end of file diff --git a/2838_Neurology.txt b/2838_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..ee266f375ea2ac5e06e2e882e62d412052db4510 --- /dev/null +++ b/2838_Neurology.txt @@ -0,0 +1,101 @@ +CC: + + Episodic monocular blindness, OS. + +HX: + + This 29 y/o RHF was in her usual healthy state until 2 months prior to her 3/11/96 presentation when she developed episodic arthralgias of her knees and ankles, bilaterally. On 3/3/96, she experienced sudden onset monocular blindness, OS + + lasting 5-10 minutes in duration. Her vision "greyed out" from the periphery to center of her visual field, OS; and during some episodes progressed to complete blindness (not even light perception). This resolved within a few minutes. She had multiple episodes of vision loss, OS + + every day until 3/7/96 when she was placed on heparin for suspected LICA dissection. She saw a local ophthalmologist on 3/4/96 and was told she had a normal funduscopic exam. She experienced 0-1 spell of blindness (OS) per day from 3/7/96 to 3/11/96. In addition, she complained of difficulty with memory since 3/7/96. She denied dysarthria, aphasia or confusion, but had occasional posterior neck and bioccipital-bitemporal headaches. + +She had no history of deep venous or arterial thrombosis. + +3/4/96, ESR=123. HCT with and without contrast on 3/7/96 and 3/11/96, and Carotid Duplex scan were "unremarkable." Rheumatoid factor=normal. 3-vessel cerebral angiogram (done locally) was reportedly "unremarkable." + +She was thought to have temporal arteritis and underwent Temporal Artery biopsy (which was unremarkable) + + She received Prednisone 80 mg qd for 2 days prior to presentation. + +On admission she complained of a left temporal headache at the biopsy site, but no loss of vision or weakness,She had been experiencing mild fevers and chills for several weeks prior to presentation. Furthermore, she had developed cyanosis of the distal #3 toes on feet, and numbness and rash on the lateral aspect of her left foot. She developed a malar rash on her face 1-2 weeks prior to presentation. + +MEDS: + + Depo-Provera, Prednisone 80mg qd, and Heparin IV. + +PMH: + + 1)Headaches for 3-4 years, 2)Heart murmur, 3) cryosurgery of cervix, 4)tonsillectomy and adenoidectomy, 5) elective abortion. She had no history of spontaneous miscarriage and had used oral birth control pill for 10 years prior to presentation. + +FHX: + + Migraine headaches on maternal side, including her mother. No family history of thrombosis. + +SHX: + + works as a metal grinder and was engaged to be married. She denied any tobacco or illicit drug use. She consumed 1 alcoholic drink per month. + +EXAM: + +BP147/74, HR103, RR14, 37.5C. + +MS: A&O to person, place and time. Speech was fluent without dysarthria. Repetition, naming and comprehension were intact. 2/3 recall at 2 minutes. + +CN: unremarkable. + +Motor: unremarkable. + +Coord: unremarkable. + +Sensory: decreased LT + + PP + + TEMP + + along the lateral aspect of the left foot. + +Gait: narrow-based and able to TT + + HW and TW without difficulty. + +Station: unremarkable. + +Reflexes: 2/2 throughout. Plantar responses were flexor, bilaterally. + +Skin: Cyanosis of the distal #3 toes on both feet. There was a reticular rash about the lateral aspect of her left foot. There were splinter-type hemorrhages under the fingernails of both hands. + +COURSE: + + ESR=108 (elevated) + + Hgb 11.3, Hct 33% + + WBC 10.0, Plt 148k, MCV 92 (low) Cr 1.3, BUN 26, CXR and EKG were unremarkable. PTT 42 (elevated). PT normal. The rest of the GS and CBC were normal. Dilute Russell Viper venom time was elevated at 27 and a 1:1 prothrombin time mix corrected to only 36. + +She was admitted to the Neurology service. Blood cultures were drawn and were negative. Transthoracic and transesophageal echocardiography on 3/12/96 was unremarkable. + +Her symptoms and elevated PTT suggested an ischemic syndrome involving anticardiolipin antibody and/or lupus anticoagulant. Her signs of rash and cyanosis suggested SLE. ANA was positive at 1:640 (speckled) + + RF (negative) + + dsDNA + + 443 (elevated). Serum cryoglobulins were positive at 1% (fractionation data lost). Serum RPR was positive, but FTA-ABS was negative (thereby confirming a false-positive RPR). Anticardiolipin antibodies IgM and IgG were positive at 56.1 and 56.3 respectively. Myeloperoxidase antibody was negative, ANCA was negative and hepatitis screen unremarkable. + +The Dermatology Service felt the patient's reticular foot rash was livedo reticularis. Rheumatology felt the patient met criteria for SLE. Hematology felt the patient met criteria for Anticardiolipin Antibody and/or Lupus anticoagulant Syndrome. Neurology felt the episodic blindness was secondary to thromboembolic events. + +Serum Iron studies revealed: FeSat 6, Serum Fe 15, TIBC 237, Reticulocyte count 108.5. The patient was placed on FeSO4 225mg tid. + +She was continued on heparin IV + + but despite this she continued to have occasional episodes of left monocular blindness or "gray outs" up to 5 times per day. She was seen by the Neuro-ophthalmology Service. The did not think she had evidence of vasculitis in her eye. They recommended treatment with ASA 325mg bid. She was placed on this 3/15/96 and tapered off heparin. She continued to have 0-4 episodes of monocular blindness (OS) for 5-10 seconds per episodes. She was discharged home. + +She returned 3/29/96 for episodic diplopia lasting 5-10 minutes per episode. The episodes began on 3/27/96. During the episodes her left eye deviated laterally while the right eye remained in primary gaze. She had no prior history of diplopia or strabismus. Hgb 10.1, Hct 30% + + WBC 5.2, MCV 89 (low) + + Plt 234k. ESR 113mm/hr. PT 12, PTT 45 (high). HCT normal. MRI brain, 3/30/96, revealed a area of increased signal on T2 weighted images in the right frontal lobe white matter. This was felt to represent a thromboembolic event. She was place on heparin IV and treated with Solu-Medrol 125mg IV q12 hours. ASA was discontinued. Hematology, Rheumatology and Neurology agreed to place her on Warfarin. She was placed on Prednisone 60mg qd following the Solu-Medrol. She continued to have transient diplopia and mild vertigo despite INR's of 2.0-2.2. ASA 81mg qd was added to her regimen. In addition, Rheumatology recommended Plaquenil 200mg bid. The neurologic symptoms decreased gradually over the ensuing 3 days. Warfarin was increased to achieve INR 2.5-3.5. + +She reported no residual symptoms or new neurologic events on her 5/3/96 Neurology Clinic follow-up visit. She continues to be event free on Warfarin according to her Hematology Clinic notes up to 12/96. \ No newline at end of file diff --git a/2841_Neurology.txt b/2841_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..a15ffcc5cb0c1450e68b773e00f2abcedd56c9ed --- /dev/null +++ b/2841_Neurology.txt @@ -0,0 +1,3 @@ +FINDINGS: + +There is a large intrasellar mass lesion producing diffuse expansion of the sella turcica. This mass lesions measures approximately 16 x 18 x 18mm (craniocaudal x AP x mediolateral) in size. \ No newline at end of file diff --git a/2843_Neurology.txt b/2843_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..5635e72aa515cb5fb2bd2950f0b89448436f4286 --- /dev/null +++ b/2843_Neurology.txt @@ -0,0 +1,41 @@ +CC: + +Progressive loss of color vision OD + +HX: + + 58 y/o female presents with a one year history of progressive loss of color vision. In the past two months she has developed blurred vision and a central scotoma OD. There are no symptoms of photopsias, diplopia, headache, or eye pain. There are no other complaints. There have been mild fluctuations of her symptoms, but her vision has never returned to its baseline prior to symptom onset one year ago. + +EXAM: + +Visual acuity with correction: 20/25+1 OD; 20/20-1 OS. Pupils were 3.5mm OU. There was a 0.8 log unit RAPD OD. Intraocular pressures were 25 and 24, OD and OS respectively; and there was an increase to 27 on upgaze OD + + but no increase on upgaze OS. Optic disk pallor was evident OD + + but not OS. Additionally, there was a small area of peripheral chorioretinal scarring in the inferotemporal area of the right eye. Foveal flicker fusion occurred at a frequency of 21.9 OD and 30.7 OS. Color plate testing scores: 6/14 OD and 10/14 OS. Goldman visual field examination showed an enlarged and deepened blind spot with an infero-temporal defect especially in the smaller diopters. + +IMPRESSION ON 2/6/89: + +Optic neuropathy/atrophy OD + + rule out mass lesion affecting optic nerve. Particular attention was paid to the area of the optic canal, cavernous sinus and sphenoid sinus. + +BRAIN CT W/CONTRAST + + 2/13/89: + + Enhancing calcified lesion in the posterior aspect of the right optic nerve, probable meningioma. + +MRI ORBITS W/ AND W/OUT GADOLINIUM CONTRAST + + 4/26/89: + + 7x3mm irregular soft tissue mass just inferior and lateral to the optic nerve OD. The mass is just proximal to the orbital apex. There is relatively homogeneous enhancement of the mass. The findings are most consistent with meningioma. + +MRI 1995: + + Mild enlargement of tumor with possible slight extension into the right cavernous sinus. + +COURSE: + +Resection and biopsy were deferred due to risk of blindness, and suspicion that the tumor was a slow growing meningioma. 3 years after initial evaluation Hertel measurements indicated a 3mm proptosis OD. Visual field testing revealed gradual worsening of deficits seen on her initial Goldman visual field exam. There was greater red color desaturation of the temporal field OD. Visual acuity had decreased from 20/20 to 20/64, OD. All other deficits seen on her initial exam remained stable or slightly worsened. By 1996 she continued to be followed at 6 months intervals and had not undergone surgical resection. \ No newline at end of file diff --git a/2844_Neurology.txt b/2844_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..8bbe39a10d6d2a978208f3561f8ac94768e15068 --- /dev/null +++ b/2844_Neurology.txt @@ -0,0 +1,29 @@ +FINDINGS: + +There is moderate to severe generalized neuronal loss of the cerebral hemispheres with moderate to severe ventricular enlargement and prominent CSF within the subarachnoid spaces. There is confluent white matter hyperintensity in a bi-hemispherical centrum semiovale distribution extending to the lateral ventricles consistent with severe vasculopathic small vessel disease and extensive white matter ischemic changes. There is normal enhancement of the dural sinuses and cortical veins and there are no enhancing intra-axial or extraaxial mass lesions. There is a cavum velum interpositum (normal variant). + +There is a linear area of T1 hypointensity becoming hyperintense on T2 images in a left para-atrial trigonal region representing either a remote lacunar infarction or prominent perivascular space. + +Normal basal ganglia and thalami. Normal internal and external capsules. Normal midbrain. + +There is amorphus hyperintensity of the basis pontis consistent with vasculopathic small vessel disease. There are areas of T2 hyperintensity involving the bilateral brachium pontis (left greater than right) with no enhancement following gadolinium augmentation most compatible with areas of chronic white matter ischemic changes. The area of white matter signal alteration in the left brachium pontis is of some concern in that is has a round morphology. Interval reassessment of this lesion is recommended. + +There is a remote lacunar infarction of the right cerebellar hemisphere. Normal left cerebellar hemisphere and vermis. + +There is increased CSF within the sella turcica and mild flattening of the pituitary gland but no sellar enlargement. There is elongation of the basilar artery elevating the mammary bodies but no dolichoectasia of the basilar artery. + +Normal flow within the carotid arteries and circle of Willis. + +Normal calvarium, central skull base and temporal bones. There is no demonstrated calvarium metastases. + +IMPRESSION: + +Severe generalized cerebral atrophy. + +Extensive chronic white matter ischemic changes in a bi-hemispheric centrum semiovale distribution with involvement of the basis pontis and probable bilateral brachium pontis. The area of white matter hyperintensity in the left brachium pontis is of some concern is that it has a round morphology but no enhancement following gadolinium augmentation. Interval reassessment of this lesion is recommended. + +Remote lacunar infarction in the right cerebellar hemisphere. + +Linear signal alteration of the left periatrial trigonal region representing either a prominent vascular space or,lacunar infarction. + +No demonstrated calvarial metastases. \ No newline at end of file diff --git a/2847_Neurology.txt b/2847_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..0d90f5a4f9053e81c6d53d4b5527ef5110a5cfa0 --- /dev/null +++ b/2847_Neurology.txt @@ -0,0 +1,61 @@ +CC: + + Sudden onset blindness. + +HX: + + This 58 y/o RHF was in her usual healthy state, until 4:00PM + + 1/8/93, when she suddenly became blind. Tongue numbness and slurred speech occurred simultaneously with the loss of vision. The vision transiently improved to "severe blurring" enroute to a local ER + + but worsened again once there. While being evaluated she became unresponsive, even to deep noxious stimuli. She was transferred to UIHC for further evaluation. Upon arrival at UIHC her signs and symptoms were present but markedly improved. + +PMH: + + 1) Hysterectomy many years previous. 2) Herniorrhaphy in past. 3) DJD + + relieved with NSAIDs. + +FHX/SHX: + + Married x 27yrs. Husband denied Tobacco/ETOH/illicit drug use for her. + +Unremarkable FHx. + +MEDS: + + none. + +EXAM: + + Vitals: 36.9C. HR 93. BP 151/93. RR 22. 98% O2Sat. + +MS: somnolent, but arousable to verbal stimulation. minimal speech. followed simple commands on occasion. + +CN: Blinked to threat from all directions. EOM appeared full, Pupils 2/2 decreasing to 1/1. +/+Corneas. Winced to PP in all areas of Face. +/+Gag. Tongue midline. Oculocephalic reflex intact. + +Motor: UE 4/5 proximally. Full strength in all other areas. Normal tone and muscle bulk. + +Sensory: Withdrew to PP in all extremities. + +Gait: ND. + +Reflexes: 2+/2+ throughout UE + + 3/3 patella, 2/2 ankles, Plantar responses were flexor bilaterally. + +Gen exam: unremarkable. + +COURSE: + +MRI Brain revealed bilateral thalamic strokes. Transthoracic echocardiogram (TTE) showed an intraatrial septal aneurysm with right to left shunt. Transesophageal echocardiogram (TEE) revealed the same. No intracardiac thrombus was found. Lower extremity dopplers were unremarkable. Carotid duplex revealed 0-15% bilateral ICA stenosis. Neuroophthalmologic evaluation revealed evidence of a supranuclear vertical gaze palsy OU (diminished up and down gaze). Neuropsychologic assessment 1/12-15/93 revealed severe impairment of anterograde verbal and visual memory, including acquisition and delayed recall and recognition. Speech was effortful and hypophonic with very defective verbal associative fluency. Reading comprehension was somewhat preserved, though she complained that despite the ability to see type clearly, she could not make sense of words. There was impairment of 2-D constructional praxis. A follow-up Neuropsychology evaluation in 7/93 revealed little improvement. Laboratory studies, TSH + + FT4, CRP + + ESR + + GS + + PT/PTT were unremarkable. Total serum cholesterol 195, Triglycerides 57, HDL 43, LDL 141. She was placed on ASA and discharged1/19/93. + +She was last seen on 5/2/95 and was speaking fluently and lucidly. She continued to have mild decreased vertical eye movements. Coordination and strength testing were fairly unremarkable. She continues to take ASA 325 mg qd. \ No newline at end of file diff --git a/2848_Neurology.txt b/2848_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..66514535208fd711f0d760fded67d6a1961ed278 --- /dev/null +++ b/2848_Neurology.txt @@ -0,0 +1,45 @@ +CC: + + Progressive visual loss. + +HX: + + 76 y/o male suddenly became anosmic following shoulder surgery 13 years prior to this presentation. He continues to be anosmic, but has also recently noted decreased vision OD. He denies any headaches, weakness, numbness, weight loss, or nasal discharge. + +MEDS: + + none. + +PMH: + + 1) Diabetes Mellitus dx 1 year ago. 2) Benign Prostatic Hypertrophy, s/p TURP. 3) Right shoulder surgery (?DJD). + +FHX: + + noncontributory. + +SHX: + + Denies history of Tobacco/ETOH/illicit drug use. + +EXAM: + + BP132/66 HR78 RR16 36.0C,MS: A&O to person, place, and time. No other specifics given in Neurosurgery/Otolaryngology/Neuro-ophthalmology notes. + +CN: Visual acuity has declined from 20/40 to 20/400, OD; 20/30, OS. No RAPD. EOM was full and smooth and without nystagmus. Goldmann visual fields revealed a central scotoma and enlarged blind spot OD and OS (OD worse) with a normal periphery. Intraocular pressures were 15/14 (OD/OS). There was moderate pallor of the disc, OD. Facial sensation was decreased on the right side (V1 distribution). + +Motor/Sensory/Coord/Station/Gait: were all unremarkable. + +Reflexes: 2/2 and symmetric throughout. Plantars were flexor, bilaterally. + +Gen Exam: unremarkable. + +COURSE: + + MRI Brain, 10/7/92, revealed: a large 6x5x6cm slightly heterogeneous, mostly isointense lesion on both T1 and T2 weighted images arising from the planum sphenoidale and olfactory groove. The mass extends approximately 3.6cm superior to the planum into both frontal regions with edema in both frontal lobes. The mass extends 2.5cm inferiorly involving the ethmoid sinuses with resultant obstruction of the sphenoid and frontal sinuses. + +It also extends into the superomedial aspect of the right maxillary sinus. There is probable partial encasement of both internal carotid arteries just above the siphon. The optic nerves are difficult to visualize but there is also probable encasement of these structures as well. The mass enhances significantly with gadolinium contrast. These finds are consistent with Meningioma. + +The patient underwent excision of this tumor by simultaneous bifrontal craniotomy and lateral rhinotomy following an intrasinus biopsy which confirmed the meningioma. Postoperatively, he lost visual acuity, OS + + but this gradually returned to baseline. His 9/6/96 neuro-ophthalmology evaluation revealed visual acuity of 20/25-3 (OD) and 20/80-2 (OS). His visual fields continued to abnormal, but improved and stable when compared to 10/92. His anosmia never resolved. \ No newline at end of file diff --git a/2850_Neurology.txt b/2850_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..330d7d09e273263b54f273e88767b54b2f76682e --- /dev/null +++ b/2850_Neurology.txt @@ -0,0 +1,75 @@ +HISTORY OF PRESENT ILLNESS: + + The patient is a 35-year-old woman who reports that on the 30th of October 2008, she had a rupture of her membranes at nine months of pregnancy, and was admitted to hospital and was given an epidural anesthetic. I do not have the records from this hospital admission, but apparently the epidural was administered for approximately 14 to 18 hours. She was sitting up during the epidural. + +She did not notice any difference in her lower extremities at the time she had the epidural; however, she reports that she was extremely sleepy and may not have been aware of any change in strength or sensation in her lower extremities at that time. She delivered on the 31st of October, by Cesarean section, because she had failed to progress and had pyrexia. + +She also had a Foley catheter placed at that time. On the 1st of November 2008, they began to mobilize her and it was at that time that she first noticed that she could not walk. She was aware that she could not move her legs at all, and then within a few days, she was aware that she could move toes in the left foot but could not move her right foot at all. Since that time, there has been a gradual improvement in strength to the point that she now has limited movement in her left leg and severely restricted movement in her right leg. She is not able to walk by herself, and needs assistance to stand. She was discharged from hospital after the Cesarean section on the 3rd of November. Unfortunately, we do not have the records and we do not know what the discussion was between the anesthesiologist and the patient at the time of discharge. She was then seen at ABC Hospital on November 05, 2008. She had an MRI scan of her spine, which showed no evidence of an abnormality, specifically there were no cord changes and no evidence of a hematoma. She also had an EMG study at that time by Dr. X, which was abnormal but not diagnostic and this was repeated again in December. At the present time, she also complains of a pressure in both her legs and in her thighs. She complains that her right foot hurts and that she has some hyperesthesia there. She has been taking gabapentin to try to reduce the discomfort, although she is on a very low dose and the effect is minimal. She has no symptoms in her arms, her bowel and bladder function is normal, and her bulbar function is normal. There is no problem with her vision, swallowing, or respiratory function. + +PAST MEDICAL HISTORY: + + Unremarkable except as noted above. She has seasonal allergies. + +CURRENT MEDICATIONS: + + Gabapentin 300 mg b.i.d. + + Centrum once a day, and another multivitamin. + +ALLERGIES: + + She has no medication allergies, but does have seasonal allergies. + +FAMILY HISTORY: + + There is a family history of diabetes and hypertension. There is no family history of a neuropathy or other neurological disease. She has one child, a son, born on October 31, 2008. + +SOCIAL HISTORY: + + The patient is a civil engineer, who currently works from home. She is working approximately half time because of limitations imposed on her by her disability, need to attend frequent physical therapy, and also the needs of looking after her baby. She does not smoke and does not drink and has never done either. + +GENERAL PHYSICAL EXAMINATION: + +VITAL SIGNS: P 74, BP 144/75, and a pain score of 0. + +GENERAL: Her general physical examination was unremarkable. + +CARDIOVASCULAR: Normal first and second heart sound, regular pulse with normal volume. + +RESPIRATORY: Unremarkable, both lung bases were clear, and respiration was normal. + +GI: Unremarkable, with no organomegaly and normal bowel sounds. + +NEUROLOGICAL EXAM: + +MSE: The patient's orientation was normal, fund of knowledge was normal, memory was normal, speech was normal, calculation was normal, and immediate and long-term recall was normal. Executive function was normal. + +CRANIAL NERVES: The cranial nerve examination II through XII was unremarkable. Both disks were normal, with normal retina. Pupils were equal and reactive to light. Eye movements were full. Facial sensation and strength was normal. Bulbar function was normal. The trapezius had normal strength. + +MOTOR: Muscle tone showed a slight increase in tone in the lower extremities, with normal tone in the upper extremities. Muscle strength was 5/5 in all muscle groups in the upper extremities. In the lower extremities, the hip flexors were 1/5 bilaterally, hip extensors were 1/5 bilaterally, knee extension on the right was 1/5 and on the left was 3-/5, knee flexion was 2/5 on the right and 3-/5 on the left, foot dorsiflexion was 0/5 on the right and 1/5 on the left, foot plantar flexion was 4-/5 on the right and 4+/5 on the left, toe extension was 0/5 on the right and 4-/5 on the left, toe flexion was 4-/5 on the right and 4+/5 on the left. + +REFLEXES: Reflexes in the upper extremities were 2+ bilaterally. In the lower extremities, they were 0 bilaterally at the knee and ankles. The abdominal reflexes were present above the umbilicus and absent below the umbilicus. The plantar responses were mute. The jaw reflex was normal. + +SENSATION: Vibration was moderately decreased in the right great toe and was mildly decreased in the left great toe. There was a sensory level to light touch at approximately T7 posteriorly and approximately T9 anteriorly. There was a range of sensation, but clearly there was a decrease in sensation below this level but not complete loss of sensation. To pain, the sensory level is even less clear, but appeared to be at about T7 on the right side. In the lower extremities, there was a slight decrease in pin and light touch in the right great toe compared to the left. There was no evidence of allodynia or hyperesthesia. Joint position sense was mildly reduced in the right toe and normal on the left. + +COORDINATION: Coordination for rapid alternating movements and finger-to-nose testing was normal. Coordination could not be tested in the lower extremities. + +GAIT: The patient was unable to stand and therefore we were unable to test gait or Romberg's. There was no evidence of focal back tenderness. + +REVIEW OF OUTSIDE RECORDS: + + I have reviewed the records from ABC Hospital, including the letter from Dr. Y and the EMG report dated 12/17/2008 from Dr. X. The EMG report shows evidence of a lumbosacral polyradiculopathy below approximately T6. The lower extremity sensory responses are essentially normal; however, there is a decrease in the amplitude of the motor responses with minimal changes in latency. I do have the MRI of lumbar spine report from 11/06/2008 with and without contrast. This showed a minimal concentric disc bulge of L4-L5 without disc herniation, but was otherwise unremarkable. The patient brought a disc with a most recent MRI study; however, we were unable to open this on our computers. The verbal report is that the study was unremarkable except for some gadolinium enhancement in the lumbar nerve roots. A Doppler of the lower extremities showed no evidence of deep venous thrombosis in either lower extremity. Chest x-ray showed some scoliosis on the lumbar spine, curve to the left, but no evidence of other abnormalities. A CT pelvis study performed on November 07, 2008 showed some nonspecific fluid in the subcutaneous fat of the back, posterior to L4 and L5 levels; however, there were no pelvic masses or other abnormalities. We were able to obtain an update of the report from the MRI of the lumbar spine with and without contrast dated 12/30/2008. The complete study included the cervical, thoracic, and lumbar spine. There was diffuse enhancement of the nerve roots of the cauda equina that had increased in enhancement since prior exam in November. It was also reported that the patient was given intravenous methylprednisolone and this had had no effect on strength in her lower extremities. + +IMPRESSION: + + The patient has a condition that is temporarily related to the epidural injection she was given at the end of October 2008, prior to her Cesarean section. It appears she became aware of weakness within two days of the administration of the epidural, she was very tired during the epidural and may have missed some change in her neurological function. She was severely weak in both lower extremities, slightly worse on the right than the left. There has been some interval improvement in her strength since the beginning of November 2008. Her EMG study from the end of December is most consistent with a lumbosacral polyradiculopathy. The MRI findings of gadolinium enhancement in the lumbar nerve roots would be most consistent with an inflammatory radiculitis most likely related to the epidural anesthesia or administration of the epidural. There had been no response to IV methylprednisolone given to her at ABC. The issue of having a lumbar puncture to look for evidence of inflammatory cells or an elevated protein had been discussed with her at both ABC and by myself. The patient did not wish to consider a lumbar puncture because of concerns that this might worsen her condition. At the present time, she is able to stand with aid but is unable to walk. There is no evidence on her previous EMG of a demyelinating neuropathy. + +RECOMMENDATIONS: + +1. The diagnostic issues were discussed with the patient at length. She is informed that this is still early in the course of the problem and that we expect her to show some improvement in her function over the next one to two years, although it is unclear as to how much function she will regain. + +2. She is strongly recommended to continue with vigorous physical therapy, and to continue with the plan to mobilize her as much as possible, with the goal of trying to get her ambulatory. If she is able to walk, she will need bilateral AFOs for her ankles, to improve her overall mobility. I am not prescribing these because at the present time she does not need them. + +3. We discussed increasing the dose of gabapentin. The paresthesias that she has may indicate that she is actually regaining some sensory function, although there is a concern that as recovery continues, she may be left with significant neuropathic pain. If this is the case, I have advised her to increase her gabapentin dose from 300 mg b.i.d. gradually up to 300 mg four times a day and then to 600 mg to 900 mg four times a day. She may need other neuropathic pain medications as needed. She will determine whether her current symptoms are significant enough to require this increase in dosage. + +4. The patient will follow up with Dr. Y and his team at ABC Hospital. She will also continue with physical therapy within the ABC system. \ No newline at end of file diff --git a/2851_Neurology.txt b/2851_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..9fcac3b832551e1fdfe7daf50ebfc5c576bab1b0 --- /dev/null +++ b/2851_Neurology.txt @@ -0,0 +1,95 @@ +CHIEF COMPLAINT: + + Headaches. + +HEADACHE HISTORY: + + The patient describes the gradual onset of a headache problem. The headache first began 2 months ago. The headaches are located behind both eyes. The pain is characterized as a sensation of pressure. The intensity is moderately severe, making normal activities difficult. Associated symptoms include sinus congestion and photophobia. The headache may be brought on by stress, lack of sleep and alcohol. The patient denies vomiting and jaw pain. + +PAST MEDICAL HISTORY: + + No significant past medical problems. + +PAST SURGICAL HISTORY: + + + +No significant past surgical history. + +FAMILY MEDICAL HISTORY: + + + +There is a history of migraine in the family. The condition affects the patient’s brother and maternal grandfather. + +ALLERGIES: + + Codeine. + +CURRENT MEDICATIONS: + + See chart. + +PERSONAL/SOCIAL HISTORY: + + Marital status: Married. The patient smokes 1 pack of cigarettes per day. Denies use of alcohol. + +NEUROLOGIC DRUG HISTORY: + + The patient has had no help with the headaches from over-the-counter analgesics. + +REVIEW OF SYSTEMS: + +ROS General: Generally healthy. Weight is stable. + +ROS Head and Eyes: Patient has complaints of headaches. Vision can best be described as normal. + +ROS Ears Nose and Throat: The patient notes some sinus congestion. + +ROS Cardiovascular: The patient has no history of any cardiovascular problems and denies any present problems. + +ROS Gastrointestinal: The patient has no history of gastrointestinal problems and denies any present problems. + +ROS Musculoskeletal: No muscle cramps, no joint back or limb pain. The patient denies any past or present problem related to the musculoskeletal system. + +EXAM: + +Exam General Appearance: The patient was alert and cooperative, and did not appear acutely or chronically ill. + +Sex and Race: Male, Caucasian. + +Exam Mental Status: Serial 7’s were performed normally. The patient was oriented with regard to time, place and situation. + +Three out of three objects were readily recalled after several minutes. The patient correctly identified the president and past president. The patient could repeat 7 digits forward and 4 digits reversed without difficulty. The patient’s affect and emotional response was normal and appropriate. The patient related the clinical history in a coherent, organized fashion. + +Exam Cranial Nerves: Sense of smell was intact. + +Exam Neck: Neck range of motion was normal in all directions. There was no evidence of cervical muscle spasm. No radicular symptoms were elicited by neck motions. Shoulder range of motion was normal bilaterally. There were no areas of tenderness. Tests of neurovascular compression were negative. There were no carotid bruits. + +Exam Back: Back range of motion was normal in all directions. + +Exam Sensory: Position and vibratory sense was normal. + +Exam Reflexes: Active and symmetrical. There were no pathological reflexes. + +Exam Coordination: The patient’s gait had no abnormal components. Tandem gait was performed normally. + +Exam Musculoskeletal: Peripheral pulses palpably normal. There is no edema or significant varicosities. No lesions identified. + +IMPRESSION DIAGNOSIS: + +Migraine without aura (346.91) + +COMMENTS: + + The patient has evolved into a chronic progressive course. Medications Prescribed: Therapeutic trial of Inderal 40mg - 1/2 tab b.i.d. x 1 week, then 1 tab. b.i.d. x 1 week then 1 tab t.i.d. + +OTHER TREATMENT: + + The patient was given a thorough explanation of the role of stress in migraine, and given a number of suggestions about implementing appropriate changes in lifestyle. + +RATIONALE FOR TREATMENT PLAN: + + The treatment plan chosen is the most effective and should result in the most beneficial outcome for the patient. There are no reasonable alternatives. + +FOLLOW UP INSTRUCTIONS: \ No newline at end of file diff --git a/2852_Neurology.txt b/2852_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..7f3414729e363032c3f23964dfd9e0d409473c59 --- /dev/null +++ b/2852_Neurology.txt @@ -0,0 +1,51 @@ +CC: + +Delayed motor development. + +HX: + + This 21 month old male presented for delayed motor development, "jaw quivering" and "lazy eye." He was an 8 pound 10 ounce product of a full term, uncomplicated pregnancy-labor-spontaneous vaginal delivery to a G3P3 married white female mother. There had been no known toxic intrauterine exposures. He had no serious illnesses or hospitalizations since birth. He sat independently at 7 months, stood at 11 months, crawled at 16 months, but did not cruise until 18 months. + +He currently cannot walk and easily falls. His gait is reportedly marked by left "intoeing." His upper extremity strength and coordination reportedly appear quite normal and he is able to feed himself, throw and transfer objects easily. He knows greater than 20 words and speaks two-word phrases. + +No seizures or unusual behavior were reported except for "quivering" movement of his jaw. This has occurred since birth. In addition the parents have noted transient left exotropia. + +PMH: + +As above. + +FHX: + + Many family members with "lazy eye." No other neurologic diseases declared. + +9 and 5 year old sisters who are healthy. + +SHX: + + lives with parents and sisters. + +EXAM: + + BP83/67 HR122 36.4C Head circumference 48.0cm Weight 12.68kg (70%) Height 86.0cm (70%) + +MS: fairly cooperative. + +CN: Minimal transient esotropia OS. Tremulous quivering of jaw--increased with crying. No obvious papilledema, though difficult to evaluate due to patient movement. + +Motor: sat independently with normal posture and no truncal ataxia. symmetric and normal strength and muscle bulk throughout. + +Sensory: withdrew to vibration. + +Coordination: unremarkable in BUE. + +Station: no truncal ataxia. + +Gait: On attempting to walk, his right foot rotated laterally at almost 70degrees. Both lower extremities could rotate outward to 90degrees. There was marked passive eversion at the ankles as well. + +Reflexes: 2+/2+ throughout. + +Musculoskeletal: pes planovalgus bilaterally. + +COURSE: + +CK normal. The parents decided to forego an MRI in 8/90. The patient returned 12/11/92 at age 4 years. He was ambulatory and able to run awkwardly. His general health had been good, but he showed signs developmental delay. Formal evaluation had tested his IQ at 87 at age 3.5 years. He was weakest on tasks requiring visual/motor integration and fine motor and visual discrimination skills. He was 6 months delayed in cognitive development at that time. On exam, age 4 years, he displayed mild right ankle laxity on eversion and inversion, but normal gait. The rest of the neurological exam was normal. Head circumference was 49.5cm (50%) and height and weight were in the 90th percentile. Fragile X analysis and karyotyping were unremarkable. \ No newline at end of file diff --git a/2853_Neurology.txt b/2853_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..dade0d734ddf286e3c1584ecdb3f12b49fb33a8d --- /dev/null +++ b/2853_Neurology.txt @@ -0,0 +1,21 @@ +PROCEDURE: + + Lumbar puncture with moderate sedation. + +INDICATION: + + The patient is a 2-year, 2-month-old little girl who presented to the hospital with severe anemia, hemoglobin 5.8, elevated total bilirubin consistent with hemolysis and weak positive direct Coombs test. She was transfused with packed red blood cells. Her hemolysis seemed to slow down. She also on presentation had indications of urinary tract infection with urinalysis significant for 2+ leukocytes, positive nitrites, 3+ protein, 3+ blood, 25 to 100 white cells, 10 to 25 bacteria, 10 to 25 epithelial cells on clean catch specimen. Culture subsequently grew out no organisms; however, the child had been pretreated with amoxicillin about x3 doses prior to presentation to the hospital. She had a blood culture, which was also negative. She was empirically started on presentation with the cefotaxime intravenously. Her white count on presentation was significantly elevated at 20,800, subsequently increased to 24.7 and then decreased to 16.6 while on antibiotics. After antibiotics were discontinued, she increased over the next 2 days to an elevated white count of 31,000 with significant bandemia, metamyelocytes and myelocytes present. She also had three episodes of vomiting and thus she is being taken to the procedure room today for a lumbar puncture to rule out meningitis that may being inadvertently treated in treating her UTI. + +I discussed with The patient's parents prior to the procedure the lumbar puncture and moderate sedation procedures. The risks, benefits, alternatives, complications including, but not limited to bleeding, infection, respiratory depression. Questions were answered to their satisfaction. They would like to proceed. + +PROCEDURE IN DETAIL: + + After "time out" procedure was obtained, the child was given appropriate monitoring equipment including appropriate vital signs were obtained. She was then given Versed 1 mg intravenously by myself. She subsequently became sleepy, the respiratory monitors, end-tidal, cardiopulmonary and pulse oximetry were applied. She was then given 20 mcg of fentanyl intravenously by myself. She was placed in the left lateral decubitus position. Dr. X cleansed the patient's back in a normal sterile fashion with Betadine solution. She inserted a 22-gauge x 1.5-inch spinal needle in the patient's L3-L4 interspace that was carefully identified under my direct supervision. Clear fluid was not obtained initially, needle was withdrawn intact. The patient was slightly repositioned by the nurse and Dr. X reinserted the needle in the L3-L4 interspace position, the needle was able to obtain clear fluid, approximately 3 mL was obtained. The stylette was replaced and the needle was withdrawn intact and bandage was applied. Betadine solution was cleansed from the patient's back. + +During the procedure, there were no untoward complications, the end-tidal CO2, pulse oximetry, and other vitals remained stable. Of note, EMLA cream had also been applied prior procedure, this was removed prior to cleansing of the back. + +Fluid will be sent for a routine cell count, Gram stain culture, protein, and glucose. + +DISPOSITION: + + The child returned to room on the medical floor in satisfactory condition. \ No newline at end of file diff --git a/2857_Neurology.txt b/2857_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..2921efe1a6ba8ac28d6545e543cc3b8d2ff916e8 --- /dev/null +++ b/2857_Neurology.txt @@ -0,0 +1,23 @@ +HISTORY OF PRESENT ILLNESS: + +The patient comes in today because of feeling lightheaded and difficulty keeping his balance. He denies this as a spinning sensation that he had had in the past with vertigo. He just describes as feeling very lightheaded. It usually occurs with position changes such as when he stands up from the sitting position or stands up from a lying position. It tends to ease when he sits down again, but does not totally resolve for another 15 to 30 minutes and he feels shaky and weak all over. Lorazepam did not help this sensation. His blood pressure has been up lately and his dose of metoprolol was increased. They feel these symptoms have gotten worse since metoprolol was increased. + +PAST MEDICAL HISTORY: + + Detailed on our H&P form. Positive for elevated cholesterol, diabetes, glaucoma, cataracts, hypertension, heart disease, vertigo, stroke in May of 2005, congestive heart failure, CABG + + and cataract removed right eye. + +CURRENT MEDICATIONS: + + Detailed on the H&P form. + +PHYSICAL EXAMINATION: + + His blood pressure sitting down was 180/80 with a pulse rate of 56. Standing up blood pressure was 160/80 with a pulse rate of 56. His general exam and neurological exam were detailed on our H&P form. Pertinent positives on his neurological exam were decreased sensation in his left face, and left arm and leg. + +IMPRESSION AND PLAN: + +This lightheaded, he exquisitely denies vertigo, the vertigo that he has had in the past. He states this is more of a lightheaded type feeling. He did have a mild blood pressure drop here in the office. We are also concerned that bradycardia might be contributing to his feeling of lightheadedness. We are going to suggest that he gets a Holter monitor and he should speak to his general practitioner as well as his cardiologist regarding the lightheaded feeling. + +We will schedule him for the Holter monitor and refer him back to his cardiologist. \ No newline at end of file diff --git a/2858_Neurology.txt b/2858_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..ef1c254cc82484968469081b2789c52ff75b7aaa --- /dev/null +++ b/2858_Neurology.txt @@ -0,0 +1,49 @@ +CHIEF COMPLAINT: + + Headache. + +HPI: + + This is a 24-year-old man who was seen here originally on the 13th with a headache and found to have a mass on CT scan. He was discharged home with a follow up to neurosurgery on the 14th. Apparently, an MRI the next day showed that the mass was an aneurysm and he is currently scheduled for an angiogram in preparation for surgery. He has had headaches since the 13th and complains now of some worsening of his pain. He denies photophobia, fever, vomiting, and weakness of the arms or legs. + +PMH: + + As above. + +MEDS: + + Vicodin. + +ALLERGIES: + + None. + +PHYSICAL EXAM: + +BP 180/110 Pulse 65 RR 18 Temp 97.5. + +Mr. P is awake and alert, in no apparent distress. + +HEENT: Pupils equal, round, reactive to light, oropharynx moist, sclera clear. + +Neck: Supple, no meningismus. + +Lungs: Clear. + +Heart: Regular rate and rhythm, no murmur, gallop, or rub. + +Abdomen: Benign. + +Neuro: Awake and alert, motor strength normal, no numbness, normal gait, DTRs normal. Cranial nerves normal. + +COURSE IN THE ED: + +Patient had a repeat head CT to look for an intracranial bleed that shows an unchanged mass, no blood, and no hydrocephalus. I recommended an LP but he prefers not to have this done. He received morphine for pain and his headache improved. I've recommended admission but he has chosen to go home and come back in the morning for his scheduled angiogram. He left the ED against my advice. + +IMPRESSION: + + Headache, improved. Intracranial aneurysm. + +PLAN: + + The patient will return tomorrow am for his angiogram. \ No newline at end of file diff --git a/2861_Neurology.txt b/2861_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..0257780a487f3bf500d3fc8be3852ecc9e4a9a91 --- /dev/null +++ b/2861_Neurology.txt @@ -0,0 +1,55 @@ +CC: + +RLE weakness. + +HX: + +This 42y/o RHM was found 2/27/95 slumped over the steering wheel of the Fed Ex truck he was driving. He was cyanotic and pulseless according to witnesses. EMT evaluation revealed him to be in ventricular fibrillation and he was given epinephrine, lidocaine, bretylium and electrically defibrillated and intubated in the field. Upon arrival at a local ER his cardiac rhythm deteriorated and he required more than 9 counter shocks (defibrillation) at 360 joules per shock, epinephrine and lidocaine. This had no effect. He was then given intracardiac epinephrine and a subsequent electrical defibrillation placed him in atrial fibrillation. He was then taken emergently to cardiac catherization and was found to have normal coronary arteries. He was then admitted to an intensive care unit and required intraortic balloon pump pressure support via the right gorin. His blood pressure gradually improved and his balloon pump was discontinued on 5/5/95. Recovery was complicated by acute renal failure and liver failure. Initail CK=13,780, the CKMB fraction was normal at 0.8. + +On 3/10/95, the patient experienced CP and underwent cardiac catherization. This time he was found to have a single occlusion in the distal LAD with association inferior hypokinesis. Subsequent CK=1381 and CKMB=5.4 (elevated). The patient was amnestic to the event and for 10 days following the event. He was transferred to UIHC for cardiac electrophysiology study. + +MEDS: + +Nifedipine, ASA + + Amiodarone, Capoten, Isordil, Tylenol, Darvocet prn, Reglan prn, Coumadin, KCL + + SLNTG prn, CaCO3, Valium prn, Nubain prn. + +PMH: + + hypercholesterolemia. + +FHX: + + Father alive age 69 with h/o TIAs. Mother died age 62 and had CHF + + A-Fib, CAD. Maternal Grandfather died of an MI and had h/o SVT. Maternal Grandmother had h/o SVT. + +SHX: + +Married, 7 children, driver for Fed Ex. Denied tobacco/ETOH/illicit drug use. + +EXAM: + +BP112/74 HR64 RR16 Afebrile. + +MS: A&O to person, place and time. Euthymic with appropriate affect. + +CN: unremarkable. + +Motor: Hip flexion 3/5, Hip extension 5/5, Knee flexion5/5, Knee extension 2/5, Plantar flexion, extension, inversion and eversion 5/5. There was full strength thoughout BUE. + +Sensory: decreased PP/Vib/LT/TEMP about anterior aspect of thigh and leg in a femoral nerve distribution. + +Coord: poor and slowed HKS on right due to weakness. + +Station: no drift or Romberg sign. + +Gait: difficulty bearing weight on RLE. + +Reflexes: 1+/1+ throughout BUE. 0/2 patellae. 2/2 archilles. Plantar responses were flexor, bilaterally. + +COURSE: + + MRI Pelvis, 3/28/95, revealed increased T1 weighted signal within the right iliopsoas suggestive of hematoma. An intra-osseous lipoma was incidentally notice in the right sacrum. Neuropsychologic assessment showed moderately compromised anterograde verbal memory, and temporal orientation and retrograde recall were below expectations. These findings were consistent with mesial temporal dysfunction secondary to anoxic injury and were mild in lieu of his history. He underwent implantation of a Medtronic internal cardiac difibrillator. His cardiac electrophysiology study found no inducible ventricular tachycardia or fibrillation. He suffered mild to moderate permanent RLE weakness, especially involving the quadriceps. His femoral nerve compression had been present to long to warrant decompression. EMG/NCV studies revealed severe axonal degeneration. \ No newline at end of file diff --git a/2866_Neurology.txt b/2866_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..206cd2dd20a847ccb1a1471a2cd423feacd21913 --- /dev/null +++ b/2866_Neurology.txt @@ -0,0 +1,59 @@ +CC: + + Slowing of motor skills and cognitive function. + +HX: + +This 42 y/o LHM presented on 3/16/93 with gradually progressive deterioration of motor and cognitive skills over 3 years. He had difficulty holding a job. His most recent employment ended 3 years ago as he was unable to learn the correct protocols for the maintenance of a large conveyer belt. Prior to that, he was unable to hold a job in the mortgage department of a bank as could not draw and figure property assessments. For 6 months prior to presentation, he and his wife noted (his) increasingly slurred speech and slowed motor skills (i.e. dressing himself and house chores). His walk became slower and he had difficulty with balance. He became anhedonic and disinterested in social activities, and had difficulty sleeping for frequent waking and restlessness. His wife noticed "fidgety movements" of his hand and feet. + +He was placed on trials of Sertraline and Fluoxetine for depression 6 months prior to presentation by his local physician. These interventions did not appear to improve his mood and affect. + +MEDS: + + Fluoxetine. + +PMH: + +1)Right knee arthroscopic surgery 3 yrs ago. 2)Vasectomy. + +FHX: + + Mother died age 60 of complications of Huntington Disease (dx at UIHC). MGM and two MA's also died of Huntington Disease. His 38 y/o sister has attempted suicide twice. + +He and his wife have 2 adopted children. + +SHX: + +unemployed. 2 years of college education. Married 22 years. + +ROS: + +No history of Dopaminergic or Antipsychotic medication use. + +EXAM: + + Vital signs normal. + +MS: A&O to person, place, and time. Dysarthric speech with poor respiratory control. + +CN: Occasional hypometric saccades in both horizontal directions. No vertical gaze abnormalities noted. Infrequent spontaneous forehead wrinkling and mouth movements. The rest of the CN exam was unremarkable. + +Motor: Full strength throughout and normal muscle tone and bulk. Mild choreiform movements were noted in the hands and feet. + +Sensory: unremarkable. + +Coord: unremarkable. + +Station/Gait: unremarkable, except that during tandem walking mild dystonic and choreiform movements of BUE became more apparent. + +Reflexes: 2/2 throughout. Plantar responses were flexor, bilaterally. + +There was no motor impersistence on tongue protrusion or hand grip. + +COURSE: + + He was thought to have early manifestations of Huntington Disease. A HCT was unremarkable. Elavil 25mg qhs was prescribed. Neuropsychologic assessment revealed mild anterograde memory loss only. + +His chorea gradually worsened during the following 4 years. He developed motor impersistence and more prominent slowed saccadic eye movements. His mood/affect became more labile. + +6/5/96 genetic testing revealed a 45 CAg trinucleotide repeat band consistent with Huntington Disease. MRI brain, 8/23/96, showed caudate nuclei atrophy, bilaterally. \ No newline at end of file diff --git a/2867_Neurology.txt b/2867_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..4608b6cfeb85a04ea0dc9f826df4093f54c3a811 --- /dev/null +++ b/2867_Neurology.txt @@ -0,0 +1,97 @@ +CHIEF COMPLAINT: + + "A lot has been thrown at me." + +The patient is interviewed with husband in room. + +HISTORY OF PRESENT ILLNESS: + + This is a 69-year-old Caucasian woman with a history of Huntington disease, who presented to Hospital four days ago after an overdose of about 30 Haldol tablets 5 mg each and Tylenol tablet 325 mg each, 40 tablets. She has been on the medical floor for monitoring and is medically stable and was transferred to the psychiatric floor today. The patient states she had been thinking about suicide for a couple of weeks. Felt that her Huntington disease had worsened and she wanted to spare her family and husband from trouble. Reports she has been not socializing with her family because of her worsening depression. Husband notes that on Monday after speaking to Dr. X, they had been advised to alternate the patient's Pamelor (nortriptyline) to every other day because the patient was reporting dry mouth. They did as they have instructed and husband feels this may have had some factor on her worsening depression. The patient decided to ingest the pills when her husband went to work on Friday. She thought Friday would be a good day because there would be less medical people working so her chances of receiving medical care would be lessened. Her husband left around 7 in the morning and returned around 11 and found her sleeping. About 30 minutes after his arrival, he found the empty bottles and woke up the patient to bring her to the hospital. + +She says she wishes she would have died, but is happy she is alive and is currently not suicidal because she notes her sons may be have to be tested for the Huntington gene. She does not clearly explain how this has made her suicidality subside. + +This is the third suicide attempt in the last two months for this patient. About two months ago, the patient took an overdose of Tylenol and some other medication, which the husband and the patient are not able to recall. She was taken to Southwest Memorial Hermann Hospital. A few weeks ago, the patient tried to shoot herself and the gun was fired and there is a blow-hole in the floor. Husband locked the gun after that and she was taken to Bellaire Hospital. The patient has had three psychiatric admissions in the past two months, two to Southwest Memorial and one to Bellaire Hospital for 10 days. She sees Dr. X once or twice weekly. He started seeing her after her first suicide attempt. + +The patient's husband and the patient state that until March 2009, the patient was independent, was driving herself around and was socially active. Since then she has had worsening of her Huntington symptoms including short-term memory loss. At present, the patient could not operate the microwave or operate her cell phone and her husband says that she is progressively more withdrawn, complains about anxiety, and complains about shortness of breath. The patient notes that she has had depressive symptoms of quitting social life, the patient being withdrawn for the past few months and excessive worry about her Huntington disease. + +The patient's mother passed away 25 years ago from Huntington's. Her grandmother passed away 50 years ago and two brothers also passed away of Huntington's. The patient has told her husband that she does not want to go that way. The patient denies auditory or visual hallucinations, denies paranoid ideation. The husband and the patient deny any history of manic or hypomanic symptoms in the past. + +PAST PSYCHIATRIC HISTORY: + + As per the HPI + + this is her third suicide attempt in the last two months and started seeing Dr. X. She has a remote history of being on Lexapro for depression. + +MEDICATIONS: + + Her medications on admission, alprazolam 0.5 mg p.o. b.i.d. + + Artane 2 mg p.o. b.i.d. + + Haldol 2.5 mg p.o. t.i.d. + + Norvasc 10 mg p.o. daily, nortriptyline 50 mg p.o. daily. Husband has stated that the patient's chorea becomes better when she takes Haldol. Alprazolam helps her with anxiety symptoms. + +PAST MEDICAL HISTORY: + + Huntington disease, symptoms of dementia and hypertension. She has an upcoming appointment with the Neurologist. Currently, does have a primary care physician and _______ having an outpatient psychiatrist, Dr. X, and her current Neurologist, Dr. Y. + +ALLERGIES: + + CODEINE AND KEFLEX. + +FAMILY MEDICAL HISTORY: + +Strong family history for Huntington disease as per the HPI. Mother and grandmother died of Huntington disease. Two young brothers also had Huntington disease. + +FAMILY PSYCHIATRIC HISTORY: + + The patient denies history of depression, bipolar, schizophrenia, or suicide attempts. + +SOCIAL HISTORY: + +The patient lives with her husband of 48 years. She used to be employed as a registered nurse. Her husband states that she does have a pattern of self-prescribing for minor illness, but does not think that she has ever taken muscle relaxants or sedative medications without prescriptions. She rarely drinks socially. She denies any illicit substance usage. Her husband reportedly gives her medication daily. Has been proactive in terms of seeking mental health care and medical care. The patient and husband report that from March 2009, she has been relatively independent, more socially active. + +MENTAL STATUS EXAM: + +This is an elderly woman appearing stated age. Alert and oriented x4 with poor eye contact. Appears depressed, has psychomotor retardation, and some mild involuntary movements around her lips. She is cooperative. Her speech is of low volume and slow rate and rhythm. Her mood is sad. Her affect is constricted. Her thought process is logical and goal-directed. Her thought content is negative for current suicidal ideation. No homicidal ideation. No auditory or visual hallucinations. No command auditory hallucinations. No paranoia. Insight and judgment are fair and intact. + +LABORATORY DATA: + + A CT of the brain without contrast, without any definite evidence of acute intracranial abnormality. U-tox positive for amphetamines and tricyclic antidepressants. Acetaminophen level 206.7, alcohol level 0. The patient had a leukocytosis with white blood cell of 15.51, initially TSH 1.67, T4 10.4. + +ASSESSMENT: + + This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months. She took 30 tablets of Haldol and 40 tablets of Tylenol. At present, the patient is without suicidal ideation. She reports that her worsening depression has coincided with her worsening Huntington disease. She is more hopeful today, feels that she may be able to get help with her depression. + +The patient was admitted four days ago to the medical floor and has subsequently been stabilized. Her liver function tests are within normal limits. + +AXIS I: Major depressive disorder due to Huntington disease, severe. Cognitive disorder, NOS. + +AXIS II: Deferred. + +AXIS III: Hypertension, Huntington disease, status post overdose. + +AXIS IV: Chronic medical illness. + +AXIS V: 30. + +PLAN + +1. Safety. The patient would be admitted on a voluntary basis to Main-7 North. She will be placed on every 15-minute checks with suicidal precautions. + +2. Primary psychiatric issues/medical issues. The patient will be restarted as per written by the consult service for Prilosec 200 mg p.o. daily, nortriptyline 50 mg p.o. nightly, Haldol 2 mg p.o. q.8h. + + Artane 2 mg p.o. daily, Xanax 0.5 mg p.o. q.12h. + + fexofenadine 180 mg p.o. daily, Flonase 50 mcg two sprays b.i.d. + + amlodipine 10 mg p.o. daily, lorazepam 0.5 mg p.o. q.6h. p.r.n. anxiety and agitation. + +3. Substance abuse. No acute concern for alcohol or benzo withdrawal. + +4. Psychosocial. Team will update and involve family as necessary. + +DISPOSITION: + + The patient will be admitted for evaluation, observation, treatment. She will participate in the milieu therapy with daily rounds, occupational therapy, and group therapy. We will place occupational therapy consult and social work consults. \ No newline at end of file diff --git a/2869_Neurology.txt b/2869_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..2b35e2e90c9faf1f2fe5151dd7f160049370122f --- /dev/null +++ b/2869_Neurology.txt @@ -0,0 +1,61 @@ +CC: + +Depressed mental status. + +HX: + +29y/o female fell down a flight of stairs on 2/20/95, striking the right side of her head. She then walked over to and lay down on a living room couch. She was found there, the next morning, by her boyfriend, poorly responsive and amidst a coffee ground like emesis. She was taken to a local ER and HCT revealed a right supraorbital fracture, right SDH and left SAH. Spine X-rays revealed a T12 vertebral body fracture. There were retinal hemorrhages, OU. She continued to be minimally responsive and was transferred to UIHC for lack of insurance and for neurologic/neurosurgical care. + +MEDS: + + (on transfer): Dilantin, Zantac, Proventil MDI + + Tylenol. + +PMH: + + 1)pyelonephritis, 2) multiple STD's, 3) Polysubstance Abuse (ETOH + + MJ + + Amphetamine) + + 4)G5P4. + +FHX: + + unknown. + +SHX: + +polysubstance abuse. smoked 1 pack per day for 15years. + +EXAM: + +BP127/97, HR83, RR25, 37.2C,MS: Minimal to no spontaneous speech. Unresponsive to verbal commands. Lethargic and somnolent. Groaned "yes" inappropriately. + +CN: Pupils 4/4 decreasing to 2/2 on exposure to light. VFFTT. Retinal hemorrhages, OU. EOM difficult to assess. Facial movement appeared symmetric. Tongue midline. Corneal and gag responses were intact. + +MOTOR: no spontaneous movement. withdrew extremities to noxious stimulation (e.g. deep nail bed pressure). + +Sensory: withdrew to noxious stimuli. + +Coord/Station/Gait: not tested. + +Reflexes: 2+/2+ BUE. 2/2 BLE. Babinski signs were present, bilaterally. + +HEENT: Periorbital and upper lid ecchymoses about the right eye. Scleral hemorrhage, OD. + +GEN EXAM: mild bruising of the extremities. + +COURSE: + +2/27/95 HCT revealed a small liner high attenuation area lateral to the right parietal lobe with subtle increased attenuation of the tentorium cerebelli. These findings were felt to represent a right subdural hematoma and possible subarachnoid hemorrhage. + +2/28/95 brain MRI revealed: 1)a small right-sided SDH + + 2) Abnormal signal in the right occipital lobe with effacement of the gyri and sulci in the right PCA division most likely representing ischemic/vascular injury, 3)abnormal signal within the right basal ganglia/caudate nucleus consistent with ischemia, 4) abnormal signal in the uncal portion of the right frontal lobe consistent with contusion, 5) small parenchymal hemorrhage in the inferior anterior right temporal lobe, and 6) opacification of the right maxillary sinus. + +EEG + + 2/28/95, was abnormal with occasional sharp transients in the left temporal region, and irregular (more or less continuous) right greater than left delta slow waves and decreased background activity in the right hemisphere: the findings were consistent with focal pathology on the right, seizure tendency in the left temporal region, and bilateral cerebral dysfunction. By the time of discharge, 4/17/95, she was verbalizing one or two words and required assistance with feeding and ambulation. She could not function independently. \ No newline at end of file diff --git a/2871_Neurology.txt b/2871_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..b48d347e3f8cd6ff7c8eecf4b1c6f2e69f409f59 --- /dev/null +++ b/2871_Neurology.txt @@ -0,0 +1,79 @@ +CC: + + HA and vision loss. + +HX: + +71 y/o RHM developed a cataclysmic headache on 11/5/92 associated with a violent sneeze. The headache lasted 3-4 days. On 11/7/92, he had acute pain and loss of vision in the left eye. Over the following day his left pupil enlarged and his left upper eyelid began to droop. He was seen locally and a brain CT showed no sign of bleeding, but a tortuous left middle cerebral artery was visualized. The patient was transferred to UIHC 11/12/92. + +FHX: + + HTN + + stroke, coronary artery disease, melanoma. + +SHX: + + Quit smoking 15 years ago. + +MEDS: + + Lanoxin, Capoten, Lasix, KCL + + ASA + + Voltaren, Alupent MDI + +PMH: + +CHF + + Atrial Fibrillation, Obesity, Anemia, Duodenal Ulcer, Spinal AVM resection 1986 with residual T9 sensory level, hyperreflexia and bilateral babinski signs, COPD. + +EXAM: + +35.5C, BP 140/91, P86, RR20. Alert and oriented to person, place, and time. CN: No light perception OS + + Pupils: 3/7 decreasing to 2/7 on exposure to light (i.e. + + fixed/dilated pupil OS). Upon neutral gaze the left eye deviated laterally and inferiorly. There was complete ptosis OS. On downward gaze their was intorsion OS. The left eye could not move superiorly, medially or effectively downward, but could move laterally. EOM were full OD. The rest of the CN exam was unremarkable. Motor, Coordination, Station and Gait testing were unremarkable. Sensory exam revealed decreased pinprick and light touch below T9 (old). Muscle stretch reflexes were increased (3+/3+) in both lower extremities and there were bilateral babinski signs (old). The upper extremity reflexes were symmetrical (2/2). Cardiovascular exam revealed an irregularly irregular rhythm and lung sounds were coarse bilaterally. The rest of the general exam was unremarkable. + +LAB: + + CBC + + PT/PTT + + General Screen were unremarkable except for a BUN 21mg/DL. CSF: protein 88mg/DL + + glucose 58mg/DL + + RBC 2800/mm3, WBC 1/mm3. ANA + + RF + + TSH + + FT4 were WNL. + +IMPRESSION: + + CN3 palsy and loss of vision. Differential diagnosis: temporal arteritis, aneurysm, intracranial mass. + +COURSE: + + The outside Brain CT revealed a tortuous left MCA. A four-vessel cerebral angiogram revealed a dolichoectatic basilar artery and tortuous LICA. There was no evidence of aneursym. Transesophageal Echocardiogram revealed atrial enlargement only. Neuroopthalmologic evaluation revealed: Loss of color vision and visual acuity OS + + RAPD OS + + bilateral optic disk pallor (OS > OD) + + CN3 palsy and bilateral temporal field loss, OS >> OD . ESR + + CRP + + MRI were recommended to rule out temporal arteritis and intracranial mass. ESR 29mm/Hr, CRP 4.3mg/DL (high) + + The patient was placed on prednisone. Temporal artery biopsy showed no evidence of vasculitis. MRI scan could not be obtained due to patient weight. Sellar CT was done instead: coronal sections revealed sellar enlargement and upward bowing of the diaphragm sella suggesting a pituitary mass. In retrospect sellar enlargement could be seen on the angiogram X-rays. Differential consideration was given to cystic pituitary adenoma, noncalcified craniopharyngioma, or Rathke's cleft cyst with solid component. The patient refused surgery. He was seen in Neuroopthalmology Clinic 2/18/93 and was found to have mild recovery of vision OS and improved visual fields. Aberrant reinnervation of the 3rd nerve was noted as there was constriction of the pupil (OS) on adduction, downgaze and upgaze. The upper eyelid, OS + + elevated on adduction and down gaze, OS. EOM movements were otherwise full and there was no evidence of ptosis. In retrospect he was felt to have suffered pituitary apoplexy in 11/92. \ No newline at end of file diff --git a/2874_Neurology.txt b/2874_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..aeb70c8ec03dbb8f0a8fba5cc7437f085ada0194 --- /dev/null +++ b/2874_Neurology.txt @@ -0,0 +1,95 @@ +CC: + + Dysarthria,HX: + +This 52y/o RHF was transferred from a local hospital to UIHC on 10/28/94 with a history of progressive worsening of vision, dysarthria, headache, and incoordination beginning since 2/94. Her husband recalled her first difficulties became noticeable after a motor vehicle accident in 2/94. She was a belted passenger in a car struck at a stop. There was no reported head or neck injury or alteration of consciousness. She was treated and released from a local ER the same day. Her husband noted the development of mild dysarthria, incoordination, headache and exacerbation of preexisting lower back pain within 2 week of the accident. In 4/94 she developed stress urinary incontinence which spontaneously resolved in June. In 8/94, her HA changed from a dull constant aching in the bitemporal region to a sharper constant pain in the nuchal/occipital area. She also began experiencing increased blurred vision, worsening dysarthria and difficulty hand writing. In 9/94 she was evaluated by a local physician. Examination then revealed incoordination, generalized fatigue, and dysarthria. Soon after this she became poorly arousable and increasingly somnolent. She had difficulty walking and generalized weakness. On 10/14/94, she lost the ability to walk by herself. Evaluation at a local hospital revealed: 1)Normal electronystagmography, 2)two lumbar punctures which revealed some atypical mononuclear cells suggestive of "tumor or reactive lymphocytosis." One of these CSF analysis showed: Glucose 16, Protein 99, WBC 14, RBC 114. Echocardiogram was normal. Bone marrow biopsy was normal except for decreased iron. Abdominal-Pelvic CT scan, CXR + + Mammogram, PPD + + ANA + + TFT + + and RPR were unremarkable. A 10/31/94 MRI brain scan a 5x10mm area of increased signal on T2 weighted images in the right remporal lobe lateral to the anterior aspect of the temporal horn, right posterolateral aspect of the midbrain, pons, and bilateral inferior surface of the cerebellum involving gray and white matter. These areas did not enhance with gadolinium contrast on T1 weighted images. + +MEDS: + +none. + +PMH: + + 1)G3P3, 2)last menses one year ago. + +FHX: + + Mother suffered stroke in her 70's. DM and Htn in family. + +SHX: + + Married, Secretary, No h/o tobacco/ETOH/illicit drug use. + +ROS: + + no weight loss, fever, chills, nightsweats, cough, dysphagia. + +EXAM: + + BP139/74, HR 90, RR20, 36.8C,MS: Drowsy to somnolent, occasionally "giddy." Oriented to person, place, time. Minimal dysarthric speech, but appropriate. MMSE 27/30 (copy of exam not in chart). + +CN: Pupils 4/4 decreasing to 2/2 on exposure to light. Optic disks were flat and without sign of papilledema. VFFTC. EOM intact. No nystagmus. The rest of the CN exam was unremarkable. + +Motor: 5/5 strength throughout. Normal muscle tone and bulk. + +Sensory: No deficit to LT/PP/VIB/PROP. + +Coord: difficulty with RAM in BUE + + and ataxia on FNF and HKS in all extremities. + +Station: Romberg sign present. + +Gait: unsteady, wide-based, with notable difficulty on TW + + TT and HW. + +Reflexes: 2/2 BUE + + 0/1 patellae, trace at both archilles, Plantars responses were flexor, bilaterally. + +Gen Exam: unremarkable. + +COURSE: + + CSF analysis by lumbar puncture, 10/31/94: Protein 131mg/dl (normal 15-45) + + Albumin 68 (normal 14-20) + + IgG10mg/dl (normal <6.2) + + IgG index -O.1mg/24hr (normal) + +,No oligoclonal bands seen, WBC 33 (19lymphocytes, 1 neutrophil) + + RBC 29, Glucose 13, Cultures (bacteria, fungal, AFB) were negative, crytococcal Ag negative. The elevated CSF total protein, IgG, and albumin suggested breakdown of the blood brain barrier or blockage of CSF flow. The normal IgG synthesis rate and lack of oligoclonal banding did not suggest demylination. A second CSF analysis on 11/2/94 revealed similar findings; and in addition Anti-purkinje cell and Anti-neuronal antibodies (Yo and Ho) were not found; Beta-2 microglobulin was 1.8 (normal); histoplasmosis Ag negative. Serum ACE + + SPEP + + Urine histoplasmin were negative. + +Neuropsychologic assessment, 10/28/94, raised a question of a demential syndrome, but given her response style on the MMPI (marked defensiveness, with unwillingness to admit to even very common human faults) prevented such a diagnosis. Severe defects in memory, fine motor skills, and constructional praxis were noted. + +Chest-Abdominal-Pelvic CT scans were negative. 11/4/94 cerebral angiogram noted variable caliber in the RMCA + + LACA and Left AICA distributions. It was intially thought that thismight be suggestive of a vasculopathy and she was treated with a short course of IV steroids. Temporal artery biopsy was unremarkable. + +She underwent multiple MRI brain scans at UIHC: 11/4/94, 11/9/94, 11/16/94. All scans consistently showed increase in T2 signal in the brainstem, cerebellar peduncles and temporal lobes bilaterally. These areas did not enhance with gadolinium contrast. These findings were felt most suggestive of glioma. + +She underwent left temporal lobe brain biopsy on 11/10/94: This study was inconclusive and showed evidence of atypical mononuclear cells and lymphocytes in the perivascular and subarachnoid spaces. Despite cytologic atypia the cells were felt to be reactive in nature, since immunohistochemical stains failed to disclose lymphoid clonality or non-leukocytic phenomena. Little sign of vasculopathy or tumor was found. Bacterial, fungal + + HSV + + CMV and AFB cultures were negative. HSV + + and VZV antigen was negative. + +Her neurological state progressively worsened throughout her hospital stay. By time of discharge, 12/2/94, she was very somnolent and difficult to arouse and required NGT feeding and 24hour supportive care. She was made DNR after family request prior to transfer to a care facility. \ No newline at end of file diff --git a/2876_Neurology.txt b/2876_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..f23dbbbaa2c3fd7b25fb71abe5a458217aa2ee33 --- /dev/null +++ b/2876_Neurology.txt @@ -0,0 +1,33 @@ +PREOPERATIVE DIAGNOSIS: + + Right occipital arteriovenous malformation. + +POSTOPERATIVE DIAGNOSIS: + + Right occipital arteriovenous malformation. + +PROCEDURE PERFORMED: + + CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking. + +Please note no qualified resident was available to assist in the procedure. + +INDICATION: + + The patient is a 30-year-old male with a right occipital AVM. He was referred for stereotactic radiosurgery. The risks of the radiosurgical treatment were discussed with the patient including, but not limited to, failure to completely obliterate the AVM + + need for additional therapy, radiation injury, radiation necrosis, headaches, seizures, visual loss, or other neurologic deficits. The patient understands these risks and would like to proceed. + +PROCEDURE IN DETAIL: + + The patient arrived to Outpatient CyberKnife Suite one day prior to the treatment. He was placed on the treatment table. The Aquaplast mask was constructed. Initial imaging was obtained by the CyberKnife system. The patient was then transported over to the CT scanner at Stanford. Under the supervision of Dr. X, 125 mL of Omnipaque 250 contrast was administered. Dr. X then supervised the acquisition of 1.2-mm contiguous axial CT slices. These images were uploaded over the hospital network to the treatment planning computer, and the patient was discharged home. + +Treatment plan was then performed by me. I outlined the tumor volume. Inverse treatment planning was used to generate the treatment plan for this patient. This resulted in a total dose of 20 Gy delivered to 84% isodose line using a 12.5 mm collimator. The maximum dose within this center of treatment volume was 23.81 Gy. The volume treated was 2.972 mL, and the treated lesion dimensions were 1.9 x 2.7 x 1.6 cm. The volume treated at the reference dose was 98%. The coverage isodose line was 79%. The conformality index was 1.74 and modified conformality index was 1.55. The treatment plan was reviewed by me and Dr. Y of Radiation Oncology, and the treatment plan was approved. + +On the morning of May 14, 2004, the patient arrived at the Outpatient CyberKnife Suite. He was placed on the treatment table. The Aquaplast mask was applied. Initial imaging was used to bring the patient into optimal position. The patient underwent stereotactic radiosurgery to deliver the 20 Gy to the AVM margin. He tolerated the procedure well. He was given 8 mg of Decadron for prophylaxis and discharged home. + +Followup will consist of an MRI scan in 6 months. The patient will return to our clinic once that study is completed. + +I was present and participated in the entire procedure on this patient consisting of CT-guided frameless stereotactic radiosurgery for the right occipital AVM. + +Dr. X was present during the entire procedure and will be dictating his own operative note. \ No newline at end of file diff --git a/2882_Neurology.txt b/2882_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..6c74d8909ca1fd5e4365f09f83c28e204e427c94 --- /dev/null +++ b/2882_Neurology.txt @@ -0,0 +1,49 @@ +PREOPERATIVE DIAGNOSES: + +1. Epidural hematoma, cervical spine. + +2. Status post cervical laminectomy, C3 through C7 postop day #10. + +3. Central cord syndrome. + +4. Acute quadriplegia. + +POSTOPERATIVE DIAGNOSES: + +1. Epidural hematoma, cervical spine. + +2. Status post cervical laminectomy, C3 through C7 postop day #10. + +3. Central cord syndrome. + +4. Acute quadriplegia. + +PROCEDURE PERFORMED: + +1. Evacuation of epidural hematoma. + +2. Insertion of epidural drain. + +ANESTHESIA: + + General. + +COMPLICATIONS: + +None. + +ESTIMATED BLOOD LOSS: + +200 cc. + +HISTORY: + +This is a 64-year-old female who has had an extensive medical history beginning with coronary artery bypass done on emergent basis while she was in Maryland in April of 2003 after having myocardial infarction. She was then transferred to Beaumont Hospital, at which point, she developed a sternal abscess. The patient was treated for the abscess in Beaumont and then subsequently transferred to some other type of facility near her home in Warren, Michigan at which point, she developed a second what was termed minor myocardial infarction. + +The patient subsequently recovered in a Cardiac Rehab Facility and approximately two weeks later, brings us to the month of August, at which time she was at home ambulating with a walker or a cane, and then sustained a fall and at that point she was unable to walk and had acute progressive weakness and was identified as having a central cord syndrome based on an MRI + + which showed record signal change. The patient underwent cervical laminectomy and seemed to be improving subjectively in terms of neurologic recovery, but objectively there was not much improvement. Approximately 10 days after the surgery, brings us to today's date, the health officer was notified of the patient's labored breathing. When she examined the patient, she also noted that the patient was unable to move her extremities. She was concerned and called the Orthopedic resident who identified the patient to be truly quadriplegic. I was notified and ordered the operative crew to report immediately and recommended emergent decompression for the possibility of an epidural hematoma. On clinical examination, there was swelling in the posterior aspect of the neck. The patient has no active movement in the upper and lower extremity muscle groups. Reflexes are absent in the upper and lower extremities. Long track signs are absent. Sensory level is at the C4 dermatome. Rectal tone is absent. I discussed the findings with the patient and also the daughter. We discussed the possibility of this is permanent quadriplegia, but at this time, the compression of the epidural space was warranted and certainly for exploration reasons be sure that there is a hematoma there and they have agreed to proceed with surgery. They are aware that it is possible she had known permanent neurologic status regardless of my intervention and they have agreed to accept this and has signed the consent form for surgery. + +OPERATIVE PROCEDURE: + +The patient was taken to OR #1 at ABCD General Hospital on a gurney. Department of Anesthesia administered fiberoptic intubation and general anesthetic. A Foley catheter was placed in the bladder. The patient was log rolled in a prone position on the Jackson table. Bony prominences were well padded. The patient's head was placed in the prone view anesthesia head holder. At this point, the wound was examined closely and there was hematoma at the caudal pole of the wound. Next, the patient was prepped and draped in the usual sterile fashion. The previous skin incision was reopened. At this point, hematoma properly exits from the wound. All sutures were removed and the epidural spaces were encountered at this time. The self-retaining retractors were placed in the depth of the wound. Consolidated hematoma was now removed from the wound. Next, the epidural space was encountered. There was no additional hematoma in the epidural space or on the thecal sac. A curette was carefully used to scrape along the thecal sac and there was no film or lining covering the sac. The inferior edge of the C2 lamina was explored and there was no compression at this level and the superior lamina of T1 was explored and again no compression was identified at this area as well. Next, the wound was irrigated copiously with one liter of saline using a syringe. The walls of the wound were explored. There was no active bleeding. Retractors were removed at this time and even without pressure on the musculature, there was no active bleeding. A #19 French Hemovac drain was passed percutaneously at this point and placed into the epidural space. Fascia was reapproximated with #1 Vicryl sutures, subcutaneous tissue with #3-0 Vicryl sutures. Steri-Strips covered the incision and dressing was then applied over the incision. The patient was then log rolled in the supine position on the hospital gurney. She remained intubated for airway precautions and transferred to the recovery room in stable condition. Once in the recovery room, she was alert. She was following simple commands and using her head to nod, but she did not have any active movement of her upper or lower extremities. Prognosis for this patient is guarded. \ No newline at end of file diff --git a/2888_Neurology.txt b/2888_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..71b7bc2e6333874d89636542da296271e2a85790 --- /dev/null +++ b/2888_Neurology.txt @@ -0,0 +1,17 @@ +REFERRING DIAGNOSIS: + + Motor neuron disease. + +PERTINENT HISTORY AND EXAMINATION: + + Briefly, the patient is an 83-year-old woman with a history of progression of dysphagia for the past year, dysarthria, weakness of her right arm, cramps in her legs, and now with progressive weakness in her upper extremities. + +SUMMARY: + +The right median sensory response showed a borderline normal amplitude for age with mild slowing of conduction velocity. The right ulnar sensory amplitude was reduced with slowing of the conduction velocity. The right radial sensory amplitude was reduced with slowing of the conduction velocity. The right sural and left sural sensory responses were absent. The right median motor response showed a prolonged distal latency across the wrist, with proximal slowing. The distal amplitude was very reduced, and there was a reduction with proximal stimulation. The right ulnar motor amplitude was borderline normal, with slowing of the conduction velocity across the elbow. The right common peroneal motor response showed a decreased amplitude when recorded from the EDB + + with mild slowing of the proximal conduction velocity across the knee. The right tibial motor response showed a reduced amplitude with prolongation of the distal latency. The left common peroneal response recorded from the EDB showed a decreased amplitude with mild distal slowing. The left tibial motor response showed a decreased amplitude with a borderline normal distal latency. The minimum F-wave latencies were normal with the exception of a mild prolongation of the ulnar F-wave latency, and the tibial F-wave latency as indicated above. With repetitive nerve stimulation, there was no significant decrement noted in either the right nasalis or the right trapezius muscles. Concentric needle EMG studies were performed in the right lower extremity, right upper extremity, thoracic paraspinals, and in the tongue. There was evidence of increased insertional activity in the right tibialis anterior muscle, with evidence of fasciculations noted in several lower and upper extremity muscles and in the tongue. In addition, there was evidence of increased amplitude, long duration and polyphasic motor units with a decreased recruitment noted in most muscles tested as indicated in the table above. + +INTERPRETATION: + + Abnormal electrodiagnostic study. There is electrodiagnostic evidence of a disorder of the anterior motor neurons affecting at least four segments. There is also evidence of a more generalized neuropathy that seems to be present in both the upper and lower extremities. There is also evidence of a right median mononeuropathy at the wrist and a right ulnar neuropathy at the elbow. Even despite the patient's age, the decrease in sensory responses is concerning, and makes it difficult to be certain about the diagnosis of motor neuron disease. However, the overall changes on the needle EMG would be consistent with a diagnosis of motor neuron disease. The patient will return for further evaluation. \ No newline at end of file diff --git a/2890_Neurology.txt b/2890_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..e3d771a9599ca63e3cab63ff0101dca604f27520 --- /dev/null +++ b/2890_Neurology.txt @@ -0,0 +1,19 @@ +HISTORY: + + The patient is a 34-year-old right-handed female who states her symptoms first started after a motor vehicle accident in September 2005. She may have had a brief loss of consciousness at the time of the accident since shortly thereafter she had some blurred vision, which lasted about a week and then resolved. Since that time she has had right low neck pain and left low back pain. She has been extensively worked up and treated for this. MRI of the C & T spine and LS spine has been normal. She has improved significantly, but still complains of pain. In June of this year she had different symptoms, which she feels are unrelated. She had some chest pain and feeling of tightness in the left arm and leg and face. By the next morning she had numbness around her lips on the left side and encompassing the whole left arm and leg. Symptoms lasted for about two days and then resolved. However, since that time she has had intermittent numbness in the left hand and leg. The face numbness has completely resolved. Symptoms are mild. She denies any previous similar episodes. She denies associated dizziness, vision changes incoordination, weakness, change in gait, or change in bowel or bladder function. There is no associated headache. + +Brief examination reveals normal motor examination with no pronator drift and no incoordination. Normal gait. Cranial nerves are intact. Sensory examination reveals normal facial sensation. She has normal and symmetrical light touch, temperature, and pinprick in the upper extremities. In the lower extremities she has a feeling of dysesthesia in the lateral aspect of the left calf into the lateral aspect of the left foot. In this area she has normal light touch and pinprick. She describes it as a strange unusual sensation. + +NERVE CONDUCTION STUDIES: + + Motor and sensory distal latencies, evoked response amplitudes, conduction velocities, and F-waves are normal in the left arm and leg. + +NEEDLE EMG: + + Needle EMG was performed in the left leg, lumbosacral paraspinal, right tibialis anterior, and right upper thoracic paraspinal muscles using a disposable concentric needle. It revealed normal insertional activity, no spontaneous activity, and normal motor unit action potential form in all muscles tested. + +IMPRESSION: + + This electrical study is normal. There is no evidence for peripheral neuropathy, entrapment neuropathy, plexopathy, or lumbosacral radiculopathy. EMG was also performed in the right upper thoracic paraspinal where she has experienced a lot of pain since the motor vehicle accident. This was normal. + +Based on her history of sudden onset of left face, arm, and leg weakness as well as a normal EMG and MRI of her spine I am concerned that she had a central event in June of this year. Symptoms are now very mild, but I have ordered an MRI of the brain with and without contrast and MRA of the head and neck with contrast to further elucidate her symptoms. Once she has the test done she will phone me and further management will be based on the results. \ No newline at end of file diff --git a/2891_Neurology.txt b/2891_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..1e2d031dbaab090be58ec53ed12558efe6247543 --- /dev/null +++ b/2891_Neurology.txt @@ -0,0 +1,21 @@ +HISTORY: + + This is a digital EEG performed on a 75-year-old male with seizures. + +BACKGROUND ACTIVITY: + + The background activity consists of a 8 Hz to 9 Hz rhythm arising in the posterior head region. This rhythm is also accompanied by some beta activity which occurs infrequently. There are also muscle contractions occurring at 4 Hz to 5 Hz which suggests possible Parkinson's. Part of the EEG is obscured by the muscle contraction artifact. There are also left temporal sharps occurring infrequently during the tracing. At one point of time, there was some slowing occurring in the right frontal head region. + +ACTIVATION PROCEDURES: + + Photic stimulation was performed and did not show any significant abnormality. + +SLEEP PATTERNS: + + No sleep architecture was observed during this tracing. + +IMPRESSION: + + This awake/alert/drowsy EEG is abnormal due to the presence of slowing in the right frontal head region, due to the presence of sharps arising in the left temporal head region, and due to the tremors. The slowing can be consistent with underlying structural abnormalities, so a stroke, subdural hematoma, etc. + + should be ruled out. The tremor probably represents a Parkinson's tremor and the sharps arising in the left temporal head region can potentially give way to seizures or may also represent underlying structural abnormalities, so clinical correlation is recommended. \ No newline at end of file diff --git a/2894_Neurology.txt b/2894_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..863f31560a69e9fa480a5aeef1f464875cffb331 --- /dev/null +++ b/2894_Neurology.txt @@ -0,0 +1,9 @@ +PROCEDURE: + + A 21-channel digital electroencephalogram was performed on a patient in the awake state. Per the technician's notes, the patient is taking Depakene. + +The recording consists of symmetric 9 Hz alpha activity. Throughout the recording, repetitive episodes of bursts of 3 per second spike and wave activity are noted. The episodes last from approximately1 to 7 seconds. The episodes are exacerbated by hyperventilation. + +IMPRESSION: + + Abnormal electroencephalogram with repetitive bursts of 3 per second spike and wave activity exacerbated by hyperventilation. This activity could represent true petit mal epilepsy. Clinical correlation is suggested. \ No newline at end of file diff --git a/2898_Neurology.txt b/2898_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..e87285ed31f7b3729697af327a2e934704214b5f --- /dev/null +++ b/2898_Neurology.txt @@ -0,0 +1,21 @@ +HISTORY: + + The patient is a 78-year-old right-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back pain radiating into the right leg. She was undergoing a spinal epidural injection about a month ago and had worsening of right low back pain, which radiates down into her buttocks and down to posterior aspect of her thigh into her knee. This has required large amounts of opioid analgesics to control. She has been basically bedridden because of this. She was brought into hospital for further investigations. + +PHYSICAL EXAMINATION: + + On examination, she has positive straight leg rising on the right with severe shooting, radicular type pain with right leg movement. Difficult to assess individual muscles, but strength is largely intact. Sensory examination is symmetric. Deep tendon reflexes reveal hyporeflexia in both patellae, which probably represents a cervical myelopathy from prior cord compression. She has slightly decreased right versus left ankle reflexes. The Babinski's are positive. On nerve conduction studies, motor and sensory distal latencies, evoked response amplitudes, conduction velocities, and F-waves are normal in lower extremities. + +NEEDLE EMG: + + Needle EMG was performed on the right leg and lumbosacral paraspinal muscles using a disposable concentric needle. It reveals the spontaneous activity in right peroneus longus and gastrocnemius medialis muscles as well as the right lower lumbosacral paraspinal muscles. There is evidence of denervation in right gastrocnemius medialis muscle. + +IMPRESSION: + + This electrical study is abnormal. It reveals the following: + +1. Inactive right S1 (L5) radiculopathy. + +2. There is no evidence of left lower extremity radiculopathy, peripheral neuropathy or entrapment neuropathy. + +Results were discussed with the patient and she is scheduled for imaging studies in the next day. \ No newline at end of file diff --git a/2900_Neurology.txt b/2900_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..8367bdd27cb3a93448607ea0895afbcc00e854db --- /dev/null +++ b/2900_Neurology.txt @@ -0,0 +1,3 @@ +IMPRESSION: + + Abnormal electroencephalogram revealing generalized poorly organized slowing, with more prominent slowing noted at the right compared to the left hemisphere head regions and rare sharp wave activity noted bilaterally, somewhat more prevalent on the right. Clinical correlation is suggested. \ No newline at end of file diff --git a/2902_Neurology.txt b/2902_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..2ae554ab214ea2bd3d20248100264a116810e9bd --- /dev/null +++ b/2902_Neurology.txt @@ -0,0 +1,11 @@ +DIAGNOSIS: + + Possible cerebrovascular accident. + +DESCRIPTION: + + The EEG was obtained using 21 electrodes placed in scalp-to-scalp and scalp-to-vertex montages. The background activity appears to consist of fairly organized somewhat pleomorphic low to occasional medium amplitude of 7-8 cycle per second activity and was seen mostly posteriorly bilaterally symmetrically. A large amount of movement artifacts and electromyographic effects were noted intermixed throughout the recording session. Transient periods of drowsiness occurred naturally producing irregular 5-7 cycle per second activity mostly over the anterior regions. Hyperventilation was not performed. No epileptiform activity or any definite lateralizing findings were seen. + +IMPRESSION: + + Mildly abnormal study. The findings are suggestive of a generalized cerebral disorder. Due to the abundant amount of movement artifacts, any lateralizing findings, if any cannot be well appreciated. Clinical correlation is recommended. \ No newline at end of file diff --git a/2905_Neurology.txt b/2905_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..7023489ddd6c83b7282ae1180adf7294548f74df --- /dev/null +++ b/2905_Neurology.txt @@ -0,0 +1,89 @@ +CHIEF COMPLAINT: + + Recurrent dizziness x1 month. + +HISTORY OF PRESENT ILLNESS: + + This is a 77-year-old African-American female with multiple medical problems including CHF (O2 dependent) + + atrial fibrillation, diabetes mellitus, hypothyroidism, possible stroke, multiple joint disease including gout, arthritis, both rheumatoid and DJD + + who presents with a complaint of one month of dizziness. She reports a rotational sensation upon arising from the bed or chair that lasts for several minutes and requires her to sit back down and stay in one place. She gets similar symptoms when she rolls over in bed. She is not able to describe what direction she feels like she is spinning. At times, she also feels as though she is going to pass out. These sensations stop if she just sits in one place or lies down for several minutes. She does note that it is worse when she turns to the right and when she turns to the left. She also complains that she gets similar sensations when she looks up. She denies any recent fever, chills, earache, diplopia, dysarthria, dysphagia, other change in vision, or recent new headaches. She also notes occasional tinnitus to her right ear. + +PAST MEDICAL HISTORY: + +1. CHF (uses portable oxygen). + +2. Atrial fibrillation. + +3. Gout. + +4. Arthritis (DJD/rheumatoid). + +5. Diabetes mellitus. + +6. Hypothyroidism. + +7. Hypertension. + +8. GERD. + +9. Possible stroke treated in 2003 at University of Maryland with acute onset of presyncopal sensations, sharp pains in the left side of her head and right-sided hemiparesis and numbness. + +FAMILY HISTORY: + + Noncontributory. + +SOCIAL HISTORY: + + She is married. She does not smoke, use alcohol or use illicit drugs. + +MEDICATIONS: + + Please see medication sheet in the chart. It includes potassium, Pravachol, Prevacid, Synthroid, Diovan, Amaryl, Vitamin B12, Coreg, Coumadin, furosemide, Actos, aspirin, colchicine, Cipro, Percocet, Ultram (has held the latter two medications for the past two weeks due to concerns of exacerbating dizziness). + +REVIEW OF SYSTEMS: + + Please see note in chart essentially entirely positive including cardiovascular problems of shortness of breath, PND and palpitations, chronic lack of energy, weight gain, the dizziness for which she presented. Tinnitus in the right ear. Diabetes and hypothyroidism. Chronic nausea. Chronic severe musculoskeletal pains to all extremities as well as to chest and abdomen and back. Right-sided numbness as well as complaints of bilateral lower extremity numbness and difficulty walking. She says her mood is sad and may be depressed and she is also extremely anxious. She has chronic shortness of breath and coughs easily when has to breathe deeply. She also endorses poor sleep. + +PHYSICAL EXAMINATION: + +VITAL SIGNS: Sitting BP 112/84 with a pulse of 84, standing after two minutes 130/90 with a pulse of 66. Respiratory rate is 20. Weight is 257 pounds. Pain scale is 7. + +GENERAL: This is a somewhat anxious elderly African-American female who tends to amplify findings on examination. It is a difficult examination due to the fact that no matter where the patient was touched she would wince in pain and withdraw. She is obese. + +HEENT: She is normocephalic and atraumatic. Conjunctivae and sclerae are clear. Tympanic membranes were visualized bilaterally. There is tenderness to palpation of any sinus region. There are no palpable cervical nodes. + +NECK: Supple although she complains of pain when rotating her neck. + +CHEST: Clear to auscultation bilaterally. + +HEART: Heart sounds are distant. There are no carotid bruits. + +EXTREMITIES: She has 1-2+ pitting edema to the mid shins bilaterally. + +NEUROLOGIC EXAMINATION: + +MENTAL STATUS: She is alert and oriented x3. Her speech is fluent; however, she is extremely tangential. She is unable to give a cogent medical history including details of hospitalization one month ago when she was admitted for a gout attack and urinary tract infection and underwent several days of rehabilitation. + +CRANIAL NERVES: Cranial nerves are intact throughout; specifically there is no nystagmus, her gaze is conjugate, there is no diplopia, visual fields are full to confrontation, pupils are equal, round and reactive to light and accommodation, extraocular movements are intact, facial sensation and expression are symmetric, vestibuloocular reflexes are intact, hearing is intact to finger rub bilaterally, palate rises symmetrically, normal cough, shoulder shrug is symmetric which shows easy breakaway give, and tongue protrudes in the midline. + +MOTOR: This is a limited exam due to easy breakaway gait and pain that appears exaggerated to movement of any extremity. There is suggestion of some mild right-sided paresis; however, the degree was inconsistent and her phasic strength is estimated at 4-4+ throughout. Her tone is normal throughout. + +SENSORY: She appears to have diffuse light tough and pinprick and temperature to the right arm and proximal leg. She also reports that she is numb in both feet; however, sensation testing of light tough, pinprick and vibration was intact. + +COORDINATION: There is no obvious dysmetria. + +GAIT: She uses a walker to stand up, and several near falls when asked to stand unassisted and can only ambulate with a walker. There are some mild right lower extremity circumduction present. + +REFLEXES: Biceps 1, triceps trace, brachioradialis 1, patella and ankle absent. Toes are equivocal. + +OTHER: Barany maneuver was attempted; however, when the patient was placed supine she immediately began screaming, "Oh my back, oh my back" + + and was unable to complete the maneuver. Brief inspection of her eyes failed to show any nystagmus at that time. + +IMPRESSION AND PLAN: + + This is a 77-year-old African-American female with multiple medical problems who presents with episodic positionally related dizziness of unclear etiology. Most certainly there is significant exaggeration of the underlying problem and her neurological examination is compounded by much functional overlay, limiting the interpretation of my findings. I suspect this is just a mild benign positional vertigo, although I cannot rule out vertebrobasilar compromise. I agree with symptomatic treatment with Antivert. + +We will schedule her for CT of head, CT angiogram to evaluate for possible brain stroke and vertebrobasilar insufficiency. In addition, we will attempt to get further objective data by ENG testing. I will see the patient again after these tests are completed and she has a trial of the Antivert. \ No newline at end of file diff --git a/2906_Neurology.txt b/2906_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..f09e8004b27e0901f90a8299c6a3305214cd5730 --- /dev/null +++ b/2906_Neurology.txt @@ -0,0 +1,67 @@ +CC: + +Vertigo. + +HX: + +This 61y/o RHF experienced a 2-3 minute episode of lightheadedness while driving home from the dentist in 5/92. In 11/92, while eating breakfast, she suddenly experienced vertigo. This was immediately followed by nausea and several episodes of vomiting. The vertigo lasted 2-3minutes. She retired to her room for a 2 hour nap after vomiting. When she awoke, the symptoms had resolved. On 1/13/93 she had an episode of right arm numbness lasting 4-5hours. There was no associated weakness, HA + + dysarthria, dysphagia, visual change, vertigo or lightheadedness. + +OUTSIDE RECORDS: + + 12/16/92 Carotid Doppler (RICA 30-40% + + LICA 10-20%). 12/4/92, brain MRI revealed a right cerebellar hypodensity consistent with infarct. + +MEDS: + + Zantac 150mg bid, Proventil MDI bid, Azmacort MDI bid, Doxycycline 100mg bid, Premarin 0.625mg qd, Provera 2.5mg qd. ASA 325mg qd. + +PMH: + + 1)MDD off antidepressants since 6/92. 2)asthma. 3)allergic rhinitis. 4)chronic sinusitis. 5)s/p Caldwell-Luc 1978, and nasal polypectomy. 6) GERD. 7)h/o elevated TSH. 8)hypercholesterolemia 287 on 11/20/93. 9)h/o heme positive stool: BE 11/24/92 and UGI 11/25/92 negative. + +FHX: + +Father died of a thoracic aortic aneurysm, age 71. Mother died of stroke, age 81. + +SHX: + + Married. One son deceased. Salesperson. Denied tobacco/ETOH/illicit drug use. + +EXAM + +: BP (RUE)132/72 LUE (136/76). HR67 RR16 Afebrile. 59.2kg. + +MS: A&O to person, place, time. Speech fluent and without dysarthria. Thought lucid. + +CN: unremarkable. + +Motor: 5/5 strength throughout with normal muscle bulk and tone. + +Sensory: No deficits appreciated. + +Coord: unremarkable. + +Station: no pronator drift, truncal ataxia, or Romberg sign. + +Gait: not done. + +Reflexes: 2/2 throughout BUE and at patellae. 1/1 at Achilles. Plantar responses were flexor, bilaterally. + +Gen Exam: Obese. + +COURSE: + +CBC + + GS + + PT/PTT + + UA were unremarkable. The patient was admitted with a working diagnosis of posterior circulation TIA and history of cerebellar stroke. She was placed on Ticlid 250mg bid. HCT + +1/15/93: low density focus in the right medial and posterior cerebellar hemisphere. MRI and MRA + + 1/18/93, revealed a well circumscribed lesion within the posterior aspect of the right cerebellar hemisphere suggestive of vascular malformation (e.g. cavernous angioma. An abnormal vascular blush was seen on the MRA. This area appeared to be supplied by one of the external carotid arteries (which one is was not specified). this finding maybe suggestive of a vascular malformation. 1/20/93 Cerebral Angiogram: The right cerebellar hemisphere lesion seen on MRI as a possible cavernous angioma was not seen on angiography. Upon review of the MRI and HCT the lesion was felt to probably represent an old infarction with hemosiderin deposition. The "vascular blush" seen on MRA was no visualized on angiography. The patient was discharged home on 1/25/93. \ No newline at end of file diff --git a/2909_Neurology.txt b/2909_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..af50f7c838a7f44f63299abfc036c90af7ef639a --- /dev/null +++ b/2909_Neurology.txt @@ -0,0 +1,63 @@ +CC: + + Seizure D/O,HX: + + 29 y/o male with cerebral palsy, non-shunted hydrocephalus, spastic quadriplegia, mental retardation, bilateral sensory neural hearing loss, severe neurogenic scoliosis and multiple contractures of the 4 extremities, neurogenic bowel and bladder incontinence, and a history of seizures. + +He was seen for evaluation of seizures which first began at age 27 years, two years before presentation. His typical episodes consist of facial twitching (side not specified) + + unresponsive pupils, and moaning. The episodes last approximately 1-2 minutes in duration and are followed by post-ictal fatigue. He was placed on DPH + + but there was no record of an EEG prior to presentation. He had had no seizure events in over 1 year prior to presentation while on DPH 100mg--O--200mg. He also complained of headaches for the past 10 years. + +BIRTH HX: + + Spontaneous Vaginal delivery at 36weeks gestation to a G2P1 mother. Birth weight 7#10oz. No instrumentation required. Labor = 11hours. "Light gas anesthesia" given. Apgars unknown. Mother reportedly had the "flu" in the 7th or 8th month of gestation. + +Patient discharged 5 days post-partum. + +Development: spoke first words between 1 and 2 years of age. Rolled side to side at age 2, but did not walk. Fed self with hands at age 2 years. Never toilet trained. + +PMH: + +1)Hydrocephalus manifested by macrocephaly by age 2-3 months. Head circumference 50.5cm at 4 months of age (wide sutures and bulging fontanels). Underwent ventriculogram, age 4 months, which illustrated massive enlargement of the lateral ventricles and normal sized aqueduct and 4th ventricle. The cortex of the cerebral hemisphere was less than 1cm. in thickness; especially in the occipital regions where only a thin rim of tissue was left. Neurosurgical intervention was not attempted and the patient deemed inoperable at the time. By 31 months of age the patients head circumference was 68cm, at which point the head size arrested. Other problems mentioned above. + +SHX: + +institutionalized at age 18 years. + +FHX: + +unremarkable. + +EXAM: + + Vitals unknown. + +MS: awake with occasional use of intelligible but inappropriately used words. + +CN: Rightward beating nystagmus increase on leftward gaze. Right gaze preference. Corneal responses were intact bilaterally. Fundoscopic exam not noted. + +Motor: spastic quadriparesis. moves RUE more than other extremities. + +Sensory: withdrew to PP in 4 extremities. + +Coord: ND + +Station: ND + +Gait: ND + + wheel chair bound. + +Reflexes: RUE 2+ + + LUE 3+ + + RLE 4+ with sustained cross adductor clonus in the right quadriceps. LLE 3+. + +Other: Macrocephaly (measurement not given). Scoliosis. Rest of general exam unremarkable except for numerous abdominal scars. + +COURSE: + + EEG 8/26/92: Abnormal with diffuse slowing and depressed background (left worse than right) and poorly formed background activity at 5-7hz. Right posterior sharp transients, and rhythmic delta-theta bursts from the right temporal region. The findings are consistent with diffuse cerebral dysfunction and underlying seizure tendency of multifocal origin. \ No newline at end of file diff --git a/2910_Neurology.txt b/2910_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..548850d69f51fd8315c31440fdbff9add41c7813 --- /dev/null +++ b/2910_Neurology.txt @@ -0,0 +1,31 @@ +DIAGNOSES ON ADMISSION + +1. Cerebrovascular accident (CVA) with right arm weakness. + +2. Bronchitis. + +3. Atherosclerotic cardiovascular disease. + +4. Hyperlipidemia. + +5. Thrombocytopenia. + +DIAGNOSES ON DISCHARGE + +1. Cerebrovascular accident with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect. + +2. Old coronary infarct, anterior aspect of the right external capsule. + +3. Acute bronchitis with reactive airway disease. + +4. Thrombocytopenia most likely due to old coronary infarct, anterior aspect of the right external capsule. + +5. Atherosclerotic cardiovascular disease. + +6. Hyperlipidemia. + +HOSPITAL COURSE: + + The patient was admitted to the emergency room. Plavix was started in addition to baby aspirin. He was kept on oral Zithromax for his cough. He was given Xopenex treatment, because of his respiratory distress. Carotid ultrasound was reviewed and revealed a 50 to 69% obstruction of left internal carotid. Dr. X saw him in consultation and recommended CT angiogram. This showed no significant obstructive lesion other than what was known on the ultrasound. Head MRI was done and revealed the above findings. The patient was begun on PT and improved. By discharge, he had much improved strength in his right arm. He had no further progressions. His cough improved with oral Zithromax and nebulizer treatments. His platelets also improved as well. By discharge, his platelets was up to 107,000. His H&H was stable at 41.7 and 14.6 and his white count was 4300 with a normal differential. Chest x-ray revealed a mild elevated right hemidiaphragm, but no infiltrate. Last chemistry panel on December 5, 2003, sodium 137, potassium 4.0, chloride 106, CO2 23, glucose 88, BUN 17, creatinine 0.7, calcium was 9.1. PT/INR on admission was 1.03, PTT 34.7. At the time of discharge, the patient's cough was much improved. His right arm weakness has much improved. His lung examination has just occasional rhonchi. He was changed to a metered dose inhaler with albuterol. He is being discharged home. An echocardiogram revealed mild concentric LVH with normal left ventricular function with an EF of 57% + + moderate left atrial enlargement and diastolic dysfunction with mild mitral regurgitation. He will follow up in my office in 1 week. He is to start PT and OT as an outpatient. He is to avoid driving his car. He is to notify, if further symptoms. He has 2 more doses of Zithromax at home, he will complete. His prognosis is good. \ No newline at end of file diff --git a/2912_Neurology.txt b/2912_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..a4cf85569aebba8a1156987b77500be17e5f06dd --- /dev/null +++ b/2912_Neurology.txt @@ -0,0 +1,81 @@ +CC: + + Confusion. + +HX: + + A 71 y/o RHM + +with a history of two strokes ( one in 11/90 and one in 11/91) + + had been in a stable state of health until 12/31/92 when he became confused, and displayed left-sided weakness and difficulty speaking. The symptoms resolved within hours and recurred the following day. He was then evaluated locally and HCT revealed an old right parietal stroke. Carotid duplex scan revealed a "high grade stenosis" of the RICA. Cerebral Angiogram revealed 90%RICA and 50%LICA stenosis. He was then transferred to UIHC Vascular Surgery for carotid endarterectomy. His confusion persisted and he was evaluated by Neurology on 1/8/93 and transferred to Neurology on 1/11/93. + +PMH: + + 1)cholecystectomy. 2)inguinal herniorrhaphies, bilaterally. 3)ETOH abuse: 3-10 beers/day. 4)Right parietal stroke 10/87 with residual left hemiparesis (Leg worse than arm). 5) 2nd stoke in distant past of unspecified type. + +MEDS: + + None on admission. + +FHX: + + Alzheimer's disease and stroke on paternal side of family. + +SHX: + + 50+pack-yr cigarette use. + +ROS: + + no weight loss. poor appetite/selective eater. + +EXAM: + + BP137/70 HR81 RR13 O2Sat 95% Afebrile. + +MS: Oriented to city and month, but did not know date or hospital. Naming and verbal comprehension were intact. He could tell which direction Iowa City and Des Moines were from Clinton and remembered 2-3 objects in two minutes, but both with assistance only. Incorrectly spelled "world" backward, as "dlow." + +CN: unremarkable except neglects left visual field to double simultaneous stimulation. + +Motor: Deltoids 4+/4- + + biceps 5-/4, triceps 5/4+ + + grip 4+/4+ + + HF4+/4- + + HE 4+/4+ + + Hamstrings 5-/5- + + AE 5-/5- + + AF 5-/5-. + +Sensory: intact PP/LT/Vib. + +Coord: dysdiadochokinesis on RAM + + bilaterally. + +Station: dyssynergic RUE on FNF movement. + +Gait: ND + +Reflexes: 2+/2+ throughout BUE and at patellae. Absent at ankles. Right plantar was flexor; and Left plantar was equivocal. + +COURSE: + + CBC revealed normal Hgb, Hct, Plt and WBC + + but Mean corpuscular volume was large at 103FL (normal 82-98). Urinalysis revealed 20+WBC. GS + + TSH + + FT4, VDRL + + ANA and RF were unremarkable. He was treated for a UTI with amoxacillin. Vitamin B12 level was reduced at 139pg/ml (normal 232-1137). Schillings test was inconclusive dure to inability to complete a 24-hour urine collection. He was placed on empiric Vitamin B12 1000mcg IM qd x 7 days; then qMonth. He was also placed on Thiamine 100mg qd, Folate 1mg qd, and ASA 325mg qd. His ESR and CRP were elevated on admission, but fell as his UTI was treated. + +EEG showed diffuse slowing and focal slowing in the theta-delta range in the right temporal area. HCT with contrast on 1/19/93 revealed a gyriform enhancing lesion in the left parietal lobe consistent with a new infarct; and an old right parietal hypodensity (infarct). His confusion was ascribed to the UTI in the face of old and new strokes and Vitamin B12 deficiency. He was lost to follow-up and did not undergo carotid endarterectomy. \ No newline at end of file diff --git a/2914_Neurology.txt b/2914_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..6a9634dacccdb3d476b5dfe61a16823b0fa3d5d3 --- /dev/null +++ b/2914_Neurology.txt @@ -0,0 +1,26 @@ +EXAM: + + Lumbar spine CT without contrast. + +HISTORY: + + Back pain after a fall. + +TECHNIQUE: + + Noncontrast axial images were acquired through the lumbar spine. Coronal and sagittal reconstruction views were also obtained. + +FINDINGS: + + There is no evidence for acute fracture or subluxation. There is no spondylolysis or spondylolisthesis. The central canal and neuroforamen are grossly patent at all levels. There are no abnormal paraspinal masses. There is no wedge/compression deformity. There is intervertebral disk space narrowing to a mild degree at L2-3 and L4-5. + +Soft tissue windows demonstrate atherosclerotic calcification of the abdominal aorta, which is not dilated. There was incompletely visualized probable simple left renal cyst, exophytic at the lower pole. + +IMPRESSION: + +1. No evidence for acute fracture or subluxation. + +2. Mild degenerative changes. + +3. Probable left simple renal cyst. + diff --git a/2916_Neurology.txt b/2916_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..b7ca74180b4b00483fa07839d310ed4544135cda --- /dev/null +++ b/2916_Neurology.txt @@ -0,0 +1,13 @@ +FINDINGS: + +Axial scans were performed from L1 to S2 and reformatted images were obtained in the sagittal and coronal planes. + +Preliminary scout film demonstrates anterior end plate spondylosis at T11-12 and T12-L1. + +L1-2: There is normal disc height, anterior end plate spondylosis, very minimal vacuum change with no posterior annular disc bulging or protrusion. Normal central canal, intervertebral neural foramina and facet joints (image #4). + +L2-3: There is mild decreased disc height, anterior end plate spondylosis, circumferential disc protrusion measuring 4.6mm (AP) and right extraforaminal osteophyte disc complex. There is mild non-compressive right neural foraminal narrowing, minimal facet arthrosis, normal central canal and left neural foramen (image #13). + +L3-4: There is normal disc height, anterior end plate spondylosis, and circumferential non-compressive annular disc bulging. The disc bulging flattens the ventral thecal sac and there is minimal non-compressive right neural foraminal narrowing, minimal to mild facet arthrosis with vacuum change on the right, normal central canal and left neural foramen (image #25). + +L4-5: \ No newline at end of file diff --git a/2918_Neurology.txt b/2918_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..9cae56f98316c1ba57708249468c9ae9c9767796 --- /dev/null +++ b/2918_Neurology.txt @@ -0,0 +1,31 @@ +FINDINGS: + +High resolution computerized tomography was performed from T12-L1 to the S1 level with reformatted images in the sagittal and coronal planes and 3D reconstructions performed. COMPARISON: Previous MRI examination 10/13/2004. + +There is minimal curvature of the lumbar spine convex to the left. + +T12-L1, L1-2, L2-3: There is normal disc height with no posterior annular disc bulging or protrusion. Normal central canal, intervertebral neural foramina and facet joints. + +L3-4: There is normal disc height and non-compressive circumferential annular disc bulging eccentrically greater to the left. Normal central canal and facet joints (image #255). + +L4-5: There is normal disc height, circumferential annular disc bulging, left L5 hemilaminectomy and posterior central/right paramedian broad-based disc protrusion measuring 4mm (AP) contouring the rightward aspect of the thecal sac. Orthopedic hardware is noted posteriorly at the L5 level. Normal central canal, facet joints and intervertebral neural foramina (image #58). + +L5-S1: There is minimal decreased disc height, postsurgical change with intervertebral disc spacer, posterior lateral orthopedic hardware with bilateral pedicle screws in good postsurgical position. The orthopedic hardware creates mild streak artifact which mildly degrades images. There is a laminectomy defect, spondylolisthesis with 3.5mm of anterolisthesis of L5, posterior annular disc bulging greatest in the left foraminal region lying adjacent to the exiting left L5 nerve root. There is fusion of the facet joints, normal central canal and right neural foramen (image #69-70, 135). + +There is no bony destructive change noted. + +There is no perivertebral soft tissue abnormality. + +There is minimal to mild arteriosclerotic vascular calcifications noted in the abdominal aorta and right proximal common iliac artery. + +IMPRESSION: + +Minimal curvature of the lumbar spine convex to the left. + +L3-4 posterior non-compressive annular disc bulging eccentrically greater to the left. + +L4-5 circumferential annular disc bulging, non-compressive central/right paramedian disc protrusion, left L5 laminectomy. + +L5-S1 postsurgical change with posterolateral orthopedic fusion hardware in good postsurgical position, intervertebral disc spacer, spondylolisthesis, laminectomy defect, posterior annular disc bulging greatest in the left foraminal region adjacent to the exiting left L5 nerve root with questionable neural impingement. + +Minimal to mild arteriosclerotic vascular calcifications. \ No newline at end of file diff --git a/2919_Neurology.txt b/2919_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..da03c3ba5199b801bd70ce4ac8f4c16ff1a468fe --- /dev/null +++ b/2919_Neurology.txt @@ -0,0 +1,19 @@ +REASON FOR EXAM: + +Left arm and hand numbness. + +TECHNIQUE: + + Noncontrast axial CT images of the head were obtained with 5 mm slice thickness. + +FINDINGS: + +There is an approximately 5-mm shift of the midline towards the right side. Significant low attenuation is seen throughout the white matter of the right frontal, parietal, and temporal lobes. There is loss of the cortical sulci on the right side. These findings are compatible with edema. Within the right parietal lobe, a 1.8 cm, rounded, hyperintense mass is seen. + +No hydrocephalus is evident. + +The calvarium is intact. The visualized paranasal sinuses are clear. + +IMPRESSION: + +A 5 mm midline shift to the left side secondary to severe edema of the white matter of the right frontal, parietal, and temporal lobes. A 1.8 cm high attenuation mass in the right parietal lobe is concerning for hemorrhage given its high density. A postcontrast MRI is required for further characterization of this mass. Gradient echo imaging should be obtained. \ No newline at end of file diff --git a/2920_Neurology.txt b/2920_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..4a52a2a85368640e469597b585d2e0530c147b45 --- /dev/null +++ b/2920_Neurology.txt @@ -0,0 +1,13 @@ +REASON FOR CT SCAN: + + The patient is a 79-year-old man with adult hydrocephalus who was found to have large bilateral effusions on a CT scan performed on January 16, 2008. I changed the shunt setting from 1.5 to 2.0 on February 12, 2008 and his family obtained this repeat CT scan to determine whether his subdural effusions were improving. + +CT scan from 03/11/2008 demonstrates frontal horn span at the level of foramen of Munro of 2.6 cm. The 3rd ventricular contour which is flat with a 3rd ventricular span of 10 mm. There is a single shunt, which enters on the right occipital side and ends in the left lateral ventricle. He has symmetric bilateral subdurals that are less than 1 cm in breadth each, which is a reduction from the report from January 16, 2008, which states that he had a subdural hygroma, maximum size 1.3 cm on the right and 1.1 cm on the left. + +ASSESSMENT: + + The patient's subdural effusions are still noticeable, but they are improving at the setting of 2.0. + +PLAN: + + I would like to see the patient with a new head CT in about three months, at which time we can decide whether 2.0 is the appropriate setting for him to remain at or whether we can consider changing the shunt setting. \ No newline at end of file diff --git a/2924_Neurology.txt b/2924_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..895ed9bfe487afaca576ddd614aeb7132960cfc6 --- /dev/null +++ b/2924_Neurology.txt @@ -0,0 +1,11 @@ +TECHNIQUE: + + Sequential axial CT images were obtained from the vertex to the skull base without contrast. + +FINDINGS: + + There is mild generalized atrophy. Scattered patchy foci of decreased attenuation are seen within the sub cortical and periventricular white matter compatible with chronic small vessel ischemic changes. The brain parenchyma is otherwise normal in attenuation with no evidence of mass, hemorrhage, midline shift, hydrocephalus, extra-axial fluid, or acute infarction. The visualized paranasal sinuses and mastoid air cells are clear. The bony calvarium and skull base are within normal limits. + +IMPRESSION: + + No acute abnormalities. \ No newline at end of file diff --git a/2929_Neurology.txt b/2929_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..4bf84f1ae8e2896570b534ba3150da87b820d091 --- /dev/null +++ b/2929_Neurology.txt @@ -0,0 +1,11 @@ +TECHNIQUE: + + Sequential axial CT images were obtained through the cervical spine without contrast. Additional high resolution coronal and sagittal reconstructed images were also obtained for better visualization of the osseous structures. + +FINDINGS: + + The cervical spine demonstrates normal alignment and mineralization with no evidence of fracture, dislocation, or spondylolisthesis. The vertebral body heights and disc spaces are maintained. The central canal is patent. The pedicles and posterior elements are intact. The paravertebral soft tissues are within normal limits. The atlanto-dens interval and the dens are intact. The visualized lung apices are clear. + +IMPRESSION: + + No acute abnormalities. \ No newline at end of file diff --git a/2933_Neurology.txt b/2933_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..44b65d347ea3571249ac4733ecab3ba4593f9d65 --- /dev/null +++ b/2933_Neurology.txt @@ -0,0 +1,97 @@ +CC: + + Episodic mental status change and RUE numbness, and chorea (found on exam). + +HX: + + This 78y/o RHM was referred for an episode of unusual behavior and RUE numbness. In 9/91, he experienced near loss of consciousness, generalized weakness, headache and vomiting. Evaluation at that time revealed an serum glucose of >500mg/dL and he was placed on insulin therapy with subsequent resolution of his signs and symptoms. Since then, he became progressively more forgetful, and at the time of evaluation, 1/17/93, had lost his ability to perform his job repairing lawn mowers. His wife had taken over the family finances. + +He had also been "stumbling," when ambulating, for 2 months prior to presentation. He was noted to be occasionally confused upon awakening for last several months. On 1/15/93, he was lying on a couch when he suddenly began throwing pillows and blankets for no apparent reason. There had been no change in sleep, appetite, or complaint of depression. + +In addition, for two months prior to presentation, he had been experiencing 10-15minute episodes of RUE numbness. There was no face or lower extremity involvement. + +During the last year he had developed unusual movements of his extremities. + +MEDS: + + NPH Humulin 12U qAM and 6U qPM. Advil prn. + +PMH: + + 1) Traumatic amputation of the 4th and 5th digits of his left hand. 2) Hospitalized for an unknown "nervous" condition in the 1940's. + +SHX/FHX: + + Retired small engine mechanic who worked in a poorly ventilated shop. Married with 13 children. No history of ETOH + + Tobacco or illicit drug use. Father had tremors following a stroke. Brother died of brain aneurysm. No history of depression, suicide, or Huntington's disease in family. + +ROS: + + no history of CAD + + Renal or liver disease, SOB + + Chest pain, fevers, chills, night sweats or weight loss. No report of sign of bleeding. + +EXAM: + + BP138/63 HR65 RR15 36.1C,MS: Alert and oriented to self, season; but not date, year, or place. Latent verbal responses and direction following. Intact naming, but able to repeat only simple but not complex phrases. Slowed speech, with mild difficulty with word finding. 2/3 recall at one minute and 0/3 at 3 minutes. Knew the last 3 presidents. 14/27 on MMSE: unable to spell "world" backwards. Unable to read/write for complaint of inability to see without glasses. + +CN: II-XII appeared grossly intact. EOM were full and smooth and without unusual saccadic pursuits. OKN intact. Choreiform movements of the tongue were noted. + +Motor: 5/5 strength throughout with Guggenheim type resistance. there were choreiform type movements of all extremities bilaterally. No motor impersistence noted. + +Sensory: unreliable. + +Cord: "normal" FNF + + HKS + + and RAM + + bilaterally. + +Station: No Romberg sign. + +Gait: unsteady and wide-based. + +Reflexes: BUE 2/2, Patellar 2/2, Ankles Trace/Trace, Plantars were flexor bilaterally. + +Gen Exam: 2/6 Systolic ejection murmur in aortic area. + +COURSE: + + No family history of Huntington's disease could be elicited from relatives. Brain CT + + 1/18/93: bilateral calcification of the globus pallidi and a high attenuation focus in the right occipital lobe thought to represent artifact. Carotid duplex, 1/18/93: RICA 0-15% + + LICA 16-49% stenosis and normal vertebral artery flow bilaterally. Transthoracic Echocardiogram (TTE) + +1/18/93: revealed severe aortic fibrosis or valvular calcification with "severe" aortic stenosis in the face of "normal" LV function. Cardiology felt the patient the patient had asymptomatic aortic stenosis. EEG + + 1/20/93, showed low voltage Delta over the left posterior quadrant and intermittent background slowing over the same region consistent with focal dysfunction in this quadrant. MRI Brain, 1/22/93: multiple focal and more confluent areas of increased T2 signal in the periventricular white matter, more prominent on the left; in addition, there were irregular shaped areas of increased T2 signal and decreased T1 signal in both cerebellar hemispheres; and age related atrophy; incidentally, there is a cavum septum pellucidum et vergae and mucosal thickening of the maxillary sinuses. Impression: diffuse bilateral age related ischemic change, age related atrophy and maxillary sinus disease. There were no masses or areas of abnormal enhancement. TSH + + FT4, Vit B12, VDRL + + Urine drug and heavy metal screens were unremarkable. CSF + +1/19/93: glucose 102 (serum glucose 162mg/dL) + + Protein 45mg/dL, RBC O, WBC O, Cultures negative. SPEP negative. However serum and CSF beta2 microglobulin levels were elevated at 2.5 and 3.1mg/L, respectively. Hematology felt these may have been false positives. CBC + + 1/17/93: Hgb 10.4g/dL (low) + + HCT 31% (low) + + RBC 3/34mil/mm3 (low) + + WBC 5.8K/mm3, Plt 201K/mm3. Retic 30/1K/mm3 (normal). Serum Iron 35mcg/dL (low) + + TIBC 201mcg/dL (low) + + FeSat 17% (low) + + CRP 0.1mg/dL (normal) + + ESR 83mm/hr (high). Bone Marrow Bx: normal with adequate iron stores. Hematology felt the finding were compatible with anemia of chronic disease. Neuropsychologic evaluation on 1/17/93 revealed significant impairments in multiple realms of cognitive function (visuospatial reasoning, verbal and visual memory, visual confrontational naming, impaired arrhythmatic, dysfluent speech marked by use of phrases no longer than 5 words, frequent word finding difficulty and semantic paraphasic errors) most severe for expressive language, attention and memory. The pattern of findings reveals an atypical aphasia suggestive of left temporo-parietal dysfunction. The patient was discharged1/22/93 on ASA 325mg qd. He was given a diagnosis of senile chorea and dementia (unspecified type). 6/18/93 repeat Neuropsychological evaluation revealed moderate decline in all areas tested reflecting severe dementia. \ No newline at end of file diff --git a/2934_Neurology.txt b/2934_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..5f4597f40c3698c4db133efd733b06fec6f9b8b7 --- /dev/null +++ b/2934_Neurology.txt @@ -0,0 +1,47 @@ +CC: + + Left-sided weakness. + +HX: + + This 28y/o RHM was admitted to a local hospital on 6/30/95 for a 7 day history of fevers, chills, diaphoresis, anorexia, urinary frequency, myalgias and generalized weakness. He denied foreign travel, IV drug abuse, homosexuality, recent dental work, or open wound. Blood and urine cultures were positive for Staphylococcus Aureus, oxacillin sensitive. He was place on appropriate antibiotic therapy according to sensitivity.. A 7/3/95 transthoracic echocardiogram revealed normal left ventricular function and a damaged mitral valve with regurgitation. Later that day he developed left-sided weakness and severe dysarthria and aphasia. HCT + + on 7/3/95 revealed mild attenuated signal in the right hemisphere. On 7/4/95 he developed first degree AV block, and was transferred to UIHC. + +MEDS: + +Nafcillin 2gm IV q4hrs, Rifampin 600mg q12hrs, Gentamicin 130mg q12hrs. + +PMH: + + 1) Heart murmur dx age 5 years. + +FHX: + + Unremarkable. + +SHX: + + Employed cook. Denied ETOH/Tobacco/illicit drug use. + +EXAM: + + BP 123/54, HR 117, RR 16, 37.0C,MS: Somnolent and arousable only by shaking and repetitive verbal commands. He could follow simple commands only. He nodded appropriately to questioning most of the time. Dysarthric speech with sparse verbal output. + +CN: Pupils 3/3 decreasing to 2/2 on exposure to light. Conjugate gaze preference toward the right. Right hemianopia by visual threat testing. Optic discs flat and no retinal hemorrhages or Roth spots were seen. Left lower facial weakness. Tongue deviated to the left. Weak gag response, bilaterally. Weak left corneal response. + +MOTOR: Dense left flaccid hemiplegia. + +SENSORY: Less responsive to PP on left. + +COORD: Unable to test. + +Station and Gait: Not tested. + +Reflexes: 2/3 throughout (more brisk on the left side). Left ankle clonus and a Left Babinski sign were present. + +GEN EXAM: Holosystolic murmur heard throughout the precordium. Janeway lesions were present in the feet and hands. No Osler's nodes were seen. + +COURSE: + + 7/6/95, HCT showed a large RMCA stroke with mass shift. His neurologic exam worsened and he was intubated, hyperventilated, and given IV Mannitol. He then underwent emergent left craniectomy and duraplasty. He tolerated the procedure well and his brain was allowed to swell. He then underwent mitral valve replacement on 7/11/95 with a St. Judes valve. His post-operative recovery was complicated by pneumonia, pericardial effusion and dysphagia. He required temporary PEG placement for feeding. The 7/27/95, 8/6/95 and 10/18/96 HCT scans show the chronologic neuroradiologic documentation of a large RMCA stroke. His 10/18/96 Neurosurgery Clinic visit noted that he can ambulate without assistance with the use of a leg brace to prevent left foot drop. His proximal LLE strength was rated at a 4. His LUE was plegic. He had a seizure 6 days prior to his 10/18/96 evaluation. This began as a Jacksonian march of shaking in the LUE; then involved the LLE. There was no LOC or tongue-biting. He did have urinary incontinence. He was placed on DPH. His speech was dysarthric but fluent. He appeared bright, alert and oriented in all spheres. \ No newline at end of file diff --git a/2935_Neurology.txt b/2935_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..782796409c5e92ab8f6363d473de05ef317aee71 --- /dev/null +++ b/2935_Neurology.txt @@ -0,0 +1,49 @@ +CC: + + Decreasing visual acuity. + +HX: + +This 62 y/o RHF presented locally with a 2 month history of progressive loss of visual acuity, OD. She had a 2 year history of progressive loss of visual acuity, OS + + and is now blind in that eye. She denied any other symptomatology. Denied HA. + +PMH: + + 1) depression. 2) Blind OS + +MEDS: + + None. + +SHX/FHX: + +unremarkable for cancer, CAD + + aneurysm, MS + + stroke. No h/o Tobacco or ETOH use. + +EXAM: + + T36.0, BP121/85, HR 94, RR16,MS: Alert and oriented to person, place and time. Speech fluent and unremarkable. + +CN: Pale optic disks, OU. Visual acuity: 20/70 (OD) and able to detect only shadow of hand movement (OS). Pupils were pharmacologically dilated earlier. The rest of the CN exam was unremarkable. + +MOTOR: 5/5 throughout with normal bulk and tone. + +Sensory: no deficits to LT/PP/VIB/PROP. + +Coord: FNF-RAM-HKS intact bilaterally. + +Station: No pronator drift. Gait: ND + +Reflexes: 3/3 BUE + + 2/2 BLE. Plantar responses were flexor bilaterally. + +Gen Exam: unremarkable. No carotid/cranial bruits. + +COURSE: + + CT Brain showed large, enhancing 4 x 4 x 3 cm suprasellar-sellar mass without surrounding edema. Differential dx: included craniopharyngioma, pituitary adenoma, and aneurysm. MRI Brain findings were consistent with an aneurysm. The patient underwent 3 vessel cerebral angiogram on 12/29/92. This clearly revealed a supraclinoid giant aneurysm of the left internal carotid artery. Ten minutes following contrast injection the patient became aphasic and developed a right hemiparesis. Emergent HCT showed no evidence of hemorrhage or sign of infarct. Emergent carotid duplex showed no significant stenosis or clot. The patient was left with an expressive aphasia and right hemiparesis. SPECT scans were obtained on 1/7/93 and 2/24/93. They revealed hypoperfusion in the distribution of the left MCA and decreased left basal-ganglia perfusion which may represent in part a mass effect from the LICA aneurysm. She was discharged home and returned and underwent placement of a Selverstone Clamp on 3/9/93. The clamp was gradually and finally closed by 3/14/93. She did well, and returned home. On 3/20/93 she developed sudden confusion associated with worsening of her right hemiparesis and right expressive aphasia. A HCT then showed SAH around her aneurysm, which had thrombosed. She was place on Nimodipine. Her clinical status improved; then on 3/25/93 she rapidly deteriorated over a 2 hour period to the point of lethargy, complete expressive aphasia, and right hemiplegia. An emergent HCT demonstrated a left ACA and left MCA infarction. She required intubation and worsened as cerebral edema developed. She was pronounced brain dead. Her organs were donated for transplant. \ No newline at end of file diff --git a/2942_Neurology.txt b/2942_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..67dd6d4b090344a21558b75209b6ea458ce35303 --- /dev/null +++ b/2942_Neurology.txt @@ -0,0 +1,27 @@ +REASON FOR VISIT: + + Postoperative visit for craniopharyngioma. + +HISTORY OF PRESENT ILLNESS: + + Briefly, a 16-year-old right-handed boy who is in eleventh grade, who presents with some blurred vision and visual acuity difficulties, was found to have a suprasellar tumor. He was brought to the operating room on 01/04/07, underwent a transsphenoidal resection of tumor. Histology returned as craniopharyngioma. There is some residual disease; however, the visual apparatus was decompressed. According to him, he is doing well, back at school without any difficulties. He has some occasional headaches and tinnitus, but his vision is much improved. + +MEDICATIONS: + + Synthroid 100 mcg per day. + +FINDINGS: + + On exam, he is awake, alert and oriented x 3. Pupils are equal and reactive. EOMs are full. His visual acuity is 20/25 in the right (improved from 20/200) and the left is 20/200 improved from 20/400. He has a bitemporal hemianopsia, which is significantly improved and wider. His motor is 5 out of 5. There are no focal motor or sensory deficits. The abdominal incision is well healed. There is no evidence of erythema or collection. The lumbar drain was also well healed. + +The postoperative MRI demonstrates small residual disease. + +Histology returned as craniopharyngioma. + +ASSESSMENT: + + Postoperative visit for craniopharyngioma with residual disease. + +PLANS: + + I have recommended that he call. I discussed the options with our radiation oncologist, Dr. X. They will schedule the appointment to see him. In addition, he probably will need an MRI prior to any treatment, to follow the residual disease. \ No newline at end of file diff --git a/2944_Neurology.txt b/2944_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..6a43f5b6429189a7faadcd978fbbc379731ad821 --- /dev/null +++ b/2944_Neurology.txt @@ -0,0 +1,61 @@ +CHIEF COMPLAINT: + + Worsening seizures. + +HISTORY OF PRESENT ILLNESS: + +A pleasant 43-year-old female with past medical history of CP since birth, seizure disorder, complex partial seizure with secondary generalization and on top of generalized epilepsy, hypertension, dyslipidemia, and obesity. The patient stated she was in her normal state of well being when she was experiencing having frequent seizures. She lives in assisted living. She has been falling more frequently. The patient was driving a scooter and apparently was hitting into the wall with unresponsiveness in association with this. There was no head trauma, but apparently she was doing that many times and there was no responsiveness. The patient has no memory of the event. She is now back to her baseline. She states her seizures are worse in the setting of stress, but it is not clear to her why this has occurred. She is on Carbatrol 300 mg b.i.d. and she has been very compliant and without any problems. The patient is admitted for EMU monitoring for the characterization of these episodes and for the possibility of complex partial epilepsy syndrome or better characterization of this current syndrome. + +PAST MEDICAL HISTORY: + +Include dyslipidemia and hypertension. + +FAMILY HISTORY: + +Positive for stroke and sleep apnea. + +SOCIAL HISTORY: + + No smoking or drinking. No drugs. + +MEDICATIONS AT HOME: + + Include, Avapro, lisinopril, and dyslipidemia medication, she does not remember. + +REVIEW OF SYSTEMS: + + The patient does complain of gasping for air, witnessed apneas, and dry mouth in the morning. The patient also has excessive daytime sleepiness with EDS of 16. + +PHYSICAL EXAMINATION: + +VITAL SIGNS: Last blood pressure 130/85, respirations 20, and pulse 70. + +GENERAL: Normal. + +NEUROLOGICAL: As follows. Right-handed female, normal orientation, normal recollection to 3 objects. The patient has underlying MR. Speech, no aphasia, no dysarthria. Cranial nerves, funduscopic intact without papilledema. Pupils are equal, round, and reactive to light. Extraocular movements intact. No nystagmus. Her mood is intact. Symmetric face sensation. Symmetric smile and forehead. Intact hearing. Symmetric palate elevation. Symmetric shoulder shrug and tongue midline. Motor 5/5 proximal and distal. The patient does have limp on the right lower extremity. Her Babinski is hyperactive on the left lower extremity, upgoing toes on the left. Sensory, the patient does have sharp, soft touch, vibration intact and symmetric. The patient has trouble with ambulation. She does have ataxia and uses a walker to ambulate. There is no bradykinesia. Romberg is positive to the left. Cerebellar, finger-nose-finger is intact. Rapid alternating movements are intact. Upper airway examination, the patient has a Friedman tongue position with 4 oropharyngeal crowding. Neck more than 16 to 17 inches, BMI elevated above 33. Head and neck circumference very high. + +IMPRESSION: + +1. Cerebral palsy, worsening seizures. + +2. Hypertension. + +3. Dyslipidemia. + +4. Obstructive sleep apnea. + +5. Obesity. + +RECOMMENDATIONS: + +1. Admission to the EMU + + drop her Carbatrol 200 b.i.d. + + monitor for any epileptiform activity. Initial time of admission is 3 nights and 3 days. + +2. Outpatient polysomnogram to evaluate for obstructive sleep apnea followed by depression if clinically indicated. Continue her other medications. + +3. Consult Dr. X for hypertension, internal medicine management. + +4. I will follow this patient per EMU protocol. \ No newline at end of file diff --git a/2945_Neurology.txt b/2945_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..c7af3d86895be3762fca0198e589d3daf24d57e4 --- /dev/null +++ b/2945_Neurology.txt @@ -0,0 +1,45 @@ +PREOPERATIVE DIAGNOSES: + + Multiple metastatic lesions to the brain, a subtentorial lesion on the left, greater than 3 cm, and an infratentorial lesion on the right, greater than 3 cm. + +POSTOPERATIVE DIAGNOSES: + + Multiple metastatic lesions to the brain, a subtentorial lesion on the left, greater than 3 cm, and an infratentorial lesion on the right, greater than 3 cm. + +TITLE OF THE OPERATION: + +1. Biparietal craniotomy and excision of left parietooccipital metastasis from breast cancer. + +2. Insertion of left lateral ventriculostomy under Stealth stereotactic guidance. + +3. Right suboccipital craniectomy and excision of tumor. + +4. Microtechniques for all the above. + +5. Stealth stereotactic guidance for all of the above and intraoperative ultrasound. + +INDICATIONS: + + The patient is a 48-year-old woman with a diagnosis of breast cancer made five years ago. A year ago, she was diagnosed with cranial metastases and underwent whole brain radiation. She recently has deteriorated such that she came to my office, unable to ambulate in a wheelchair. Metastatic workup does reveal multiple bone metastases, but no spinal cord compression. She had a consult with Radiation-Oncology that decided they could radiate her metastases less than 3 cm with stereotactic radiosurgery, but the lesions greater than 3 cm needed to be removed. Consequently, this operation is performed. + +PROCEDURE IN DETAIL: + + The patient underwent a planning MRI scan with Stealth protocol. She was brought to the operating room with fiducial still on her scalp. General endotracheal anesthesia was obtained. She was placed on the Mayfield head holder and rolled into the prone position. She was well padded, secured, and so forth. The neck was flexed so as to expose the right suboccipital region as well as the left and right parietooccipital regions. The posterior aspect of the calvarium was shaved and prepared in the usual manner with Betadine soak scrub followed by Betadine paint. This was done only, of course, after fiducial were registered in planning and an excellent accuracy was obtained with the Stealth system. Sterile drapes were applied and the accuracy of the system was confirmed. A biparietal incision was performed. A linear incision was chosen so as to increase her chances of successful wound healing and that she is status post whole brain radiation. A biparietal craniotomy was carried out, carrying about 1 cm over toward the right side and about 4 cm over to the left side as guided by the Stealth stereotactic system. The dura was opened and reflected back to the midline. An inner hemispheric approach was used to reach the very large metastatic tumor. This was very delicate removing the tumor and the co-surgeons switched off to spare one another during the more delicate parts of the operation to remove the tumor. The tumor was wrapped around and included the choroidal vessels. At least one choroidal vessel was sacrificed in order to obtain a gross total excision of the tumor on the parietal occipital region. Bleeding was quite vigorous in some of the arteries and finally, however, was completely controlled. Complete removal of the tumor was confirmed by intraoperative ultrasound. + +Once the tumor had been removed and meticulous hemostasis was obtained, this wound was left opened and attention was turned to the right suboccipital area. A linear incision was made just lateral to the greater occipital nerve. Sharp dissection was carried down in the subcutaneous tissues and Bovie electrocautery was used to reach the skull. A burr hole was placed down low using a craniotome. A craniotomy was turned and then enlarged as a craniectomy to at least 4 cm in diameter. It was carried caudally to the floor of the posterior fossa and rostrally to the transverse sinus. Stealth and ultrasound were used to localize the very large tumor that was within the horizontal hemisphere of the cerebellum. The ventriculostomy had been placed on the left side with the craniotomy and removal of the tumor, and this was draining CSF relieving pressure in the posterior fossa. Upon opening the craniotomy in the parietal occipital region, the brain was noted to be extremely tight, thus necessitating placement of the ventriculostomy. + +At the posterior fossa, a corticectomy was accomplished and the tumor was countered directly. The tumor, as the one above, was removed, both piecemeal and with intraoperative Cavitron Ultrasonic Aspirator. A gross total excision of this tumor was obtained as well. + +I then explored underneath the cerebellum in hopes of finding another metastasis in the CP angle; however, this was just over the lower cranial nerves, and rather than risk paralysis of pharyngeal muscles and voice as well as possibly hearing loss, this lesion was left alone and to be radiated and that it is less than 3 cm in diameter. + +Meticulous hemostasis was obtained for this wound as well. + +The posterior fossa wound was then closed in layers. The dura was closed with interrupted and running mattress of 4-0 Nurolon. The dura was watertight, and it was covered with blue glue. Gelfoam was placed over the dural closure. Then, the muscle and fascia were closed in individual layers using #0 Ethibond. Subcutaneous was closed with interrupted inverted 2-0 and 0 Vicryl, and the skin was closed with running locking 3-0 Nylon. + +For the cranial incision, the ventriculostomy was brought out through a separate stab wound. The bone flap was brought on to the field. The dura was closed with running and interrupted 4-0 Nurolon. At the beginning of the case, dural tack-ups had been made and these were still in place. The sinuses, both the transverse sinus and sagittal sinus, were covered with thrombin-soaked Gelfoam to take care of any small bleeding areas in the sinuses. + +Once the dura was closed, the bone flap was returned to the wound and held in place with the Lorenz microplates. The wound was then closed in layers. The galea was closed with multiple sutures of interrupted 2-0 Vicryl. The skin was closed with a running locking 3-0 Nylon. + +Estimated blood loss for the case was more than 1 L. The patient received 2 units of packed red cells during the case as well as more than 1 L of Hespan and almost 3 L of crystalloid. + +Nevertheless, her vitals remained stable throughout the case, and we hopefully helped her survival and her long-term neurologic status for this really nice lady. \ No newline at end of file diff --git a/2946_Neurology.txt b/2946_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..b7cf70af8f9c74e40f10162dfc417a1be7fd2c02 --- /dev/null +++ b/2946_Neurology.txt @@ -0,0 +1,63 @@ +HISTORY OF PRESENT ILLNESS: + + The patient is a 36-year-old female with past medical history of migraine headaches, who was brought to the ER after she was having uncontrolled headaches. In the ER + + the patient had a CT scan done, which was reported negative, and lumbar puncture with normal pressure and the cell count, and was admitted for followup. Neurology consult was called to evaluate the patient in view of the current symptomatology. The headaches were refractory to the treatment. The patient has been on Topamax and Maxalt in the past, but did not work and according to the patient she got more confused. + +PAST MEDICAL HISTORY: + + History of migraine. + +PAST SURGICAL HISTORY: + +Significant for partial oophorectomy, appendectomy, and abdominoplasty. + +SOCIAL HISTORY: + +No history of any smoking, alcohol, or drug abuse. The patient is a registered nurse by profession. + +MEDICATIONS: + + Currently taking no medication. + +ALLERGIES: + + No known allergies. + +FAMILY HISTORY: + + Nothing significant. + +REVIEW OF SYSTEMS: + + The patient was considered to ask systemic review including neurology, psychiatry, sleep, ENT + + ophthalmology, pulmonary, cardiology, gastroenterology, genitourinary, hematology, rheumatology, dermatology, allergy, immunology, endocrinology, toxicology, oncology, and was found to be positive for the symptoms mentioned in the history of the presenting illness. + +PHYSICAL EXAMINATION + +VITAL SIGNS: Blood pressure of 115/66, heart rate of 69, respiratory rate of 13, temperature normal, and pulse oximetry 98% on room air at the time of initial evaluation. + +HEENT: Head, normocephalic, atraumatic. Neck supple. Throat clear. No discharge from the ears or nose. No discoloration of conjunctivae and sclerae. No bruits auscultated over temple, orbits, or the neck. + +LUNGS: Clear to auscultation. + +CARDIOVASCULAR: Normal heart sounds. + +ABDOMEN: Benign. + +EXTREMITIES: No edema, clubbing or cyanosis. + +SKIN: No rash. No neurocutaneous disorder. + +MENTAL STATUS: The patient is awake, alert and oriented to place and person. Speech is fluent. No language deficits. Mood normal. Affect is clear. Memory and insight is normal. No abnormality with thought processing and thought content. Cranial nerve examination intact II through XII. Motor examination: Normal bulk, tone and power. Deep tendon reflexes symmetrical. Downgoing toes. No sign of any myelopathy. Cortical sensation intact. Peripheral sensation grossly intact. Vibratory sense not tested. Gait not tested. Coordination is normal with no dysmetria. + +IMPRESSION: + + Intractable headaches, by description to be migraines. Complicated migraines by clinical criteria. Rule out sinusitis. Rule out vasculitis including temporal and arthritis, lupus, polyarthritis, moyamoya disease, Takayasu and Kawasaki disease. + +PLAN AND RECOMMENDATIONS: + + The patient to be given a trial of the prednisone with a plan to taper off in 6 days, as she already had received 50 mg today. Depakote as a part of migraine prophylaxis and Fioricet on p.r.n. basis. + +The patient to get vasculitis workup, as it has not been ordered by the primary care physician initially. The patient already had MRI of the brain and the cervical spine. MRI of the brain reported negative and cervical spine as shown signs of disk protrusion at C5 and C6 level, which will not explain of the temporal headache. Plan and followup discussed with the patient in detail. \ No newline at end of file diff --git a/2947_Neurology.txt b/2947_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..bb0ec2be3f002006a6300c780ea1de36830c412a --- /dev/null +++ b/2947_Neurology.txt @@ -0,0 +1,31 @@ +PREOPERATIVE DIAGNOSIS: + + Right frontotemporal chronic subacute subdural hematoma. + +POSTOPERATIVE DIAGNOSIS: + + Right frontotemporal chronic subacute subdural hematoma. + +TITLE OF THE OPERATION: + + Right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques. + +ASSISTANT: + + None. + +INDICATIONS: + + The patient is a 75-year-old man with a 6-week history of decline following a head injury. He was rendered unconscious by the head injury. He underwent an extensive syncopal workup in Mississippi. This workup was negative. The patient does indeed have a heart pacemaker. The patient was admitted to ABCD three days ago and yesterday underwent a CT scan, which showed a large appearance of subdural hematoma. There is a history of some bladder tumors and so a scan with contrast was obtained that showed some enhancement in the membranes. I decided to perform a craniotomy rather than burr hole drainage because of the enhancing membranes and the history of a bladder tumor undefined as well as layering of the blood within the cavity. The patient and the family understood the nature, indications, and risk of the surgery and agreed to go ahead. + +DESCRIPTION OF PROCEDURE: + +The patient was brought to the operating room where general and endotracheal anesthesia was obtained. The head was turned over to the left side and was supported on a cushion. There was a roll beneath the right shoulder. The right calvarium was shaved and prepared in the usual manner with Betadine-soaked scrub followed by Betadine paint. Markings were applied. Sterile drapes were applied. A linear incision was made more or less along the coronal suture extending from just above the ear up to near the midline. Sharp dissection was carried down into subcutaneous tissue and Bovie electrocautery was used to divide the galea and the temporalis muscle and fascia. Weitlaner retractors were inserted. A single bur hole was placed underneath the temporalis muscle. I placed the craniotomy a bit low in order to have better cosmesis. A cookie cutter type craniotomy was then carried out in dimensions about 5 cm x 4 cm. The bone was set aside. The dura was clearly discolored and very tense. The dura was opened in a cruciate fashion with a #15 blade. There was immediate flow of a thin motor oil fluid under high pressure. Literally the fluid shot out several inches with the first nick in the membranous cavity. The dura was reflected back and biopsy of the membranes was taken and sent for permanent section. The margins of the membrane were coagulated. The microscope was brought in and it was apparent there were septations within the cavity and these septations were for the most part divided with bipolar electrocautery. The wound was irrigated thoroughly and was inspected carefully for any sites of bleeding and there were none. The dura was then closed in a watertight fashion using running locking 4-0 Nurolon. Tack-up sutures had been placed at the beginning of the case and the bone flap was returned to the wound and fixed to the skull using the Lorenz plating system. The wound was irrigated thoroughly once more and was closed in layers. Muscle fascia and galea were closed in separate layers with interrupted inverted 2-0 Vicryl. Finally, the skin was closed with running locking 3-0 nylon. + +Estimated blood loss for the case was less than 30 mL. Sponge and needle counts were correct. + +FINDINGS: + + Chronic subdural hematoma with multiple septations and thickened subdural membrane. + +I might add that the arachnoid was not violated at all during this procedure. Also, it was noted that there was no subarachnoid blood but only subdural blood. \ No newline at end of file diff --git a/2949_Neurology.txt b/2949_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..6ab5a5b9a65dd854d80d3474291f2e523840f7c4 --- /dev/null +++ b/2949_Neurology.txt @@ -0,0 +1,23 @@ +PREOPERATIVE DIAGNOSIS: + + Right chronic subdural hematoma. + +POSTOPERATIVE DIAGNOSIS: + +Right chronic subdural hematoma. + +TYPE OF OPERATION: + + Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain. + +ANESTHESIA: + + General endotracheal anesthesia. + +ESTIMATED BLOOD LOSS: + + 100 cc. + +OPERATIVE PROCEDURE: + + In preoperative identification, the patient was taken to the operating room and placed in supine position. Following induction of satisfactory general endotracheal anesthesia, the patient was prepared for surgery. Table was turned. The right shoulder roll was placed. The head was turned to the left and rested on a doughnut. The scalp was shaved, and then prepped and draped in usual sterile fashion. Incisions were marked along a putative right frontotemporal craniotomy frontally and over the parietal boss. The parietal boss incision was opened. It was about an inch and a half in length. It was carried down to the skull. Self-retaining retractor was placed. A bur hole was now fashioned with the perforator. This was widened with a 2-mm Kerrison punch. The dura was now coagulated with bipolar electrocautery. It was opened in a cruciate-type fashion. The dural edges were coagulated back to the bony edges. There was egress of a large amount of liquid. Under pressure, we irrigated for quite sometime until irrigation was returning mostly clear. A subdural drain was now inserted under direct vision into the subdural space and brought out through a separate stab incision. It was secured with a 3-0 nylon suture. The area was closed with interrupted inverted 2-0 Vicryl sutures. The skin was closed with staples. Sterile dressing was applied. The patient was subsequently returned back to anesthesia. He was extubated in the operating room, and transported to PACU in satisfactory condition. \ No newline at end of file diff --git a/2951_Neurology.txt b/2951_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..2e97626a2a9d2bc2287bb8acc1a30f9d28236449 --- /dev/null +++ b/2951_Neurology.txt @@ -0,0 +1,49 @@ +FAMILY HISTORY AND SOCIAL HISTORY: + + Reviewed and remained unchanged. + +MEDICATIONS: + + List remained unchanged including Plavix, aspirin, levothyroxine, lisinopril, hydrochlorothiazide, Lasix, insulin and simvastatin. + +ALLERGIES: + + She has no known drug allergies. + +FALL RISK ASSESSMENT: + + Completed and there was no history of falls. + +REVIEW OF SYSTEMS: + +Full review of systems again was pertinent for shortness of breath, lack of energy, diabetes, hypothyroidism, weakness, numbness and joint pain. Rest of them was negative. + +PHYSICAL EXAMINATION: + +Vital Signs: Today, blood pressure was 170/66, heart rate was 66, respiratory rate was 16, she weighed 254 pounds as stated, and temperature was 98.0. + +General: She was a pleasant person in no acute distress. + +HEENT: Normocephalic and atraumatic. No dry mouth. No palpable cervical lymph nodes. Her conjunctivae and sclerae were clear. + +NEUROLOGICAL EXAMINATION: + + Remained unchanged. + +Mental Status: Normal. + +Cranial Nerves: Mild decrease in the left nasolabial fold. + +Motor: There was mild increased tone in the left upper extremity. Deltoids showed 5-/5. The rest showed full strength. Hip flexion again was 5-/5 on the left. The rest showed full strength. + +Reflexes: Reflexes were hypoactive and symmetrical. + +Gait: She was mildly abnormal. No ataxia noted. Wide-based, ambulated with a cane. + +IMPRESSION: + + Status post cerebrovascular accident involving the right upper pons extending into the right cerebral peduncle with a mild left hemiparesis, has been clinically stable with mild improvement. She is planned for surgical intervention for the internal carotid artery. + +RECOMMENDATIONS: + + At this time, again we discussed continued use of antiplatelet therapy and statin therapy to reduce her risk of future strokes. She will continue to follow with endocrinology for diabetes and thyroid problems. I have recommended a strict control of her blood sugar, optimizing cholesterol and blood pressure control, regular exercise and healthy diet and I have discussed with Ms. A and her daughter to give us a call for post surgical recovery. I will see her back in about four months or sooner if needed. \ No newline at end of file diff --git a/2956_Neurology.txt b/2956_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..1896fefad8632a59172afb129b05bc149a388c6c --- /dev/null +++ b/2956_Neurology.txt @@ -0,0 +1,59 @@ +HISTORY OF PRESENT ILLNESS: + + This is a 58-year-old male who reports a six to eight-week history of balance problems with fatigue and weakness. He has had several falls recently. He apparently had pneumonia 10 days prior to the onset of the symptoms. He took a course of amoxicillin for this. He complained of increased symptoms with more and more difficulty with coordination. He fell at some point near the onset of the symptoms, but believes that his symptoms had occurred first. He fell from three to five feet and landed on his back. He began seeing a chiropractor approximately five days ago and had adjustments of the neck and lumbar spine, although he clearly had symptoms prior to this. + +He has had mid and low back pain intermittently. He took a 10-day course of Cipro believing that he had a UTI. He denies, however, any bowel or bladder problems. There is no incontinence and he does not feel that he is having any difficulty voiding. + +PAST SURGICAL HISTORY: + + He has a history of surgery on the left kidney, when it was "rebuilt." He has had knee surgery, appendectomy and right inguinal hernia repair. + +MEDICATIONS: + + His only home medications had been Cipro and Aleve. However, he does take aspirin and several over the counter supplements including a multivitamin with iron, "natural" potassium, Starlix and the aspirin. + +ALLERGIES: + + HE HAS NO KNOWN DRUG ALLERGIES. + +SOCIAL HISTORY: + + He smokes one-and-one-half-packs of cigarettes per day and drinks alcohol at least several days per week. He is employed in sales, which requires quite a bit of walking, but he is not doing any lifting. He had been a golfer in the past. + +PAST MEDICAL HISTORY: + + He has had documented cervical spondylosis, apparently with an evaluation over 15 years ago. + +PHYSICAL EXAMINATION: + +VITAL SIGNS: Blood pressure 156/101, pulse was 88, respirations 18. He is afebrile. + +MENTAL STATUS: He is alert. + +CRANIAL NERVES: His pupils were reactive to light. He had a dense left cataract present. The right disk margin appears sharp. His eye movements were full. The face was symmetric. Pain and temperature sensation were intact over both sides of the face. The tongue was midline. + +NECK: His neck was supple. + +MUSCULOSKELETAL: He has intact strength and normal tone in the upper extremities. He had increased tone in both lower extremities. He had hip flexion of 4/5 on the left. He had intact strength on the right lower extremity, although had slight hammertoe deformity bilaterally. + +NEUROLOGIC: His reflexes were 2+ in the upper extremities, 3+ at the knees and 1+ at the ankles. He withdrew to plantar stimulation on the left, but did not have a Babinski response clearly present. He had intact finger-to-nose testing. Marked impairment in heel-to-shin testing. He was able to sit unassisted. He stood with assistance, but had a markedly ataxic gait. On sensory exam, he had a slight distal gradient to pin and vibratory sense in both lower extremities, but also had a decrease in sensation to pin over the right lower extremity compared to the left. + +CARDIOVASCULAR: He had no carotid bruits. His heart rhythm was regular. + +BACK: There was no focal back pain present. He did have a slight sensory level at the upper T spine at approximately T3, both anteriorly and posteriorly. + +RADIOLOGIC DATA: + + MRI by my view showed essentially unremarkable T spine. The MRI of his C spine showed significant spondylosis in the mid and lower C spine with spondylolisthesis at C7-T1. There is an abnormal signal in the cord which begins at approximately this level, but descends approximately 2 cm. There is slight enhancement at the mid-portion of the lesion. This appears to be an intrinsic lesion to the cord, not clearly associated with mild to moderate spinal stenosis at the level of the spondylolisthesis. + +LABORATORY: + +His initial labs were unremarkable. + +IMPRESSION: + +Cervical cord lesion at the C7 to T2 level of unclear etiology. Consider a transverse myelitis, tumor, contusion or ischemic lesion. + +PLAN: + + Will check labs including sedimentation rate, MRI of the brain, chest x-ray. He will probably need a lumbar puncture. He also appears to have a mild peripheral neuropathy, which I suspect is an independent problem. We will request labs for this. \ No newline at end of file diff --git a/2957_Neurology.txt b/2957_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..756bcfcbffbd309f1cd11782e42e3c2e49681889 --- /dev/null +++ b/2957_Neurology.txt @@ -0,0 +1,51 @@ +REASON FOR NEUROLOGICAL CONSULTATION: + + Cervical spondylosis and kyphotic deformity. The patient was seen in conjunction with medical resident Dr. X. I personally obtained the history, performed examination, and generated the impression and plan. + +HISTORY OF PRESENT ILLNESS: + +The patient is a 45-year-old African-American female whose symptoms first started some one and a half years ago with pain in the left shoulder and some neck pain. This has subsequently resolved. She started vigorous workouts in November 2005. In March of this year, she suddenly could not feel her right foot on the bathroom floor and subsequently went to her primary care physician. By her report, she had a nerve conduction study and a diagnosis of radiculopathy was made. She had an MRI of lumbosacral spine, which was within normal limits. She then developed a tingling sensation in the right middle toe. Symptoms progressed to sensory symptoms of her knees, elbows, and left middle toe. She then started getting sensory sensations in the left hand and arm. She states that she feels a little bit wobbly at the knees and that she is slightly dragging her left leg. Symptoms have been mildly progressive. She is unaware of any trigger other than the vigorous workouts as mentioned above. She has no associated bowel or bladder symptoms. No particular position relieves her symptoms. + +Workup has included two MRIs of the C-spine, which were personally reviewed and are discussed below. She saw you for consultation and the possibility of surgical decompression was raised. At this time, she is somewhat reluctant to go through any surgical procedure. + +PAST MEDICAL HISTORY: + +1. Ocular migraines. + +2. Myomectomy. + +3. Infertility. + +4. Hyperglycemia. + +5. Asthma. + +6. Hypercholesterolemia. + +MEDICATIONS: + + Lipitor, Pulmicort, Allegra, Xopenex, Patanol, Duac topical gel, Loprox cream, and Rhinocort. + +ALLERGIES: + + Penicillin and aspirin. + +Family history, social history, and review of systems are discussed above as well as documented in the new patient information sheet. Of note, she does not drink or smoke. She is married with two adopted children. She is a paralegal specialist. She used to exercise vigorously, but of late has been advised to stop exercising and is currently only walking. + +REVIEW OF SYSTEMS: + + She does complain of mild blurred vision, but these have occurred before and seem associated with headaches. + +PHYSICAL EXAMINATION: + + On examination, blood pressure 138/82, pulse 90, respiratory rate 14, and weight 176.5 pounds. Pain scale is 0. A full general and neurological examination was personally performed and is documented on the chart. Of note, she has a normal general examination. Neurological examination reveals normal cognition and cranial nerve examination including normal jaw jerk. She has mild postural tremor in both arms. She has mild decreased sensation in the right palm and mild decreased light touch in the right palm and decreased vibration sense in both distal lower extremities. Motor examination reveals no weakness to individual muscle testing, but on gait she does have a very subtle left hemiparesis. She has hyperreflexia in her lower extremities, worse on the left. Babinski's are downgoing. + +PERTINENT DATA: + +MRI of the brain from 05/02/06 and MRI of the C-spine from 05/02/06 and 07/25/06 were personally reviewed. MRI of the brain is broadly within normal limits. MRI of the C-spine reveals large central disc herniation at C6-C7 with evidence of mild cord compression and abnormal signal in the cord suggesting cord edema. There is also a fairly large disc at C3-C4 with cord deformity and partial effacement of the subarachnoid space. I do not appreciate any cord edema at this level. + +IMPRESSION AND PLAN: + +The patient is a 45-year-old female with cervical spondylosis with a large C6-C7 herniated disc with mild cord compression and signal change at that level. She has a small disc at C3-C4 with less severe and only subtle cord compression. History and examination are consistent with signs of a myelopathy. + +Results were discussed with the patient and her mother. I am concerned about progressive symptoms. Although she only has subtle symptoms now, we made her aware that with progression of this process, she may have paralysis. If she is involved in any type of trauma to the neck such as motor vehicle accident, she could have an acute paralysis. I strongly recommended to her and her mother that she followup with you as soon as possible for surgical evaluation. I agree with the previous physicians who have told her not to exercise as I am sure that her vigorous workouts and weight training since November 2005 have contributed to this problem. I have recommended that she wear a hard collar while driving. The results of my consultation were discussed with you telephonically. \ No newline at end of file diff --git a/2958_Neurology.txt b/2958_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..4775981a4bbf69274f7da14680a5d547d84d9026 --- /dev/null +++ b/2958_Neurology.txt @@ -0,0 +1,7 @@ +Doctor's Address,Dear Doctor: + +This letter serves as an introduction to my patient, A, who will be seeing you in the near future. He is a pleasant young man who has a diagnosis of bulbar cerebral palsy and hypotonia. He has been treated by Dr. X through the pediatric neurology clinic. He saw Dr. X recently and she noted that he was having difficulty with mouth breathing, which was contributing to some of his speech problems. She also noted and confirmed that he has significant tonsillar hypertrophy. The concern we have is whether he may benefit from surgery to remove his tonsils and improve his mouth breathing and his swallowing and speech. Therefore, I ask for your opinion on this matter. + +For his chronic allergic rhinitis symptoms, he is currently on Flonase two sprays to each nostril once a day. He also has been taking Zyrtec 10 mg a day with only partial relief of the symptoms. He does have an allergy to penicillin. + +I appreciate your input on his care. If you have any questions regarding, please feel free to call me through my office. Otherwise, I look forward to hearing back from you regarding his evaluation. \ No newline at end of file diff --git a/2967_Neurology.txt b/2967_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..23baeef59efb33d55f85c0463034f4f5eff9189a --- /dev/null +++ b/2967_Neurology.txt @@ -0,0 +1,23 @@ +CC: + + Headache. + +HX: + + 63 y/o RHF first seen by Neurology on 9/14/71 for complaint of episodic vertigo. During that evaluation she described a several year history of "migraine" headaches. She experienced her first episode of vertigo in 1969. The vertigo (clockwise) typically began suddenly after lying down, and was not associated with nausea/vomiting/headache. The vertigo had not been consistently associated with positional change and could last hours to days. + +On 3/15/71, after 5 day bout of vertigo, right ear ache, and difficulty ambulating (secondary to the vertigo) she sought medical attention and underwent an audiogram which reportedly showed a 20% decline in low tone acuity AD. She complained of associated tinnitus which she described as a "whistle." In addition, her symptoms appeared to worsen with changes in head position (i.e. looking up or down). The symptoms gradually resolved and she did well until 8/71 when she experienced a 19-day episode of vertigo, tinnitus and intermittent headaches. She was seen 9/14/71, in Neurology, and admitted for evaluation. + +Her neurologic exam at that time was unremarkable except for prominent bilateral systolic carotid bruits. Cerebral angiogram revealed an inoperable 7 x 6cm AVM in the right parietal region. The AVM was primarily fed by the right MCA. Otolaryngologic evaluation concluded that she probably also suffered from Meniere's disease. + +On 10/14/74 she underwent a 21 day admission for SAH secondary to right parietal AVM. + +On 11/23/91 she was admitted for left sided weakness (LUE > LLE) + + headache, and transient visual change. Neurological exam confirmed left sided weakness, and dysesthesia of the LUE only. Brain CT confirmed a 3 x 4 cm left parietal hemorrhage. She underwent unsuccessful embolization. Neuroradiology had planned to do 3 separate embolizations, but during the first, via the left MCA + + they were unable to cannulate many of the AVM vessels and abandoned the procedure. She recovered with residual left hemisensory loss. + +In 12/92 she presented with an interventricular hemorrhage and was managed conservatively and refused any future neuroradiologic intervention. + +In 1/93 she reconsidered neurointerventional procedure and was scheduled for evaluation at the Barrows Neurological Institute in Phoenix, AZ. \ No newline at end of file diff --git a/2970_Neurology.txt b/2970_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..72e97667a4c0ff698131b908a8bf8c9dc192d01d --- /dev/null +++ b/2970_Neurology.txt @@ -0,0 +1,55 @@ +CC: + +Episodic confusion. + +HX: + +This 65 y/o RHM reportedly suffered a stroke on 1/17/92. He presented locally at that time with complaint of episodic confusion and memory loss lasting several minutes per episode. The "stroke" was reportedly verified on MRI scan dated 1/17/92. He was subsequently placed on ASA and DPH. He admitted that there had been short periods (1-2 days duration) since then, during which he had forgotten to take his DPH. However, even when he had been taking his DPH regularly, he continued to experience the spells mentioned above. He denied any associated tonic/clonic movement, incontinence, tongue-biting, HA + + visual change, SOB + + palpitation, weakness or numbness. The episodes of confusion and memory loss last 1-2 minutes in duration, and have been occurring 2-3 times per week. + +PMH: + + Bilateral Hearing Loss of unknown etiology, S/P bilateral ear surgery many years ago. + +MEDS: + + DPH and ASA + +SHX/FHX: + + 2-4 Beers/day. 1-2 packs of cigarettes per day. + +EXAM: + + BP 111/68, P 68BPM + + 36.8C. Alert and Oriented to person, place and time, 30/30 on mini-mental status test, Speech fluent and without dysarthria. CN: Left superior quandranopia only. Motor: 5/5 strength throughout. Sensory: unremarkable except for mild decreased vibration sense in feet. Coordination: unremarkable. Gait and station testing were unremarkable. He was able to tandem walk without difficulty. Reflexes: 2+ and symmetric throughout. Flexor plantar responses bilaterally. + +LAB: + + Gen Screen, CBC + + PT + + PTT all WNL. DPH 4.6mcg/ml. + +Review of outside MRI Brain done 1/17/92 revealed decreased T1 and increased T2 signal in the Right temporal lobe involving the uncus and adjacent hippocampus. The area did not enhance with gadolinium contrast. + +CXR: + + 8/31/92: 5 x 6 mm spiculated opacity in apex right lung. + +EEG: + + 8/24/92: normal awake and asleep,MRI Brain with/without contrast: 8/31/92: Decreased T1 and increased T2 signal in the right temporal lobe. The lesion increased in size and enhances more greatly when compared to the 1/17/92 MRI exam. There is also edema surrounding the affected area and associated mass effect. + +NEUROPSYCHOLOGICAL TESTING: + + Low-average digit symbol substitution, mildly impaired verbal learning, and severely defective delayed recall. There was relative preservation of other cognitive functions. The findings were consistent with left mesiotemporal dysfunction. + +COURSE: + +Patient underwent right temporal lobectomy on 9/16/92 following initial treatment with Decadron. Pathologic analysis was consistent with a Grade 2 astrocytoma. GFAP staining positive. Following surgery he underwent 5040 cGy radiation therapy in 28 fractions to the tumor bed. \ No newline at end of file diff --git a/2971_Neurology.txt b/2971_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..e769c476be465899921529c2dab80580e6fd0b84 --- /dev/null +++ b/2971_Neurology.txt @@ -0,0 +1,73 @@ +HISTORY OF PRESENT ILLNESS: + +The patient is a 58-year-old right-handed gentleman who presents for further evaluation of right arm pain. He states that a little less than a year ago he developed pain in his right arm. It is intermittent, but has persisted since that time. He describes that he experiences a dull pain in his upper outer arm. It occurs on a daily basis. He also experiences an achy sensation in his right hand radiating to the fingers. There is no numbness or paresthesias in the hand or arm. + +He has had a 30-year history of neck pain. He sought medical attention for this problem in 2006, when he developed ear pain. This eventually led to him undergoing an MRI of the cervical spine, which showed some degenerative changes. He was then referred to Dr. X for treatment of neck pain. He has been receiving epidural injections under the care of Dr. X since 2007. When I asked him what symptom he is receiving the injections for, he states that it is for neck pain and now the more recent onset of arm pain. He also has taken several Medrol dose packs, which has caused his blood sugars to increase. He is taking multiple other pain medications. The pain does not interfere significantly with his quality of life, although he has a constant nagging pain. + +PAST MEDICAL HISTORY: + + He has had diabetes since 2003. He also has asthma, hypertension, and hypercholesterolemia. + +CURRENT MEDICATIONS: + + He takes ACTOplus, albuterol, AndroGel, Astelin, Diovan, Dolgic Plus, aspirin 81 mg, fish oil, Lipitor, Lorazepam, multivitamins, Nasacort, Pulmicort, ranitidine, Singulair, Viagra, Zetia, Zyrtec, and Uroxatral. He also uses Lidoderm patches and multiple eye drops and creams. + +ALLERGIES: + + He states that Dyazide, Zithromax, and amoxicillin cause him to feel warm and itchy. + +FAMILY HISTORY: + + His father died from breast cancer. He also had diabetes. He has a strong family history of diabetes. His mother is 89. He has a sister with diabetes. He is unaware of any family members with neurological disorders. + +SOCIAL HISTORY: + + He lives alone. He works full time in Human Resources for the State of Maryland. He previously was an alcoholic, but quit in 1984. He also quit smoking cigarettes in 1984, after 16 years of smoking. He has a history of illicit drug use, but denies IV drug use. He denies any HIV risk factors and states that his last HIV test was over two years ago. + +REVIEW OF SYSTEMS: + + He has intermittent chest discomfort. He has chronic tinnitus. He has urinary dribbling. Otherwise, a complete review of systems was obtained and was negative except for as mentioned above. This is documented in the handwritten notes from today's visit. + +PHYSICAL EXAMINATION: + +Vital Signs: HR 72. RR 16. + +General Appearance: Patient is well appearing, in no acute distress. + +Cardiovascular: There is a regular rhythm without murmurs, gallops, or rubs. There are no carotid bruits. + +Chest: The lungs are clear to auscultation bilaterally. + +Skin: There are no rashes or lesions. + +NEUROLOGICAL EXAMINATION: + +Mental Status: Speech is fluent without dysarthria or aphasia. The patient is alert and oriented to name, place, and date. Attention, concentration, registration, recall, and fund of knowledge are all intact. + +Cranial Nerves: Pupils are equal, round, and reactive to light and accommodation. Optic discs are normal. Visual fields are full. Extraocular movements are intact without nystagmus. Facial sensation is normal. There is no facial, jaw, palate, or tongue weakness. Hearing is grossly intact. Shoulder shrug is full. + +Motor: There is normal muscle bulk and tone. There is no atrophy or fasciculations. There is no action or percussion myotonia or paramyotonia. Manual muscle testing reveals MRC grade 5/5 strength in all proximal and distal muscles of the upper and lower extremities. + +Sensory: Sensation is intact to light touch, pinprick, temperature, vibratory sensation, and joint position sense. Romberg is absent. + +Coordination: There is no dysmetria or ataxia on finger-nose-finger or heel-to-shin testing. + +Deep Tendon Reflexes: Deep tendon reflexes are 2+ at the biceps, triceps, brachioradialis, patellas and ankles. Plantar reflexes are flexor. There are no finger flexors, Hoffman's sign, or jaw jerk. + +Gait and Stance: Casual gait is normal. Heel, toe, and tandem walking are all normal. + +RADIOLOGIC DATA: + + MRI of the cervical spine, 05/19/08: I personally reviewed this film, which showed narrowing of the foramen on the right at C4-C5 and other degenerative changes without central stenosis. + +IMPRESSION: + +The patient is a 58-year-old gentleman with one-year history of right arm pain. He also has a longstanding history of neck pain. His neurological examination is normal. He has an MRI that shows some degenerative changes. I do believe that his symptoms are probably referable to his neck. However, I do not think that they are severe enough for him to undergo surgery at this point in time. Perhaps another course of physical therapy may be helpful for him. I probably would not recommend anymore invasive procedure, such as a spinal stimulator, as this pain really is minimal. We could still try to treat him with neuropathic pain medications. + +RECOMMENDATIONS: + +1. I scheduled him to return for an EMG and nerve conduction studies to determine whether there is any evidence of nerve damage, although I think the likelihood is low. + +2. I gave him a prescription for Neurontin. I discussed the side effects of the medication with him. + +3. We can discuss his case tomorrow at Spine Conference to see if there are any further recommendations. \ No newline at end of file diff --git a/2972_Neurology.txt b/2972_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..6d76b7c35eca4625c2b0007d3a659b074d2f0c85 --- /dev/null +++ b/2972_Neurology.txt @@ -0,0 +1,21 @@ +XYZ + +RE: ABC + +MEDICAL RECORD#: 123,Dear Dr. XYZ: + +I saw ABC back in Neuro-Oncology Clinic today. He comes in for an urgent visit because of increasing questions about what to do next for his anaplastic astrocytoma. + +Within the last several days, he has seen you in clinic and once again discussed whether or not to undergo radiation for his left temporal lesion. The patient has clearly been extremely ambivalent about this therapy for reasons that are not immediately apparent. It is clear that his MRI is progressing and that it seems unlikely at this time that anything other than radiation would be particularly effective. Despite repeatedly emphasizing this; however, the patient still is worried about potential long-term side effects from treatment that frankly seem unwarranted at this particular time. + +After seeing you in clinic, he and his friend again wanted to discuss possible changes in the chemotherapy regimen. They came in with a list of eight possible agents that they would like to be administered within the next two weeks. They then wanted another MRI to be performed and they were hoping that with the use of this type of approach, they might be able to induce another remission from which he can once again be spared radiation. + +From my view, I noticed a man whose language has deteriorated in the week since I last saw him. This is very worrisome. Today, for the first time, I felt that there was a definite right facial droop as well. Therefore, there is no doubt that he is becoming symptomatic from his growing tumor. It suggests that he is approaching the end of his compliance curve and that the things may rapidly deteriorate in the near future. + +Emphasizing this once again, in addition, to recommending steroids I once again tried to convince him to undergo radiation. Despite an hour, this again amazingly was not possible. It is not that he does not want treatment, however. Because I told him that I did not feel it was ethical to just put him on the radical regimen that him and his friend devised, we compromised and elected to go back to Temodar in a low dose daily type regimen. We would plan on giving 75 mg/sq m everyday for 21 days out of 28 days. In addition, we will stop thalidomide 100 mg/day. If he tolerates this for one week, we then agree that we would institute another one of the medications that he listed for us. At this stage, we are thinking of using Accutane at that point. + +While I am very uncomfortable with this type of approach, I think as long as he is going to be monitored closely that we may be able to get away with this for at least a reasonable interval. In the spirit of compromise, he again consented to be evaluated by radiation and this time, seemed more resigned to the fact that it was going to happen sooner than later. I will look at this as a positive sign because I think radiation is the one therapy from which he can get a reasonable response in the long term. + +I will keep you apprised of followups. If you have any questions or if I could be of any further assistance, feel free to contact me. + +Sincerely, \ No newline at end of file diff --git a/2980_Neurology.txt b/2980_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..c3abcc0829a785c7601dde071b0e226c8221b0ea --- /dev/null +++ b/2980_Neurology.txt @@ -0,0 +1,59 @@ +CC: + + Memory difficulty. + +HX: + +This 64 y/o RHM had had difficulty remembering names, phone numbers and events for 12 months prior to presentation, on 2/28/95. This had been called to his attention by the clerical staff at his parish--he was a Catholic priest. He had had no professional or social faux pas or mishaps due to his memory. He could not tell whether his problem was becoming worse, so he brought himself to the Neurology clinic on his own referral. + +MEDS: + + None. + +PMH: + +1)appendectomy, 2)tonsillectomy, 3)childhood pneumonia, 4)allergy to sulfa drugs. + +FHX: + + Both parents experienced memory problems in their ninth decades, but not earlier. 5 siblings have had no memory trouble. There are no neurological illnesses in his family. + +SHX: + + Catholic priest. Denied Tobacco/ETOH/illicit drug use. + +EXAM: + + BP131/74, HR78, RR12, 36.9C, Wt. 77kg, Ht. 178cm. + +MS: A&O to person, place and time. 29/30 on MMSE; 2/3 recall at 5 minutes. 2/10 word recall at 10 minutes. Unable to remember the name of the President (Clinton). 23words/60 sec on Category fluency testing (normal). Mild visual constructive deficit. + +The rest of the neurologic exam was unremarkable and there were no extrapyramidal signs or primitive reflexes noted. + +COURSE: + + TSH 5.1, T4 7.9, RPR non-reactive. Neuropsychological evaluation, 3/6/95, revealed: 1)well preserved intellectual functioning and orientation, 2) significant deficits in verbal and visual memory, proper naming, category fluency and working memory, 3)performances which were below expectations on tests of speed of reading, visual scanning, visual construction and clock drawing, 4)limited insight into the scope and magnitude of cognitive dysfunction. The findings indicated multiple areas of cerebral dysfunction. With the exception of the patient's report of minimal occupational dysfunction ( which may reflect poor insight) + + the clinical picture is consistent with a progressive dementia syndrome such as Alzheimer's disease. MRI brain, 3/6/95, showed mild generalized atrophy, more severe in the occipital-parietal regions. + +In 4/96, his performance on repeat neuropsychological evaluation was relatively stable. His verbal learning and delayed recognition were within normal limits, whereas delayed recall was "moderately severely" impaired. Immediate and delayed visual memory were slightly below expectations. Temporal orientation and expressive language skills were below expectation, especially in word retrieval. These findings were suggestive of particular, but not exclusive, involvement of the temporal lobes. + +On 9/30/96, he was evaluated for a 5 minute spell of visual loss, OU. The episode occurred on Friday, 9/27/96, in the morning while sitting at his desk doing paperwork. He suddenly felt that his gaze was pulled toward a pile of letters; then a "curtain" came down over both visual fields, like "everything was in the shade." During the episode he felt fully alert and aware of his surroundings. He concurrently heard a "grating sound" in his head. After the episode, he made several phone calls, during which he reportedly sounded confused, and perseverated about opening a bank account. He then drove to visit his sister in Muscatine, Iowa, without accident. He was reportedly "normal" when he reached her house. He was able to perform Mass over the weekend without any difficulty. Neurologic examination, 9/30/96, was notable for: 1)category fluency score of 18items/60 sec. 2)VFFTC and EOM were intact. There was no RAPD + + INO + + loss of visual acuity. Glucose 178 (elevated) + + ESR + +Lipid profile, GS + + CBC with differential, Carotid duplex scan, EKG + + and EEG were all normal. MRI brain, 9/30/96, was unchanged from previous, 3/6/95. + +On 1/3/97, he had a 30 second spell of lightheadedness without vertigo, but with balance difficulty, after picking up a box of books. The episode was felt due to orthostatic changes. + +1/8/97 neuropsychological evaluation was stable and his MMSE score was 25/30 (with deficits in visual construction, orientation, and 2/3 recall at 1 minute). Category fluency score 23 items/60 sec. Neurologic exam was notable for graphesthesia in the left hand. + +In 2/97, he had episodes of anxiety, marked fluctuations in job performance and resigned his pastoral position. His neurologic exam was unchanged. An FDG-PET scan on 2/14/97 revealed decreased uptake in the right posterior temporal-parietal and lateral occipital regions. \ No newline at end of file diff --git a/2982_Neurology.txt b/2982_Neurology.txt new file mode 100644 index 0000000000000000000000000000000000000000..d4281d62972e85e6b74ffe8005f5ab49de997cd3 --- /dev/null +++ b/2982_Neurology.txt @@ -0,0 +1,91 @@ +REASON FOR VISIT: + + The patient is a 74-year-old woman who presents for neurological consultation referred by Dr. X. She is accompanied to the appointment by her husband and together they give her history. + +HISTORY OF PRESENT ILLNESS: + + The patient is a lovely 74-year-old woman who presents with possible adult hydrocephalus. Danish is her native language, but she has been in the United States for many many years and speaks fluent English, as does her husband. + +With respect to her walking and balance, she states "I think I walk funny." Her husband has noticed over the last six months or so that she has broadened her base and become more stooped in her pasture. Her balance has also gradually declined such that she frequently touches walls and furniture to stabilize herself. She has difficulty stepping up on to things like a scale because of this imbalance. She does not festinate. Her husband has noticed some slowing of her speed. She does not need to use an assistive device. She has occasional difficulty getting in and out of a car. Recently she has had more frequent falls. In March of 2007, she fell when she was walking to the bedroom and broke her wrist. Since that time, she has not had any emergency room trips, but she has had other falls. + +With respect to her bowel and bladder, she has no issues and no trouble with frequency or urgency. + +The patient does not have headaches. + +With respect to thinking and memory, she states she is still able to pay the bills, but over the last few months she states, "I do not feel as smart as I used to be." She feels that her thinking has slowed down. Her husband states that he has noticed, she will occasionally start a sentence and then not know what words to use as she is continuing. + +The patient has not had trouble with syncope. She has had past episodes of vertigo, but not recently. + +PAST MEDICAL HISTORY: + +Significant for hypertension diagnosed in 2006, reflux in 2000, insomnia, but no snoring or apnea. She has been on Ambien, which is no longer been helpful. She has had arthritis since year 2000, thyroid abnormalities diagnosed in 1968, a hysterectomy in 1986, and a right wrist operation after her fall in 2007 with a titanium plate and eight screws. + +FAMILY HISTORY: + + Her father died with heart disease in his 60s and her mother died of colon cancer. She has a sister who she believes is probably healthy. She has had two sons one who died of a blood clot after having been a heavy smoker and another who is healthy. She has two normal vaginal deliveries. + +SOCIAL HISTORY: + +She lives with her husband. She is a nonsmoker and no history of drug or alcohol abuse. She does drink two to three drinks daily. She completed 12th grade. + +ALLERGIES: + + Codeine and sulfa. + +She has a Living Will and if unable to make decisions for herself, she would want her husband, Vilheim to make decisions for her. + +MEDICATIONS + +: Premarin 0.625 mg p.o. q.o.d. + + Aciphex 20 mg p.o. q. daily, Toprol 50 mg p.o. q. daily, Norvasc 5 mg p.o. q. daily, multivitamin, Caltrate plus D, B-complex vitamins, calcium and magnesium, and vitamin C daily. + +MAJOR FINDINGS: + + On examination today, this is a pleasant and healthy appearing woman. + +VITAL SIGNS: Blood pressure 154/72, heart rate 87, and weight 153 pounds. Pain is 0/10. + +HEAD: Head is normocephalic and atraumatic. Head circumference is 54 cm, which is in the 10-25th percentile for a woman who is 5 foot and 6 inches tall. + +SPINE: Spine is straight and nontender. Spinous processes are easily palpable. She has very mild kyphosis, but no scoliosis. + +SKIN: There are no neurocutaneous stigmata. + +CARDIOVASCULAR EXAM: Regular rate and rhythm. No carotid bruits. No edema. No murmur. Peripheral pulses are good. Lungs are clear. + +MENTAL STATUS: Assessed for recent and remote memory, attention span, concentration, and fund of knowledge. She scored 30/30 on the MMSE when attention was tested with either spelling or calculations. She had no difficulty with visual structures. + +CRANIAL NERVES: Pupils are equal. Extraocular movements are intact. Face is symmetric. Tongue and palate are midline. Jaw muscles strong. Cough is normal. SCM and shrug 5 and 5. Visual fields intact. + +MOTOR EXAM: Normal for bulk, strength, and tone. There was no drift or tremor. + +SENSORY EXAM: Intact for pinprick and proprioception. + +COORDINATION: Normal for finger-to-nose. + +REFLEXES: Are 2+ throughout. + +GAIT: Assessed using the Tinetti assessment tool. She was fairly quick, but had some unsteadiness and a widened base. She did not need an assistive device. I gave her a score of 13/16 for balance and 9/12 for gait for a total score of 22/28. + +REVIEW OF X-RAYS: + + MRI was reviewed from June 26, 2008. It shows mild ventriculomegaly with a trace expansion into the temporal horns. The frontal horn span at the level of foramen of Munro is 3.8 cm with a flat 3rd ventricular contour and a 3rd ventricular span of 11 mm. The sylvian aqueduct is patent. There is no pulsation artifact. Her corpus callosum is bowed and effaced. She has a couple of small T2 signal abnormalities, but no significant periventricular signal change. + +ASSESSMENT: + +The patient is a 74-year-old woman who presents with mild progressive gait impairment and possible slowing of her cognition in the setting of ventriculomegaly suggesting possible adult hydrocephalus. + +PROBLEMS/DIAGNOSES: + +1. Possible adult hydrocephalus (331.5). + +2. Mild gait impairment (781.2). + +3. Mild cognitive slowing (290.0). + +PLAN: + + I had a long discussion with the patient her husband. + +I think it is possible that the patient is developing symptomatic adult hydrocephalus. At this point, her symptoms are fairly mild. I explained to them the two methods of testing with CSF drainage. It is possible that a large volume lumbar puncture would reveal whether she is likely to respond to shunt and I described that test. About 30% of my patients with walking impairment in a setting of possible adult hydrocephalus can be diagnosed with a large volume lumbar puncture. Alternatively, I could bring her into the hospital for four days of CSF drainage to determine whether she is likely to respond to shunt surgery. This procedure carries a 2% to 3% risk of meningitis. I also explained that it would be reasonable to start with an outpatient lumbar puncture and if that is not sufficient we could proceed with admission for the spinal catheter protocol. \ No newline at end of file diff --git a/3201_General Medicine.txt b/3201_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..e6ffb4c6ea0b3c8f91bc25a9e687d9a056c60bb7 --- /dev/null +++ b/3201_General Medicine.txt @@ -0,0 +1,43 @@ +SUBJECTIVE: + + Mom brings patient in today because of sore throat starting last night. Eyes have been very puffy. He has taken some Benadryl when all of this congestion started but with a sudden onset just yesterday. He has had low-grade fever and just felt very run down, appearing very tired. He is still eating and drinking well, and his voice has been hoarse but no coughing. No shortness of breath, vomiting, diarrhea or abdominal pain. + +PAST MEDICAL HISTORY: + + Unremarkable. There is no history of allergies. He does have some history of some episodes of high blood pressure, and his weight is up about 14 pounds from the last year. + +FAMILY HISTORY: + + Noncontributory. No one else at home is sick. + +OBJECTIVE: + +General: A 13-year-old male appearing tired but in no acute distress. + +Neck: Supple without adenopathy. + +HEENT: Ear canals clear. TMs, bilaterally, gray in color. Good light reflex. Oropharynx pink and moist. No erythema or exudate. Some drainage is seen in the posterior pharynx. Nares: Swollen, red. No drainage seen. No sinus tenderness. Eyes are clear. + +Chest: Respirations are regular and nonlabored. + +Lungs: Clear to auscultation throughout. + +Heart: Regular rhythm without murmur. + +Skin: Warm, dry and pink, moist mucous membranes. No rash. + +LABORATORY: + + Strep test is negative. Strep culture is negative. + +RADIOLOGY: + + Water's View of the sinuses is negative for any sinusitis or acute infection. + +ASSESSMENT: + + Upper respiratory infection. + +PLAN: + + At this point just treat symptomatically. I gave him some samples of Levall for the congestion and as an expectorant. Push fluids and rest. May use ibuprofen or Tylenol for discomfort. \ No newline at end of file diff --git a/3203_General Medicine.txt b/3203_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..d04e6aa7aeb421c67db436906bebd05cd2f9c9f1 --- /dev/null +++ b/3203_General Medicine.txt @@ -0,0 +1,17 @@ +CHIEF COMPLAINT: + + "Trouble breathing." + +HISTORY OF PRESENT ILLNESS: + + A 37-year-old German woman was brought to a Shock Room at the General Hospital with worsening shortness of breath and cough. Over the year preceding admission, the patient had begun to experience the insidious onset of shortness of breath. She had smoked one half pack of cigarettes per day for 20 years, but had quit smoking approximately 2 months prior to admission. Approximately 2 weeks prior to admission, she noted worsening shortness of breath and the development of a dry nonproductive cough. Approximately 1 week before admission, the shortness of breath became more severe and began to limit her activities. On the day of admission, her dyspnea had worsened to the point that she became markedly short of breath after walking a short distance, and she elected to seek medical attention. On arrival at the hospital, she was short of breath at rest and was having difficulty completing her sentences. She denied orthopnea, paroxysmal nocturnal dyspnea, swelling in her legs, chest pain, weight loss or gain, fever, chills, palpitations, and sick contacts. She denied any history of IVDA + + tattoos, or high risk sexual behavior. She did report a distant history of pulmonary embolism in 1997 with recurrent venous thromboembolism in 1999 for which an IVC filter had been placed in Germany . She had been living in the United States for years, and had had no recent travel. She denied any occupational exposures. Before the onset of her shortness of breath she had been very active and had exercised regularly. + +PAST MEDICAL HISTORY: + + Pulmonary embolism in 1997 which had been treated with thrombolysis in Germany. She reported that she had been on warfarin for 6 months after her diagnosis. Recurrent venous thromboembolism in 1999 at which time an IVC filter had been placed. Psoriasis. She denied any history of miscarriage. + +PAST SURGICAL HISTORY: + + IVC filter placement 1999. \ No newline at end of file diff --git a/3206_General Medicine.txt b/3206_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..8ca5c3dda427811831148117f29958e57a03632a --- /dev/null +++ b/3206_General Medicine.txt @@ -0,0 +1,53 @@ +CHIEF COMPLAINT: + + Toothache. + +HISTORY OF PRESENT ILLNESS: + +This is a 29-year-old male who has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled. Complains of new tooth pain. The patient states his current toothache is to both upper and lower teeth on the left side for approximately three days. The patient states that he would have gone to see his regular dentist but he has missed so many appointments that they now do not allow him to schedule regular appointments, he has to be on standby appointments only. The patient denies any other problems or complaints. The patient denies any recent illness or injuries. The patient does have OxyContin and Vicodin at home which he uses for his knee pain but he wants more pain medicines because he does not want to use up that medicine for his toothache when he wants to say this with me. + +REVIEW OF SYSTEMS: + + CONSTITUTIONAL: No fever or chills. No fatigue or weakness. No recent weight change. HEENT: No headache, no neck pain, the toothache pain for the past three days as previously mentioned. There is no throat swelling, no sore throat, no difficulty swallowing solids or liquids. The patient denies any rhinorrhea. No sinus congestion, pressure or pain, no ear pain, no hearing change, no eye pain or vision change. CARDIOVASCULAR: No chest pain. RESPIRATIONS: No shortness of breath or cough. GASTROINTESTINAL: No abdominal pain. No nausea or vomiting. GENITOURINARY: No dysuria. MUSCULOSKELETAL: No back pain. No muscle or joint aches. SKIN: No rashes or lesions. NEUROLOGIC: No vision or hearing change. No focal weakness or numbness. Normal speech. HEMATOLOGIC/LYMPHATIC: No lymph node swelling has been noted. + +PAST MEDICAL HISTORY: + + Chronic knee pain. + +CURRENT MEDICATIONS: + + OxyContin and Vicodin. + +ALLERGIES: + + PENICILLIN AND CODEINE. + +SOCIAL HISTORY: + + The patient is still a smoker. + +PHYSICAL EXAMINATION: + + VITAL SIGNS: Temperature 97.9 oral, blood pressure is 146/83, pulse is 74, respirations 16, oxygen saturation 98% on room air and interpreted as normal. CONSTITUTIONAL: The patient is well nourished and well developed. The patient is a little overweight but otherwise appears to be healthy. The patient is calm, comfortable, in no acute distress, and looks well. The patient is pleasant and cooperative. HEENT: Eyes are normal with clear conjunctiva and cornea bilaterally. There is no icterus, injection, or discharge. Pupils are 3 mm and equally round and reactive to light bilaterally. There is no absence of light sensitivity or photophobia. Extraocular motions are intact bilaterally. Ears are normal bilaterally without any sign of infection. There is no erythema, swelling of canals. Tympanic membranes are intact without any erythema, bulging or fluid levels or bubbles behind it. Nose is normal without rhinorrhea or audible congestion. There is no tenderness over the sinuses. NECK: Supple, nontender, and full range of motion. There is no meningismus. No cervical lymphadenopathy. No JVD. Mouth and oropharynx shows multiple denture and multiple dental caries. The patient has tenderness to tooth #12 as well as tooth #21. The patient has normal gums. There is no erythema or swelling. There is no purulent or other discharge noted. There is no fluctuance or suggestion of abscess. There are no new dental fractures. The oropharynx is normal without any sign of infection. There is no erythema, exudate, lesion or swelling. The buccal membranes are normal. Mucous membranes are moist. The floor of the mouth is normal without any abscess, suggestion of Ludwig's syndrome. CARDIOVASCULAR: Heart is regular rate and rhythm without murmur, rub, or gallop. RESPIRATIONS: Clear to auscultation bilaterally without shortness of breath. GASTROINTESTINAL: Abdomen is normal and nontender. MUSCULOSKELETAL: No abnormalities are noted to back, arms and legs. The patient has normal use of his extremities. SKIN: No rashes or lesions. NEUROLOGIC: Cranial nerves II through XII are intact. Motor and sensory are intact to the extremities. The patient has normal speech and normal ambulation. PSYCHIATRIC: The patient is alert and oriented x4. Normal mood and affect. HEMATOLOGIC/LYMPHATIC: No cervical lymphadenopathy is palpated. + +EMERGENCY DEPARTMENT COURSE: + + The patient did request a pain shot and the patient was given Dilaudid of 4 mg IM without any adverse reaction. + +DIAGNOSES: + +1. ODONTALGIA. + +2. MULTIPLE DENTAL CARIES. + +CONDITION UPON DISPOSITION: + +Stable. + +DISPOSITION: + + To home. + +PLAN: + + The patient was given a list of local dental clinics that he can follow up with or he can choose to stay with his own dentist that he wishes. The patient was requested to have reevaluation within two days. The patient was given a prescription for Percocet and clindamycin. The patient was given drug precautions for the use of these medicines. The patient was offered discharge instructions on toothache but states that he already has it. He declined the instructions. The patient was asked to return to the emergency room, should he have any worsening of his condition or develop any other problems or symptoms of concern. \ No newline at end of file diff --git a/3211_General Medicine.txt b/3211_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..4111036061ae5a8d541ba01eb9785ffc82bece8d --- /dev/null +++ b/3211_General Medicine.txt @@ -0,0 +1,13 @@ +She was evaluated this a.m. and was without any significant clinical change. Her white count has been improving and down to 12,000. A chest x-ray obtained today showed some bilateral infiltrates, but no acute cardiopulmonary change. There was a suggestion of a bilateral lower lobe pneumonitis or pneumonia. + +She has been on Zosyn for the infection. + +Throughout her hospitalization, we have been trying to adjust her pain medications. She states that the methadone did not work for her. She was "immune" to oxycodone. She had been on tramadol before and was placed back on that. There was some question that this may have been causing some dizziness. She also was on clonazepam and alprazolam for the underlying bipolar disorder. + +Apparently, her husband was in this afternoon. He had a box of her pain medications. It is unclear whether she took a bunch of these or precisely what happened. I was contacted that she was less responsive. She periodically has some difficulty to arouse due to pain medications, which she has been requesting repeatedly, though at times does not appear to have objective signs of ongoing pain. The nurse found her and was unable to arouse her at this point. There was a concern that she had taken some medications from home. She was given Narcan and appeared to come around some. Breathing remained somewhat labored and she had some diffuse scattered rhonchi, which certainly changed from this a.m. Additional Narcan was given as well as some medications to reverse a possible benzodiazepine toxicity. With O2 via mask, oxygenation was stable at 90% to 95% after initial hypoxia was noted. A chest x-ray was obtained at this time. An ECG was obtained, which shows a sinus tachycardia, noted to have ischemic abnormalities. + +In light of the acute decompensation, she was then transferred to the ICU. We will continue the IV Zosyn. Respiratory protocol with respiratory management. Continue alprazolam p.r.n. + + but avoid if she appears sedated. We will attempt to avoid additional pain medications, but we will continue with the Dilaudid for time being. I suspect she will need something to control her bipolar disorder. + +Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission. At this juncture, she does not appear to need an intubation. Pending chest x-ray, she may require additional IV furosemide. \ No newline at end of file diff --git a/3212_General Medicine.txt b/3212_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..f4c28b5fcc8ab06ef380c31b6e0bbe1d20950315 --- /dev/null +++ b/3212_General Medicine.txt @@ -0,0 +1,7 @@ +CHRONIC SNORING + +Chronic snoring in children can be associated with obstructive sleep apnea or upper airway resistant syndrome. Both conditions may lead to sleep fragmentation and/or intermittent oxygen desaturation, both of which have significant health implications including poor sleep quality and stress on the cardiovascular system. Symptoms like daytime somnolence, fatigue, hyperactivity, behavior difficulty (i.e. + + ADHD) and decreased school performance have been reported with these conditions. In addition, the most severe cases may be associated with right ventricular hypertrophy, pulmonary and/or systemic hypertension and even cor pulmonale. + +In this patient, the risks for a sleep-disordered breathing include obesity and the tonsillar hypertrophy. It is therefore indicated and medically necessary to perform a polysomnogram for further evaluation. A two week sleep diary will be given to the parents to fill out daily before the polysomnogram is performed. \ No newline at end of file diff --git a/3213_General Medicine.txt b/3213_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..cd7b0c9e83955eb52ecbcb0870faa8da36bacd13 --- /dev/null +++ b/3213_General Medicine.txt @@ -0,0 +1,15 @@ +SUBJECTIVE: + + This patient presents to the office today with his mom for checkup. He used to live in the city. He used to go to college down in the city. He got addicted to drugs. He decided it would be a good idea to get away from the "bad crowd" and come up and live with his mom. He has a history of doing heroin. He was injecting into his vein. He was seeing a physician in the city. They were prescribing methadone for some time. He says that did help. He was on 10 mg of methadone. He was on it for three to four months. He tried to wean down on the methadone a couple of different times, but failed. He has been intermittently using heroin. He says one of the big problems is that he lives in a household full of drug users and he could not get away from it. All that changed now that he is living with his mom. The last time he did heroin was about seven to eight days ago. He has not had any methadone in about a week either. He is coming in today specifically requesting methadone. He also admits to being depressed. He is sad a lot and down. He does not have much energy. He does not have the enthusiasm. He denies any suicidal or homicidal ideations at the present time. I questioned him on the symptoms of bipolar disorder and he does not seem to have those symptoms. His past medical history is significant for no medical problems. Surgical history, he voluntarily donated his left kidney. Family and social history were reviewed per the nursing notes. His allergies are no known drug allergies. Medications, he takes no medications regularly. + +OBJECTIVE: + + His weight is 164 pounds, blood pressure 108/60, pulse 88, respirations 16, and temperature was not taken. General: He is nontoxic and in no acute distress. Psychiatric: Alert and oriented times 3. Skin: I examined his upper extremities. He showed me his injection sites. I can see marks, but they seem to be healing up nicely. I do not see any evidence of cellulitis. There is no evidence of necrotizing fasciitis. + +ASSESSMENT: + + Substance abuse. + +PLAN: + + I had a long talk with the patient and his mom. I am not prescribing him any narcotics or controlled substances. I am not in the practice of trading one addiction for another. It has been one week without any sort of drugs at all. I do not think he needs weaning. I think right now it is mostly psychological, although there still could be some residual physical addiction. However, once again I do not believe it to be necessary to prescribe him any sort of controlled substance at the present time. I do believe that his depression needs to be treated. I gave him fluoxetine 20 mg one tablet daily. I discussed the side effects in detail. I did also warn him that all antidepressant medications carry an increased risk of suicide. If he should start to feel any of these symptoms, he should call #911 or go to the emergency room immediately. If he has any problems or side effects, he was also directed to call me here at the office. After-hours, he can go to the emergency room or call #911. I am going to see him back in three weeks for the depression. I gave him the name and phone number of Behavioral Health and I told him to call so that he can get into rehabilitation program or at least a support group. We are unable to make a referral for him to do that. He has to call on his own. He has no insurance. However, I think fluoxetine is very affordable. He can get it for $4 per month at Wal-Mart. His mom is going to keep an eye on him as well. He is going to be staying there. It sounds like he is looking for a job. \ No newline at end of file diff --git a/3214_General Medicine.txt b/3214_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..d7f0ecce6b9655f365f80cd6cf7504f26c879c34 --- /dev/null +++ b/3214_General Medicine.txt @@ -0,0 +1,47 @@ +REASON FOR VISIT: + + Mr. ABC is a 30-year-old man who returns in followup of his still moderate-to-severe sleep apnea. He returns today to review his response to CPAP. + +HISTORY OF PRESENT ILLNESS: + + The patient initially presented with loud obnoxious snoring that disrupted the sleep of his bed partner. He was found to have moderate-to-severe sleep apnea (predominantly hypopnea) + + was treated with nasal CPAP at 10 cm H2O nasal pressure. He has been on CPAP now for several months, and returns for followup to review his response to treatment. + +The patient reports that the CPAP has limited his snoring at night. Occasionally, his bed partner wakes him in the middle of the night, when the mask comes off, and reminds him to replace the mask. The patient estimates that he uses the CPAP approximately 5 to 7 nights per week, and on occasion takes it off and does not replace the mask when he awakens spontaneously in the middle of the night. + +The patient's sleep pattern consists of going to bed between 11:00 and 11:30 at night and awakening between 6 to 7 a.m. on weekdays. On weekends, he might sleep until 8 to 9 a.m. On Saturday night, he might go to bed approximately mid night. + +As noted, the patient is not snoring on CPAP. He denies much tossing and turning and does not awaken with the sheets in disarray. He awakens feeling relatively refreshed. + +In the past few months, the patient has lost between 15 and 18 pounds in combination of dietary and exercise measures. + +He continues to work at Smith Barney in downtown Baltimore. He generally works from 8 to 8:30 a.m. until approximately 5 to 5:30 p.m. He is involved in training purpose to how to sell managed funds and accounts. + +The patient reports no change in daytime stamina. He has no difficulty staying awake during the daytime or evening hours. + +The past medical history is notable for allergic rhinitis. + +MEDICATIONS: + + He is maintained on Flonase and denies much in the way of nasal symptoms. + +ALLERGIES: + + Molds. + +FINDINGS: + +Vital signs: Blood pressure 126/75, pulse 67, respiratory rate 16, weight 172 pounds, height 5 feet 9 inches, temperature 98.4 degrees and SaO2 is 99% on room air at rest. + +The patient has adenoidal facies as noted previously. + +Laboratories: The patient forgot to bring his smart card in for downloading today. + +ASSESSMENT: + + Moderate-to-severe sleep apnea. I have recommended the patient continue CPAP indefinitely. He will be sending me his smart card for downloading to determine his CPAP usage pattern. In addition, he will continue efforts to maintain his weight at current levels or below. Should he succeed in reducing further, we might consider re-running a sleep study to determine whether he still requires a CPAP. + +PLANS: + + In the meantime, if it is also that the possible nasal obstruction is contributing to snoring and obstructive hypopnea. I have recommended that a fiberoptic ENT exam be performed to exclude adenoidal tissue that may be contributing to obstruction. He will be returning for routine followup in 6 months. \ No newline at end of file diff --git a/3216_General Medicine.txt b/3216_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..7a30f330968d327916373202795fbe1170d50842 --- /dev/null +++ b/3216_General Medicine.txt @@ -0,0 +1,83 @@ +REASON FOR CONSULTATION: + + Thrombocytopenia. + +HISTORY OF PRESENT ILLNESS: + + Mrs. XXX is a 17-year-old lady who is going to be 18 in about 3 weeks. She has been referred for the further evaluation of her thrombocytopenia. This thrombocytopenia was detected on a routine blood test performed on the 10th of June 2006. Her hemoglobin was 13.3 with white count of 11.8 at that time. Her lymphocyte count was 6.7. The patient, subsequently, had a CBC repeated on the 10th at Hospital where her hemoglobin was 12.4 with a platelet count of 26,000. She had a repeat of her CBC again on the 12th of June 2006 with hemoglobin of 14, white count of 11.6 with an increase in the number of lymphocytes. Platelet count was 38. Her rapid strep screen was negative but the infectious mononucleosis screen is positive. The patient had a normal platelet count prior too and she is being evaluated for this low platelet count. + +The patient gives a history of feeling generally unwell for a couple of days towards the end of May. She was fine for a few days after that but then she had sore throat and fever 2-3 days subsequent to that. The patient continues to have sore throat. + +She denies any history of epistaxis. Denies any history of gum bleeding. The patient denies any history of petechiae. She denies any history of abnormal bleeding. Denies any history of nausea, vomiting, neck pain, or any headaches at the present time. + +The patient was accompanied by her parents. + +PAST MEDICAL HISTORY: + + Asthma. + +CURRENT MEDICATIONS: + + Birth control pills, Albuterol, QVAR and Rhinocort. + +DRUG ALLERGIES: + + None. + +PERSONAL HISTORY: + + She lives with her parents. + +SOCIAL HISTORY: + + Denies the use of alcohol or tobacco. + +FAMILY HISTORY: + + Noncontributory. + +OCCUPATION: + + The patient is currently in school. + +REVIEW OF SYSTEMS: + +Constitutional: The history of fever about 2 weeks ago. + +HEENT: Complains of some difficulty in swallowing. + +Cardiovascular: Negative. + +Respiratory: Negative. + +Gastrointestinal: No nausea, vomiting, or abdominal pain. + +Genitourinary: No dysuria or hematuria. + +Musculoskeletal: Complains of generalized body aches. + +Psychiatric: No anxiety or depression. + +Neurologic: Complains of episode of headaches about 2-3 weeks ago. + +PHYSICAL EXAMINATION: + +She was not in any distress. She appears her stated age. Temperature 97.9. Pulse 84. Blood pressure was 110/60. Weighs 162 pounds. Height of 61 inches. Lungs - Normal effort. Clear. No wheezing. Heart - Rate and rhythm regular. No S3, no S4. Abdomen - Soft. Bowel sounds are present. No palpable hepatosplenomegaly. Extremities - Without any edema, pallor, or cyanosis. Neurological: Alert and oriented x 3. No focal deficit. Lymph Nodes - No palpable lymphadenopathy in the neck or the axilla. Skin examination reveals few petechiae along the lateral aspect of the left thigh but otherwise there were no ecchymotic patches. + +DIAGNOSTIC DATA: + + The patient's CBC results from before were reviewed. Her CBC performed in the office today showed hemoglobin of 13.7, white count of 13.3, lymphocyte count of 7.6, and platelet count of 26,000. + +IMPRESSION: + + ITP + + the patient has a normal platelet count. + +PLAN: + +1. I had a long discussion with family regarding the treatment of ITP. In view of the fact that the patient's platelet count is 26,000 and she is asymptomatic, we will continue to monitor the counts. + +2. An ultrasound of the abdomen will be performed tomorrow. + +3. I have given her a requisition to obtain some blood work tomorrow. \ No newline at end of file diff --git a/3217_General Medicine.txt b/3217_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..519a60bd2384a9674c891ab8989509b896bef589 --- /dev/null +++ b/3217_General Medicine.txt @@ -0,0 +1,89 @@ +REASON FOR VISIT: + + This 48-year-old woman returns in followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. + +HISTORY OF PRESENT ILLNESS: + + The patient presented initially to the Pulmonary Clinic with dyspnea on minimal exertion. At that time, she was evaluated and found to have evidence for sleep disruption and daytime fatigue. She also complained of nocturnal choking episodes that have since abated over the past several months. In the meantime, she had been scheduled for an overnight sleep study performed to evaluate her for sleep apnea, returns today to review her study results. + +The patient's sleep patterns consist of going to bed between 9.00 and 10.00 p.m. and awakening in the morning between 5.00 and 6.00 a.m. She reports difficulty in initiating sleep and then recurrent awakenings every 1 to 2 hours throughout the night. She reports tossing and turning throughout the night and awakening with the sheets in disarray. She reports that her sleep was much better quality in the sleep laboratory as compared to home. When she awakens, she might have a dull headache and feels tired in the morning. Her daughter reports that she has heard the patient talking during sleep and snoring. There are no apneic episodes. The patient reports that she used to cough a lot in the middle of the night, but has no longer been doing so in recent weeks. + +During the daytime, the patient reports spending a lot of sedentary time reading and watching TV. She routinely dozes off during these sedentary activities. She also might nap between 2.00 and 3.00 p.m. + + and nods off in the evening hours. + +The patient smokes perhaps one to two packs of cigarettes per day, particularly after dinner. + +She reports that her weight has fluctuated and peaked at 260 pounds approximately 1 year ago. Since that time, her weight is down by approximately 30 pounds. + +The patient is managed in Outpatient Psychiatry and at her Maintenance Clinic. She takes methadone, trazodone, and Seroquel. + +PAST MEDICAL HISTORY: + +1. Depression. + +2. Hepatitis C. + +3. Hypertension. + +4. Inhaled and intravenous drug abuse history. + +The patient has a history of smoking two packs per day of cigarettes for approximately 25 pounds. She also has a history of recurrent atypical chest pain for which she has been evaluated. + +FAMILY HISTORY: + + As previously documented. + +SOCIAL HISTORY: + +The patient has a history of inhalation on intravenous drug abuse. She is currently on methadone maintenance. She is being followed in Psychiatry for depression and substance abuse issues. She lives with a room-mate. + +REVIEW OF SYSTEMS: + + Not contributory. + +MEDICATIONS: + + Current medications include the following: + +1. Methadone 110 mg by mouth every day. + +2. Paxil 60 mg by mouth every day. + +3. Trazodone 30 mg by mouth nightly. + +4. Seroquel 20 mg by mouth nightly. + +5. Avalide (irbesartan) and hydrochlorothiazide. + +6. Albuterol and Flovent inhalers two puffs by mouth twice a day. + +7. Atrovent as needed. + +FINDINGS: + + Vital Signs: Blood pressure 126/84, pulse 67, respiratory rate 18, weight 232 pounds, height 5 feet 8 inches, temperature 97.4 degrees, SaO2 is 99 percent on room air at rest. HEENT: Sclerae anicteric. Conjunctivae pink. Extraocular movements are intact. Pupils are equal, round, and reactive to light. The nasal passages show deviation in the nasal septum to the right. There is a slight bloody exudate at the right naris. Some nasal mucosal edema was noted with serous exudate bilaterally. The jaw is not foreshortened. The tongue is not large. Mallampati airway score was 3. The oropharynx was not shallow. There is no pharyngeal mucosa hypertrophy. No tonsillar tissue noted. The tongue is not large. Neck is supple. Thyroid without nodules or masses. Carotid upstrokes normal. No bruits. No jugular venous distention. Chest is clear to auscultation and percussion. No wheezing, rales, rhonchi or adventitious sounds. No prolongation of the expiratory phase. Cardiac: PMI not palpable. Regular rate and rhythm. S1 and S2 normal. No murmurs or gallops. Abdomen: Nontender. Bowel sounds normal. No liver or spleen palpable. Extremities: No clubbing or cyanosis. There is 1+ pretibial edema. Pulses are 2+ in upper and lower extremities. Neurologic: Grossly nonfocal. + +LABORATORIES: + + Pulmonary function studies reportedly show a mild restrictive ventilatory defect without obstruction. Diffusing capacity is well preserved. + +An overnight sleep study was performed on this patient at the end of 02/07. At that time, she reported that her sleep was better in the laboratories compared to home. She slept for a total sleep time of 398 minutes out of 432 minutes in bed (sleep proficiency 92 percent). She fell asleep in the middle of latency of less than 1 minute. She woke up after sleep onset of 34 minutes. She had stage I sleep that was some elevated at 28 percent of total sleep time, and stage I sleep is predominantly evident in the lateral portion of the night. The remainders were stage II at 69 percent, stage III and IV at 3 percent of total sleep time. + +The patient had no REM sleep. + +The patient had no periodic limb movements during sleep. + +The patient had no significant sleep-disordered breathing during non-REM sleep with less than one episode per hour. Oxyhemoglobin saturation remained in the low to mid 90s throughout the night. + +Intermittent inspiratory flow limitation compatible with snoring was observed during non-REM sleep. + +ASSESSMENT AND PLAN: + + This patient presents with history of sleep disruption and daytime sleepiness with fatigue. Her symptoms are multifactorial. + +Regarding the etiology of difficulty in initiating and maintaining sleep, the patient has a component of psychophysiologic insomnia, based on reports of better sleep in the laboratory as compared to home. In addition, nontrivial smoking in the home setting may be contributing significantly to sleep disruption. + +Regarding her daytime sleepiness, the patient is taking a number of long-acting central nervous system acting medications to sedate her and can produce a lasting sedation throughout the daytime. These include trazodone, Seroquel, and methadone. Of these medications, the methadone is clearly indicative, given the history of substance abuse. It would be desirable to reduce or discontinue trazodone and then perhaps consider doing the same with Seroquel. I brought this possibility up with the patient, and I asked her to discuss this further with her psychiatrist. + +Finally, to help mitigate sleep disruption at night, I have provided her with tips for sleep hygiene. These include bedtime rituals, stimulus control therapy, and sleep restriction as well as avoidance of nicotine in the evening hours. \ No newline at end of file diff --git a/3218_General Medicine.txt b/3218_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..d3d9b236f6880d2dbb855b87dbb355ec1b581dd5 --- /dev/null +++ b/3218_General Medicine.txt @@ -0,0 +1,23 @@ +REASON FOR CONSULTATION: + + Please evaluate stomatitis, possibly methotrexate related. + +HISTORY OF PRESENT ILLNESS: + + The patient is a very pleasant 57-year old white female, a native of Cuba, being seen for evaluation and treatment of sores in her mouth that she has had for the last 10-12 days. The patient has a long history of severe and debilitating rheumatoid arthritis for which she has had numerous treatments, but over the past ten years she has been treated with methotrexate quite successfully. Her dosage has varied somewhere between 20 and 25 mg per week. About the beginning of this year, her dosage was decreased from 25 mg to 20 mg, but because of the flare of the rheumatoid arthritis, it was increased to 22.5 mg per week. She has had no problems with methotrexate as far as she knows. She also took an NSAID about a month ago that was recently continued because of the ulcerations in her mouth. About two weeks ago, just about the time the stomatitis began she was placed on an antibiotic for suspected upper respiratory infection. She does not remember the name of the antibiotic. Although she claims she remembers taking this type of medication in the past without any problems. She was on that medication three pills a day for three to four days. She notes no other problems with her skin. She remembers no allergic reactions to medication. She has no previous history of fever blisters. + +PHYSICAL EXAMINATION: + + Reveals superficial erosions along the lips particularly the lower lips. The posterior buccal mucosa along the sides of the tongue and also some superficial erosions along the upper and lower gingiva. Her posterior pharynx was difficult to visualize, but I saw no erosions on the areas today. There did however appear to be one small erosion on the soft palate. Examination of the rest of her skin revealed no areas of dermatitis or blistering. There were some macular hyperpigmentation on the right arm where she has had a previous burn, plus the deformities from her rheumatoid arthritis on her hands and feet as well as scars on her knees from total joint replacement surgeries. + +IMPRESSION: + + Erosive stomatitis probably secondary to methotrexate even though the medication has been used for ten years without any problems. Methotrexate may produce an erosive stomatitis and enteritis after such a use. The patient also may have an enteritis that at this point may have become more quiescent as she notes that she did have some diarrhea about the time her mouth problem developed. She has had no diarrhea today, however. She has noted no blood in her stools and has had no episodes of nausea or vomiting. + +I am not as familiar with the NSAID causing an erosive stomatitis. I understand that it can cause gastrointestinal upset, but given the choice between the two, I would think the methotrexate is the most likely etiology for the stomatitis. + +RECOMMENDED THERAPY: + +I agree with your therapeutic regimen regarding this condition with the use of prednisone and folic acid. I also agree that the methotrexate must be discontinued in order to produce a resolution of this patients’ skin problem. However, in my experience, this stomatitis may take a number of weeks to go away completely if a patient been on methotrexate, for an extended period of time, because the medication is stored within the liver and in fatty tissue. Topically I have prescribed Lidex gel, which I find works extremely well in stomatitis conditions. It can be applied t.i.d. + +Thank you very much for allowing me to share in the care of this pleasant patient. I will follow her with you as needed. \ No newline at end of file diff --git a/3219_General Medicine.txt b/3219_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..18bc3978e613294f2578cae328dac133ac26674f --- /dev/null +++ b/3219_General Medicine.txt @@ -0,0 +1,85 @@ +IDENTIFYING DATA: + + This is a 40-year-old male seen today for a 90-day revocation admission. He had been reported by his case manager as being noncompliant with medications, refusing oral or IM medications, became agitated, had to be taken to ABCD for evaluation, admitted at that time to auditory hallucinations and confusion and was committed for admission at this time. He has a psychiatric history of schizophrenia, was previously admitted here at XYZ on 12/19/2009, had another voluntary admission in ABCD in 1998. + +MEDICATIONS: + + Listed as Invega and Risperdal. + +ALLERGIES: + + None known to medications. + +PAST MEDICAL HISTORY: + +The only identified problem in his chart is that he is being treated for hyperlipidemia with gemfibrozil. The patient is unaware and cannot remember what medications he had been taking or whether he had been taking them at all as an outpatient. + +FAMILY HISTORY: + + Listed as unknown in the chart as far as other psychiatric illnesses. The patient himself states that his parents are deceased and that he raised himself in the Philippines. + +SOCIAL HISTORY: + + He immigrated to this country in 1984, although he lists himself as having a green card still at this time. He states he lives on his own. He is a single male with no history of marriage or children and that he had high school education. His recreational drug use in the chart indicates that he has had a history of methamphetamines. The patient denies this at this time. He also denies current alcohol use. He does smoke. He is unable to tell me of any PCP. He is in counseling service with his case manager being XYZ. + +LEGAL HISTORY: + + He had an assault in December 2009, which led to his previous detention. It is unknown whether he is under legal constraints at this time. + +OBJECTIVE FINDINGS: + +VITAL SIGNS: + + Blood pressure is 125/75. His weight is 197 with height 5 feet 4 inches. + +GENERAL: + + He is cooperative, although disorganized and focusing entirely and telling me that he is here because there was some confusion in how he took his medications. He does not endorse any voices at this time. + +HEENT: + + His head exam is normal with normal scalp. HEENT is unremarkable. Pupils equal and reactive to light and accommodation. TMs are normal. + +NECK: + + Unremarkable with no masses or tenderness. + +CARDIOVASCULAR: + + Normal S1 and S2. No murmurs. + +LUNGS: + + Clear. + +ABDOMEN: + +Negative with no scars. + +GU: + +Not done. + +RECTAL: + + Not done. + +DERM: + + He does have a scarring of acne lesions, both face and back. + +EXTREMITIES: + + Otherwise negative. + +NEUROLOGIC: + + Cranial nerves II through X normal. Reflexes are normal and gait is unremarkable. + +LABORATORY DATA: + + His labs done at ABCD showed his CMP to be normal with an elevated white count of 17.2. Chest x-ray was indicated as being done and normal as was a UA and he did apparently receive hydration in the hospital with IV fluids. + +ASSESSMENT: + + History of hyperlipidemia with elevated triglycerides. We will maintain his gemfibrozil 600 b.i.d. and for health maintenance issues, we will also maintain just a vitamin daily and we will obtain recheck on his labs and lipid levels in one week after treatment is initiated. \ No newline at end of file diff --git a/3220_General Medicine.txt b/3220_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..d2c9fec9cb2de3b3fe5b597f4d81d46b38f0d761 --- /dev/null +++ b/3220_General Medicine.txt @@ -0,0 +1,41 @@ +REASON FOR CONSULTATION: + + Recurrent abscesses in the thigh, as well as the pubic area for at least about 2 years. + +HISTORY OF PRESENT ILLNESS: + + A 23-year-old female who is approximately 5 months' pregnant, who has had recurrent abscesses in the above-mentioned areas. She would usually have pustular type of lesion that would eventually break and would be quite painful. The drainage would be malodorous. It would initially not be infected as far as she knows, but then could eventually become infected. She stated that this first started after she had her first born about 2 years ago. She had recurrences of these abscesses and had pain, actually hospitalized at Hospital approximately a year and a half ago for about 1-1/2 months. She was treated with multiple courses of antibiotics. She had biopsies done. She was seen by Dr. X. Reportedly, she had a HIV test done that was negative. She had been seen by a dermatologist who said that she had a problem with her sweat glands. She has been on multiple courses of antibiotics. She never had any fevers. She has pain, drainage, and reportedly there was some bleeding in the area of the perineum/vaginal area. + +PAST MEDICAL HISTORY: + +1. History of recurrent abscesses in the perineum, upper medial thigh, and the vulva area for about 2 years. Per her report, a dermatologist had told her that she had an overactive sweat gland, and I believe she probably has hidradenitis suppurativa. Probably, she has had Staphylococcus infection associated with it as well. + +2. Reported history of asthma. + +GYNECOLOGIC HISTORY: + + G3, P1. She is currently 5 months' pregnant. + +ALLERGIES: + + None. + +MEDICATIONS: + + Her medication had been Augmentin. + +SOCIAL HISTORY: + + She is followed by a gynecologist in Bartow. She is not an alcohol or tobacco user. She is not married. She has a 2-year-old child. + +FAMILY HISTORY: + +Noncontributory. + +REVIEW OF SYSTEMS: + + The patient has been complaining of diarrhea about 5 or 6 times a day for several weeks now. + +PHYSICAL EXAMINATION + +GENERAL: \ No newline at end of file diff --git a/3221_General Medicine.txt b/3221_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..8311158251cfbf4390dde132e329b5ecf03cad7d --- /dev/null +++ b/3221_General Medicine.txt @@ -0,0 +1,85 @@ +REASON FOR CONSULT: + + Renal insufficiency. + +HISTORY OF PRESENT ILLNESS: + + A 48-year-old African-American male with a history of coronary artery disease, COPD + + congestive heart failure with EF of 20%-25% + + hypertension, renal insufficiency, and recurrent episodes of hypertensive emergency, admitted secondary to shortness of breath and productive cough. The patient denies any chest pain, palpitations, syncope, or fever. Denied any urinary disturbances, difficulty, burning micturition, hematuria, or back pain. Nephrology is consulted regarding renal insufficiency. + +REVIEW OF SYSTEMS: + + Reviewed entirely and negative except for HPI. + +PAST MEDICAL HISTORY: + + Hypertension, congestive heart failure with ejection fraction of 20%-25% in December 2005, COPD + + mild diffuse coronary artery disease, and renal insufficiency. + +ALLERGIES: + + NO KNOWN DRUG ALLERGIES. + +MEDICATIONS: + + Clonidine 0.3 p.o. q.8, aspirin 325 daily, hydralazine 100 q.8, Lipitor 20 at bedtime, Toprol XL 100 daily. + +FAMILY HISTORY: + + Noncontributory. + +SOCIAL HISTORY: + + The patient denies any alcohol, IV drug abuse, tobacco, or any recreational drugs. + +PHYSICAL EXAMINATION: + +VITAL SIGNS: Blood pressure 180/110. Temperature 98.1. Pulse rate 60. Respiratory rate 23. O2 sat 95% on room air. + +GENERAL: A 48-year-old African-American male in no acute distress. + +HEENT: Pupils equal, round, and reactive to light and accommodation. No pallor or icterus. + +NECK: No JVD + + bruit, or lymphadenopathy. + +HEART: S1 and S2, regular rate and rhythm, no murmurs, rubs, or gallops. + +LUNGS: Clear. No wheezes or crackles. + +ABDOMEN: Soft, nontender, nondistended, no organomegaly, bowel sounds present. + +EXTREMITIES: No cyanosis, clubbing, or edema. + +CNS: Exam is nonfocal. + +LABS: + + WBC 7, H and H 13 and 40, platelets 330, PT 12, PTT 26, CO2 20, BUN 27, creatinine 3.1, cholesterol 174, BNP 973, troponin 0.18. Previous creatinine levels were 2.7 in December. Urine drug screen positive for cocaine. + +ASSESSMENT: + + A 48-year-old African-American male with a history of coronary artery disease, congestive heart failure, COPD + + hypertension, and renal insufficiency with: + +1. Hypertensive emergency. + +2. Acute on chronic renal failure. + +3. Urine drug screen positive. + +4. Question CHF versus COPD exacerbation. + +PLAN: + +1. Most likely, renal insufficiency is a chronic problem. Hypertensive etiology worsened by the patient's chronic cocaine abuse. + +2. Control blood pressure with medications as indicated. Hypertensive emergency most likely related to cocaine drug abuse. + +Thank you for this consult. We will continue to follow the patient with you. \ No newline at end of file diff --git a/3229_General Medicine.txt b/3229_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..b543491489d3d58d19399d1495ef4579080f6683 --- /dev/null +++ b/3229_General Medicine.txt @@ -0,0 +1,55 @@ +CHIEF COMPLAINT: + + "My potassium is high" + +HISTORY OF PRESENT ILLNESS: + + A 47-year-old Latin American man presented to the emergency room after being told to come in for a high potassium value drawn the previous day. He had gone to an outside clinic the day prior to presentation complaining of weakness and fatigue. Labs drawn there revealed a potassium of 7.0 and he was told to come here for further evaluation. At time of his assessment in the emergency room, he noted general malaise and fatigue for eight months. Over this same time period he had subjective fevers and chills, night sweats, and a twenty-pound weight loss. He described anorexia with occasional nausea and vomiting of non-bilious material along with a feeling of light-headedness that occurred shortly after standing from a sitting or lying position. He denied a productive cough but did note chronic left sided upper back pain located in the ribs that was worse with cough and better with massage. He denied orthopnea or paroxysmal nocturnal dyspnea but did become dyspneic after walking 2-3 blocks where before he had been able to jog 2-3 miles. He also noted that over the past year his left testicle had been getting progressively more swollen and painful. He had been seen for this at the onset of symptoms and given a course of antibiotics without improvement. Over the last several months there had been chronic drainage of yellowish material from this testicle. He denied trauma to this area. He denied diarrhea or constipation, changes in his urinary habits, rashes or skin changes, arthritis, arthralgias, abdominal pain, headache or visual changes. + +PAST MEDICAL HISTORY: + + None. + +PAST SURGICAL HISTORY: + + Mone. + +MEDICATIONS: + + Occasional acetaminophen. + +ALLERGIES: + + NKDA. + +SOCIAL HISTORY: + + He drank a 6 pack of beer per day for the past 30 years. He smoked a pack and a half of cigarettes per day for the past 35 years. He was currently unemployed but had worked as a mechanic and as a carpet layer in the past. He had been briefly incarcerated 5 years prior to admission. He denied intravenous drug use or unprotected sexual exposures. + +FAMILY HISTORY: + + There was a history of coronary artery disease and diabetes mellitus in the family. + +PHYSICAL EXAM: + +VITAL SIGNS - Temp 98.6° F, Respirations 16/minute Lying down - Blood pressure 109/70, pulse 70/minute Sitting - Blood pressure 78/65, pulse 79/minute Standing - Blood pressure 83/70, pulse 95/minute GENERAL: well developed, well nourished, no acute distress HEENT: Normocephalic, atraumatic. Sclerae anicteric. Oropharynx with hyperpigmented patches on the mucosa of the palate. No oral thrush. No lymphadenopathy. No jugular venous distension. No thyromegaly. Neck supple. LUNGS: Decreased intensity of breath sounds throughout without adventitious sounds. No dullness to percussion or changes in fremitus. CARDIOVASCULAR: Regular rate and rhythm. No murmurs, gallops, or rubs. Normal intensity of heart sounds. Normal peripheral pulses. ABDOMEN: Soft, non-tender, non-distended. Positive bowel sounds. No organomegaly. RECTAL: Normal sphincter tone. No masses. Normal prostate. Guaiac negative stool. GENITOURINARY: Left testicle indurated and painful to palpation with slight amount of pustular drainage expressible on anterior aspect. Right testicle normal. EXTREMITIES: Marked clubbing noted in fingers and toes. No cyanosis or edema. No rash or arthritis. LYMPHATICS: 1 x 1 cm mobile, firm, non-tender lymph node noted in left inguinal region. Otherwise no other palpable lymphadenopathy. + +CHEST X-RAY: + + Ill-defined reticular densities in both apices. No pleural effusions. Cardiomediastinal silhouette within normal range. + +CHEST CT SCAN: + + Multiple bilateral apical nodules/masses. Largest 3.2 x 1.6 cm in left apex. Several of these masses demonstrate spiculation. There is an associated 1 cm lymph node in the prevascular space as well as subcentimeter nodes in the pretracheal and subcarinal regions. There is a subcarinal node that demonstrates calcifications. + +ABDOMINAL CT SCAN: + +Multiple hypodense lesions are noted throughout the liver. The right adrenal gland is full, measuring 1.0 x 2.3 cm. Otherwise the spleen, pancreas, left adrenal, and kidneys are free of gross mass. No significant lymphadenopathy or abnormal fluid collections are seen. + +TESTICULAR ULTRASOUND: + +There is an enlarged irregular inhomogenous left epididymis with increased vascularity throughout the left epididymis and testis. There is a large septated hydrocele on the left. The right epididymis and testis is normal. + +HOSPITAL COURSE: + + The above-mentioned studies were obtained. Further laboratory tests and a diagnostic procedure were performed. \ No newline at end of file diff --git a/3230_General Medicine.txt b/3230_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..77717106e35025c4ba12bbcec0bb3505f787c02a --- /dev/null +++ b/3230_General Medicine.txt @@ -0,0 +1,63 @@ +HISTORY OF PRESENT ILLNESS: + + This is a 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study, on CPAP and oxygen to evaluate her for difficulty in initiating and maintaining sleep. She returns today to review results of an inpatient study performed approximately two weeks ago. + +In the meantime, the patient reports she continues on substantial doses of opiate medication to control leg pain from mononeuritis multiplex. + +She also takes Lasix for lower extremity edema. + +The patient reports that she generally initiates sleep on CPAP + + but rips her mask off, tosses and turns throughout the night and has "terrible quality sleep." + +MEDICATIONS: + + Current medications are as previously noted. Changes include reduction in prednisone from 9 to 6 mg by mouth every morning. She continues to take Ativan 1 mg every six hours as needed. She takes imipramine 425 mg at bedtime. + +Her MS Contin dose is 150 mg every 8 to 12 hours and an immediate release morphine preparation, 45 to 75 mg by mouth every 8 hours as needed. + +FINDINGS: + + Vital signs: Blood pressure 153/81, pulse 90, respiratory rate 20, weight 311.8 pounds (up 10 pounds from earlier this month) + + height 5 feet 6 inches, temperature 98.4 degrees, SaO2 is 88% on room air at rest. Chest is clear. Extremities show lower extremity pretibial edema with erythema. + +LABORATORIES: + + An arterial blood gas on room air showed a pH of 7.38, PCO2 of 52, and PO2 of 57. + +CPAP compliance monitoring over the past two to three weeks showed average use of 3 hours 26 minutes on nights used. She used it for greater than 4 hours per night on 67% of night surveyed. Her estimated apnea/hypopnea index was 3 per hour. Her average leak flow was 67 liters per minute. + +The patient's overnight sleep study was performed as an inpatient sleep study during a routine hospitalization for intravenous gamma globulin therapy. She slept for a total sleep time of 257 minutes out of 272 minutes in bed (sleep efficiency approximately 90%). Sleep stage distribution was relatively normal with 2% stage I, 72% stage II + + 24% stage III + + IV + + and 2% stage REM sleep. + +There were no periodic limb movements during sleep. + +There was evidence of a severe predominantly central sleep apnea during non-REM sleep at 173 episodes per hour and during REM sleep at 77 episodes per hour. Oxyhemoglobin saturations during non-REM sleep fluctuated from the baseline of 92% to an average low of 82%. During REM sleep, the baseline oxyhemoglobin saturation was 87% + + decreased to 81% with sleep-disordered breathing episodes. + +Of note, the sleep study was performed on CPAP at 10.5 cm of H2O with oxygen at 8 liters per minute. + +ASSESSMENT: + +1. Obesity hypoventilation syndrome. The patient has evidence of a well-compensated respiratory acidosis, which is probably primarily related to severe obesity. In addition, there may be contribution from large doses of opiates and standing doses of gabapentin. + +2. Severe central sleep apnea, on CPAP at 10 cmH2O and supplemental oxygen at 8 liters per minute. The breathing pattern is that of cluster or Biot's breathing throughout sleep. The primary etiology is probably opiate use, with contribution with further exacerbation by severe obesity which acts to lower the baseline oxyhemoglobin saturation, and worsen desaturations during apneic episodes. + +3. Mononeuritis multiplex with pain requiring significant substantial doses of analgesia. + +4. Hypoxemia primarily due to obesity, hypoventilation, and presumably basilar atelectasis and a combination of V/Q mismatch and shunt on that basis. + +PLANS: + + My overall impression is that we should treat this patient's sleep disruption with measures to decrease central sleep apnea during sleep. These will include, (1). Decrease in evening doses of MS Contin, (2). Modest weight loss of approximately 10 to 20 pounds, and (3). Instituting Automated Servo Ventilation via nasal mask. With regard to latter, the patient will be returning for a trial of ASV to examine its effect on sleep-disordered breathing patterns. + +In addition, the patient will benefit from modest diuresis, with improvement of oxygenation, as well as nocturnal desaturation and oxygen requirements. I have encouraged the patient to increase her dose of Lasix from 100 to 120 mg by mouth every morning as previously prescribed. I have also asked her to add Lasix in additional late afternoon to evening dose of Lasix at 40 mg by mouth at that time. She was instructed to take between one and two K-Tab with her evening dose of Lasix (10 to 20 mEq). + +In addition, we will obtain a complete set of pulmonary function studies to evaluate this patient for underlying causes of parenchymal lung disease that may interfere with oxygenation. Further workup for hypoxemia may include high-resolution CT scanning if evidence for significant pulmonary restriction and/or reductions in diffusion capacity is evident on pulmonary function testing. \ No newline at end of file diff --git a/3232_General Medicine.txt b/3232_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..b4ae8bd316362ff5668ace0ab5f2d39d1de964a0 --- /dev/null +++ b/3232_General Medicine.txt @@ -0,0 +1,21 @@ +HISTORY OF PRESENT ILLNESS: + +This is a 53-year-old man, who presented to emergency room with multiple complaints including pain from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain. At the time of my exam, he states that his left lower extremity pain has improved considerably. He apparently had more significant paresthesias in the past and now he feels that the paresthesias have improved considerably. He does have a history of multiple medical problems including atrial fibrillation, he is on Coumadin, which is currently subtherapeutic, multiple CVAs in the past, peripheral vascular disease, and congestive heart failure. He has multiple chronic history of previous ischemia of his large bowel in the past. + +PHYSICAL EXAM + +VITAL SIGNS: Currently his temperature is 98.2, pulse is 95, and blood pressure is 138/98. + +HEENT: Unremarkable. + +LUNGS: Clear. + +CARDIOVASCULAR: An irregular rhythm. + +ABDOMEN: Soft. + +EXTREMITIES: His upper extremities are well perfused. He has palpable radial and femoral pulses. He does not have any palpable pedal pulses in either right or left lower extremity. He does have reasonable capillary refill in both feet. He has about one second capillary refill on both the right hand and left lower extremities and his left foot is perhaps little cool, but it is relatively warm. Apparently, this was lot worst few hours ago. He describes significant pain and pallor, which he feels has improved and certainly clinically at this point does not appear to be as significant. + +IMPRESSION AND PLAN: + + This gentleman with a history of multiple comorbidities as detailed above had what sounds clinically like acute exacerbation of chronic peripheral vascular disease, essentially related to spasm versus a small clot, which may have been lysed to some extent. He currently has a viable extremity and viable foot, but certainly has significant making compromised flow. It is unclear to me whether this is chronic or acute, and whether he is a candidate for any type of intervention. He certainly would benefit from an angiogram to better to define his anatomy and anticoagulation in the meantime. Given his potential history of recent lower GI bleeding, he has been evaluated by GI to see whether or not he is a candidate for heparinization. We will order an angiogram for the next few hours and followup on those results to better define his anatomy and to determine whether or not if any interventions are appropriate. Again, at this point, he has no pain, relatively rapid capillary refill, and relatively normal motor function suggesting a viable extremity. We will follow him along closely. \ No newline at end of file diff --git a/3235_General Medicine.txt b/3235_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..c3de474717230a5f30139997b03478d21d2fd74b --- /dev/null +++ b/3235_General Medicine.txt @@ -0,0 +1,21 @@ +GENERAL: Negative for any nausea, vomiting, fevers, chills, or weight loss. + +NEUROLOGIC: Negative for any blurry vision, blind spots, double vision, facial asymmetry, dysphagia, dysarthria, hemiparesis, hemisensory deficits, vertigo, ataxia. + +HEENT: Negative for any head trauma, neck trauma, neck stiffness, photophobia, phonophobia, sinusitis, rhinitis. + +CARDIAC: Negative for any chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, peripheral edema. + +PULMONARY: Negative for any shortness of breath, wheezing, COPD + + or TB exposure. + +GASTROINTESTINAL: Negative for any abdominal pain, nausea, vomiting, bright red blood per rectum, melena. + +GENITOURINARY: Negative for any dysuria, hematuria, incontinence. + +INTEGUMENTARY: Negative for any rashes, cuts, insect bites. + +RHEUMATOLOGIC: Negative for any joint pains, photosensitive rashes, history of vasculitis or kidney problems. + +HEMATOLOGIC: Negative for any abnormal bruising, frequent infections or bleeding. \ No newline at end of file diff --git a/3238_General Medicine.txt b/3238_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..527d0f6f42d85cdcfb067fb7b04dd4611898a94f --- /dev/null +++ b/3238_General Medicine.txt @@ -0,0 +1,59 @@ +EYES: + + The conjunctivae are clear. The lids are normal appearing without evidence of chalazion or hordeolum. The pupils are round and reactive. The irides are without any obvious lesions noted. Funduscopic examination shows sharp disk margins. There are no exudates or hemorrhages noted. The vessels are normal appearing. + +EARS + + NOSE + + MOUTH AND THROAT: + + The nose is without any evidence of any deformity. The ears are with normal-appearing pinna. Examination of the canals is normal appearing bilaterally. There is no drainage or erythema noted. The tympanic membranes are normal appearing with pearly color, normal-appearing landmarks and normal light reflex. Hearing is grossly intact to finger rubbing and whisper. The nasal mucosa is moist. The septum is midline. There is no evidence of septal hematoma. The turbinates are without abnormality. No obvious abnormalities to the lips. The teeth are unremarkable. The gingivae are without any obvious evidence of infection. The oral mucosa is moist and pink. There are no obvious masses to the hard or soft palate. The uvula is midline. The salivary glands appear unremarkable. The tongue is midline. The posterior pharynx is without erythema or exudate. The tonsils are normal appearing. + +NECK: + + The neck is nontender and supple. The trachea is midline. The thyroid is without any evidence of thyromegaly. No obvious adenopathy is noted to the neck. + +RESPIRATORY: + + The patient has normal respiratory effort. There is normal lung excursion. Percussion of the chest is without any obvious dullness. There is no tactile fremitus or egophony noted. There is no tenderness to the chest wall or ribs. There are no obvious abnormalities. The lungs are clear to auscultation. There are no wheezes, rales or rhonchi heard. There are no obvious rubs noted. + +CARDIOVASCULAR: + + There is a normal PMI on palpation. I do not hear any obvious abnormal sounds. There are no obvious murmurs. There are no rubs or gallops noted. The carotid arteries are without bruit. No obvious thrill is palpated. There is no evidence of enlarged abdominal aorta to palpation. There is no abdominal mass to suggest enlargement of the aorta. Good strong femoral pulses are palpated. The pedal pulses are intact. There is no obvious edema noted to the extremities. There is no evidence of any varicosities or phlebitis noted. + +GASTROINTESTINAL: + + The abdomen is soft. Bowel sounds are present in all quadrants. There are no obvious masses. There is no organomegaly, and no liver or spleen is palpable. No obvious hernia is noted. The perineum and anus are normal in appearance. There is good sphincter tone and no obvious hemorrhoids are noted. There are no masses. On digital examination, there is no evidence of any tenderness to the rectal vault; no lesions are noted. Stool is brown and guaiac negative. + +GENITOURINARY (FEMALE): + + The external genitalia is normal appearing with no obvious lesions, no evidence of any unusual rash. The vagina is normal in appearance with normal-appearing mucosa. The urethra is without any obvious lesions or discharge. The cervix is normal in color with no obvious cervical discharge. There are no obvious cervical lesions noted. The uterus is nontender and small, and there is no evidence of any adnexal masses or tenderness. The bladder is nontender to palpation. It is not enlarged. + +GENITOURINARY (MALE): + + Normal scrotal contents are noted. The testes are descended and nontender. There are no masses and no swelling to the epididymis noted. The penis is without any lesions. There is no urethral discharge. Digital examination of the prostate reveals a nontender, non-nodular prostate. + +BREASTS: + + The breasts are normal in appearance. There is no puckering noted. There is no evidence of any nipple discharge. There are no obvious masses palpable. There is no axillary adenopathy. The skin is normal appearing over the breasts. + +LYMPHATICS: + + There is no evidence of any adenopathy to the anterior cervical chain. There is no evidence of submandibular nodes noted. There are no supraclavicular nodes palpable. The axillae are without any abnormal nodes. No inguinal adenopathy is palpable. No obvious epitrochlear nodes are noted. + +MUSCULOSKELETAL/EXTREMITIES: + + The patient has normal gait and station. The patient has normal muscle strength and tone to all extremities. There is no obvious evidence of any muscle atrophy. The joints are all stable. There is no evidence of any subluxation or laxity to any of the joints. There is no evidence of any dislocation. There is good range of motion of all extremities without any pain or tenderness to the joints or extremities. There is no evidence of any contractures or crepitus. There is no evidence of any joint effusions. No obvious evidence of erythema overlying any of the joints is noted. There is good range of motion at all joints. There are normal-appearing digits. There are no obvious lesions to any of the nails or nail beds. + +SKIN: + + There is no obvious evidence of any rash. There are no petechiae, pallor or cyanosis noted. There are no unusual nodules or masses palpable. + +NEUROLOGIC: + + The cranial nerves II XII are tested and are intact. Deep tendon reflexes are symmetrical bilaterally. The toes are downgoing with normal Babinskis. Sensation to light touch is intact and symmetrical. Cerebellar testing reveals normal finger nose, heel shin. Normal gait. No ataxia. + +PSYCHIATRIC: + +The patient is oriented to person, place and time. The patient is also oriented to situation. Mood and affect are appropriate for the present situation. The patient can remember 3 objects after 3 minutes without any difficulties. Remote memory appears to be intact. The patient seems to have normal judgment and insight into the situation. \ No newline at end of file diff --git a/3244_General Medicine.txt b/3244_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..a89fe22048632289b3fb9125f0e86e06bfa390a7 --- /dev/null +++ b/3244_General Medicine.txt @@ -0,0 +1,47 @@ +GENERAL: + + A well-developed infant in no acute respiratory distress. + +VITAL SIGNS: + +Initial temperature was XX + + pulse XX + + respirations XX. Weight XX grams, length XX cm, head circumference XX cm. + +HEENT: + +Head is normocephalic with anterior fontanelle open, soft, and non-bulging. Eyes: Red reflex elicited bilaterally. TMs occluded with vernix and not well visualized. Nose and throat are patent without palatal defect. + +NECK: + + Supple without clavicular fracture. + +LUNGS: + + Clear to auscultation. + +HEART: + + Regular rate without murmur, click, or gallop present. Pulses are 2/4 for brachial and femoral. + +ABDOMEN: + + Soft with bowel sounds present. No masses or organomegaly. + +GENITALIA: + + Normal. + +EXTREMITIES: + + Without evidence of hip defects. + +NEUROLOGIC: + +The infant has good Moro, grasp, and suck reflexes. + +SKIN: + + Warm and dry without evidence of rash. \ No newline at end of file diff --git a/3248_General Medicine.txt b/3248_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..b730ca6b89aee3e2422c1a07c84262388e0bc009 --- /dev/null +++ b/3248_General Medicine.txt @@ -0,0 +1,73 @@ +GENERAL APPEARANCE: + + This is a well-developed and well-nourished, ?? + +VITAL SIGNS: + + Blood pressure ?? + + heart rate ?? and regular, respiratory rate ?? + + temperature is ?? degrees Fahrenheit. Height is ?? feet ?? inches. Weight is ?? pounds. This yields a body mass index of ??. + +HEAD + + EYES + + EARS + + NOSE AND THROAT: + + The pupils were equal, round and reactive to light. Extraocular movements are intact. Sclera are nonicteric. Ears, nose, mouth and throat - Externally the ears and nose are normal. The mucous membranes are moist and midline. + +NECK: + +The neck is supple without masses. No thyromegaly, no carotid bruits, no adenopathy. + +LUNGS: + +There is a normal respiratory effort. Bilateral breath sounds are clear. No wheezes or rales or rhonchi. + +CARDIAC: + + Normal cardiac impulse location. S1 and S2 are normal. No rubs, murmurs or gallops. A regular rate and rhythm. There are no abdominal aortic bruits. The carotid, brachial, radial, femoral, popliteal and dorsalis pedis pulses are 2+ and equal bilaterally. + +EXTREMITIES: + + The extremities are without clubbing, cyanosis, or edema. + +CHEST: + + The chest examination is unremarkable. + +BREASTS: + +The breasts show no masses or tenderness. No axillary adenopathy. + +ABDOMEN: + + The abdomen is flat, soft, nontender, no organomegaly, no masses, normal bowel sounds are present. + +RECTAL: + + Examination was deferred. + +LYMPHATIC: + + No neck, axillary or groin adenopathy was noted. + +SKIN EXAMINATION: + + Unremarkable. + +MUSCULOSKELETAL EXAMINATION: + + Grossly normal. + +NEUROLOGIC: + + The cranial nerves two through twelve are grossly intact. Patellar and biceps reflexes are normal. + +PSYCHIATRIC: + + The patient is awake, alert and oriented times three. Judgment and insight are good. Affect is appropriate. \ No newline at end of file diff --git a/3249_General Medicine.txt b/3249_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..4f359a0931ae168afd6656aff84c1e6d09b4610f --- /dev/null +++ b/3249_General Medicine.txt @@ -0,0 +1,84 @@ +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. + diff --git a/3252_General Medicine.txt b/3252_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..3c132b942aa53ae3b590956660c94439407aa951 --- /dev/null +++ b/3252_General Medicine.txt @@ -0,0 +1,25 @@ +MALE PHYSICAL EXAMINATION + +HEENT: Pupils equal, round and reactive to light and accommodation. Extraocular movements are intact. Sclerae are anicteric. TMs are clear bilaterally. Oropharynx is clear without erythema or exudate. + +NECK: Supple without lymphadenopathy or thyromegaly. Carotids are silent. There is no jugular venous distention. + +CHEST: Clear to auscultation bilaterally. + +CARDIOVASCULAR: Regular rate and rhythm without S3, S4. No murmurs or rubs are appreciated. + +ABDOMEN: Soft, nontender, nondistended with positive bowel sounds. No masses, hepatomegaly or splenomegaly are appreciated. + +GU: Normal **circumcised male. No discharge or hernias. No testicular masses. + +RECTAL EXAM: Normal rectal tone. Prostate is smooth and not enlarged. Stool is Hemoccult negative. + +EXTREMITIES: Reveal no clubbing, cyanosis, or edema. Peripheral pulses are +2 and equal bilaterally in all four extremities. + +JOINT EXAM: Reveals no tenosynovitis. + +NEUROLOGIC: Cranial nerves II through XII are grossly intact. Motor strength is 5/5 and equal in all four extremities. Deep tendon reflexes are +2/4 and equal bilaterally. Patient is alert and oriented times 3. + +PSYCHIATRIC: Grossly normal. + +DERMATOLOGIC: No lesions or rashes. \ No newline at end of file diff --git a/3253_General Medicine.txt b/3253_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..02b06ba7a3a3ad57095df6400ddd429b196dc386 --- /dev/null +++ b/3253_General Medicine.txt @@ -0,0 +1,35 @@ +MALE PHYSICAL EXAMINATION + +Eye: Eyelids normal color, no edema. Conjunctivae with no erythema, foreign body, or lacerations. Sclerae normal white color, no jaundice. Cornea clear without lesions. Pupils equally responsive to light. Iris normal color, no lesions. Anterior chamber clear. Lacrimal ducts normal. Fundi clear. + +Ear: External ear has no erythema, edema, or lesions. Ear canal unobstructed without edema, discharge, or lesions. Tympanic membranes clear with normal light reflex. No middle ear effusions. + +Nose: External nose symmetrical. No skin lesions. Nares open and free of lesions. Turbinates normal color, size and shape. Mucus clear. No internal lesions. + +Throat: No erythema or exudates. Buccal mucosa clear. Lips normal color without lesions. Tongue normal shape and color without lesion. Hard and soft palate normal color without lesions. Teeth show no remarkable features. No adenopathy. Tonsils normal shape and size. Uvula normal shape and color. + +Neck: Skin has no lesions. Neck symmetrical. No adenopathy, thyromegaly, or masses. Normal range of motion, nontender. Trachea midline. + +Chest: Symmetrical. Clear to auscultation bilaterally. No wheezing, rales or rhonchi. Chest nontender. Normal lung excursion. No accessory muscle use. + +Cardiovascular: Heart has regular rate and rhythm with no S3 or S4. Heart rate is normal. + +Abdominal: Soft, nontender, nondistended, bowel sounds present. No hepatomegaly, splenomegaly, masses, or bruits. + +Genital: Penis normal shape without lesions. Testicles normal shape and contour without tenderness. Epididymides normal shape and contour without tenderness. Rectum normal tone to sphincter. Prostate normal shape and contour without nodules. Stool hemoccult negative. No external hemorrhoids. No skin lesions. + +Musculoskeletal: Normal strength all muscle groups. Normal range of motion all joints. No joint effusions. Joints normal shape and contour. No muscle masses. + +Foot: No erythema. No edema. Normal range of motion all joints in the foot. Nontender. No pain with inversion, eversion, plantar or dorsiflexion. + +Ankle: Anterior and posterior drawer test negative. No pain with inversion, eversion, dorsiflexion, or plantar flexion. Collateral ligaments intact. No joint effusion, erythema, edema, crepitus, ecchymosis, or tenderness. + +Knee: Normal range of motion. No joint effusion, erythema, nontender. Anterior and posterior drawer tests negative. Lachman's test negative. Collateral ligaments intact. Bursas nontender without edema. + +Wrist: Normal range of motion. No edema or effusion, nontender. Negative Tinel and Phalen tests. Normal strength all muscle groups. + +Elbow: Normal range of motion. No joint effusion or erythema. Normal strength all muscle groups. Nontender. Olecranon bursa flat and nontender, no edema. Normal supination and pronation of forearm. No crepitus. + +Hip: Negative swinging test. Trochanteric bursa nontender. Normal range of motion. Normal strength all muscle groups. No pain with eversion and inversion. No crepitus. Normal gait. + +Psychiatric: Alert and oriented times four. No delusions or hallucinations, no loose associations, no flight of ideas, no tangentiality. Affect is appropriate. No psychomotor slowing or agitation. Eye contact is appropriate. \ No newline at end of file diff --git a/3254_General Medicine.txt b/3254_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..972c5bd8cb6f1a826d63c03cf152c2718d8114c4 --- /dev/null +++ b/3254_General Medicine.txt @@ -0,0 +1,63 @@ +VITAL SIGNS: + + Blood pressure * + + pulse * + + respirations * + + temperature *. + +GENERAL APPEARANCE: + + Alert and in no apparent distress, calm, cooperative, and communicative. + +HEENT: + + Eyes: EOMI. PERRLA. Sclerae nonicteric. No lesions lids, lashes, brows, or conjunctivae noted. Funduscopic examination unremarkable. No papilledema, glaucoma, or cataracts. Ears: Normal set and shape with normal hearing and normal TMs. Nose and Sinus: Unremarkable. Mouth, Tongue, Teeth, and Throat: Negative except for dental work. + +NECK: + + Supple and pain free without carotid bruit, JVD + + or significant cervical adenopathy. Trachea is midline without stridor, shift, or subcutaneous emphysema. Thyroid is palpable, nontender, not enlarged, and free of nodularity. + +CHEST: + + Lungs bilaterally clear to auscultation and percussion. + +HEART: + + S1 and S2. Regular rate and rhythm without murmur, heave, click, lift, thrill, rub, or gallop. PMI is nondisplaced. Chest wall is unremarkable to inspection and palpation. No axillary or supraclavicular adenopathy detected. + +BREASTS: + + Normal male breast tissue. + +ABDOMEN: + + No hepatosplenomegaly, mass, tenderness, rebound, rigidity, or guarding. No widening of the aortic impulse and intraabdominal bruit on auscultation. + +EXTERNAL GENITALIA: + + Normal for age. Normal penis with bilaterally descended testes that are normal in size, shape, and contour, and without evidence of hernia or hydrocele. + +RECTAL: + + Negative to 7 cm by gloved digital palpation with Hemoccult-negative stool and normal-sized prostate that is free of nodularity or tenderness. No rectal masses palpated. + +EXTREMITIES: + + Good distal pulse and perfusion without evidence of edema, cyanosis, clubbing, or deep venous thrombosis. Nails of the hands and feet, and creases of the palms and soles are unremarkable. Good active and passive range of motion of all major joints. + +BACK: + + Normal to inspection and percussion. Negative for spinous process tenderness or CVA tenderness. Negative straight-leg raising, Kernig, and Brudzinski signs. + +NEUROLOGIC: + + Nonfocal for cranial and peripheral nervous systems, strength, sensation, and cerebellar function. Affect is normal. Speech is clear and fluent. Thought process is lucid and rational. Gait and station are unremarkable. + +SKIN: + +Unremarkable for any premalignant or malignant condition with normal changes for age. \ No newline at end of file diff --git a/3256_General Medicine.txt b/3256_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..b817956ab6ccb481289823d6e40c9b2101f8fb13 --- /dev/null +++ b/3256_General Medicine.txt @@ -0,0 +1,47 @@ +CHILD PHYSICAL EXAMINATION + +VITAL SIGNS: Birth weight is ** grams, length ** + + occipitofrontal circumference **. Character of cry was lusty. + +GENERAL APPEARANCE: Well. + +BREATHING: Unlabored. + +SKIN: Clear. No cyanosis, pallor, or icterus. Subcutaneous tissue is ample. + +HEAD: Normal. Fontanelles are soft and flat. Sutures are opposed. + +EYES: Normal with red reflex x2. + +EARS: Patent. Normal pinnae, canals, TMs. + +NOSE: Patent nares. + +MOUTH: No cleft. + +THROAT: Clear. + +NECK: No masses. + +CHEST: Normal clavicles. + +LUNGS: Clear bilaterally. + +HEART: Regular rate and rhythm without murmur. + +ABDOMEN: Soft, flat. No hepatosplenomegaly. The cord is three vessel. + +GENITALIA: Normal ** genitalia **with testes descended bilaterally. + +ANUS: Patent. + +SPINE: Straight and without deformity. + +EXTREMITIES: Equal movements. + +MUSCLE TONE: Good. + +REFLEXES: Moro, grasp, and suck are normal. + +HIPS: No click or clunk. \ No newline at end of file diff --git a/3258_General Medicine.txt b/3258_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..3dc301cf1ae8b8f3fc6338f03b69a5de06b27633 --- /dev/null +++ b/3258_General Medicine.txt @@ -0,0 +1,17 @@ +EARS + + NOSE + + MOUTH AND THROAT + +EARS/NOSE: + + The auricles are normal to palpation and inspection without any surrounding lymphadenitis. There are no signs of acute trauma. The nose is normal to palpation and inspection externally without evidence of acute trauma. Otoscopic examination of the auditory canals and tympanic membranes reveals the auditory canals without signs of mass lesion, inflammation or swelling. The tympanic membranes are without disruption or infection. Hearing intact bilaterally to normal level speech. Nasal mucosa, septum and turbinate examination reveals normal mucous membranes without disruption or inflammation. The septum is without acute traumatic lesions or disruption. The turbinates are without abnormal swelling. There is no unusual rhinorrhea or bleeding. + +LIPS/TEETH/GUMS: + +The lips are without infection, mass lesion or traumatic lesions. The teeth are intact without obvious signs of infection. The gingivae are normal to palpation and inspection. + +OROPHARYNX: + +The oral mucosa is normal. The salivary glands are without swelling. The hard and soft palates are intact. The tongue is without masses or swelling with normal movement. The tonsils are without inflammation. The posterior pharynx is without mass lesion with good patent oropharyngeal airway. \ No newline at end of file diff --git a/3259_General Medicine.txt b/3259_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..b404a300f787731a5c3a0e6fa5613d0d164d6d0e --- /dev/null +++ b/3259_General Medicine.txt @@ -0,0 +1,37 @@ +HISTORY OF PRESENT ILLNESS: + + She is a 28-year-old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood-tinged vomit starting approximately worse over the past couple of days. This is patient's fourth trip to the emergency room and second trip for admission. + +PAST MEDICAL HISTORY: + + Nonsignificant. + +PAST SURGICAL HISTORY: + + None. + +SOCIAL HISTORY: + + No alcohol, drugs, or tobacco. + +PAST OBSTETRICAL HISTORY: + +This is her first pregnancy. + +PAST GYNECOLOGICAL HISTORY: + + Not pertinent. + +While in the emergency room, the patient was found to have slight low sodium, potassium slightly elevated and her ALT of 93, AST of 35, total bilirubin is 1.2. Her urine was 3+ ketones, 2+ protein, and 1+ esterase, and rbc too numerous to count with moderate amount of bacteria. H and H stable at 14.1 and 48.7. She was then admitted after giving some Phenergan and Zofran IV. As started on IV + + given hydration as well as given a dose of Rocephin to treat bladder infection. She was admitted overnight, nausea and vomiting resolved to only one episode of vomiting after receiving Maalox, tolerated fluids as well as p.o. food. Followup chemistry was obtained for AST + + ALT and we will plan for discharge if lab variables resolve. + +ASSESSMENT AND PLAN: + +1. This is a 28-year-old G1 at approximately 8 to 9 weeks gestation with one hyperemesis gravidarum admit for IV hydration and followup. + +2. Slightly elevated ALT + + questionable, likely due to the nausea and vomiting. We will recheck for followup. \ No newline at end of file diff --git a/3261_General Medicine.txt b/3261_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..47f4abc01fad2f31cb4a2492a22ee58d245a5892 --- /dev/null +++ b/3261_General Medicine.txt @@ -0,0 +1,59 @@ +CONSTITUTIONAL: + + Normal; negative for fever, weight change, fatigue, or aching. + +HEENT: + + Eyes normal; Negative for glasses, cataracts, glaucoma, retinopathy, irritation, or visual field defects. Ears normal; Negative for hearing or balance problems. Nose normal; Negative for runny nose, sinus problems, or nosebleeds. Mouth normal; Negative for dental problems, dentures, or bleeding gums. Throat normal; Negative for hoarseness, difficulty swallowing, or sore throat. + +CARDIOVASCULAR: + + Normal; Negative for angina, previous MI + + irregular heartbeat, heart murmurs, bad heart valves, palpitations, swelling of feet, high blood pressure, orthopnea, paroxysmal nocturnal dyspnea, or history of stress test, arteriogram, or pacemaker implantation. + +PULMONARY: + + Normal; Negative for cough, sputum, shortness of breath, wheezing, asthma, or emphysema. + +GASTROINTESTINAL: + + Normal; Negative for pain, vomiting, heartburn, peptic ulcer disease, change in stool, rectal pain, hernia, hepatitis, gallbladder disease, hemorrhoids, or bleeding. + +GENITOURINARY: + + Normal female OR male; Negative for incontinence, UTI + + dysuria, hematuria, vaginal discharge, abnormal bleeding, breast lumps, nipple discharge, skin or nipple changes, sexually transmitted diseases, incontinence, yeast infections, or itching. + +SKIN: + + Normal; Negative for rashes, keratoses, skin cancers, or acne. + +MUSCULOSKELETAL: + + Normal; Negative for back pain, joint pain, joint swelling, arthritis, joint deformity, problems with ambulation, stiffness, osteoporosis, or injuries. + +NEUROLOGIC: + + Normal; Negative for blackouts, headaches, seizures, stroke, or dizziness. + +PSYCHIATRIC: + + Normal; Negative for anxiety, depression, or phobias. + +ENDOCRINE: + + Normal; Negative for diabetes, thyroid, or problems with cholesterol or hormones. + +HEMATOLOGIC/LYMPHATIC: + + Normal; Negative for anemia, swollen glands, or blood disorders. + +IMMUNOLOGIC: + + Negative; Negative for steroids, chemotherapy, or cancer. + +VASCULAR: + + Normal; Negative for varicose veins, blood clots, atherosclerosis, or leg ulcers. \ No newline at end of file diff --git a/3264_General Medicine.txt b/3264_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..83793d4497625055f32ec9943820ad7c4fe0d0e1 --- /dev/null +++ b/3264_General Medicine.txt @@ -0,0 +1,63 @@ +CC: + + Found down. + +HX: + + 54y/o RHF went to bed at 10 PM at her boyfriend's home on 1/16/96. She was found lethargic by her son the next morning. Three other individuals in the house were lethargic and complained of HA that same morning. Her last memory was talking to her granddaughter at 5:00PM on 1/16/96. She next remembered riding in the ambulance from a Hospital. Initial Carboxyhemoglobin level was 24% (normal < 1.5%) and ABG 7.41/30/370 with O2Sat 75% on 100%FiO2. + +MEDS: + + unknown anxiolytic, estrogen. + +PMH: + + PUD + + ?stroke and memory difficulty in the past 1-2 years. + +FHX: + + unknown. + +SHX: + + divorced. unknown history of tobacco/ETOH/illicit drug use. + +EXAM: + +BP126/91, HR86, RR 30, 37.1C. + +MS: + + Oriented to name only. Speech without dysarthria. 2/3 recall at 5minutes. + +CN: + + unremarkable. + +MOTOR: + +full strength throughout with normal muscle tone and bulk. + +SENSORY: + +unremarkable. + +COORD/STATION: + + unremarkable. + +GAIT: + + not tested on admission. + +GEN EXAM: + + notable for erythema of the face and chest. + +COURSE: + + She underwent a total of four dives under Hyperbaric Oxygen ( 2 dives on 1/17 and 2 dives on 1/18). Neuropsychologic assessment on 1/18/96 revealed marked cognitive impairments with defects in anterograde memory, praxis, associative fluency, attention, and speed of information processing. She was discharged home on 1/19/96 and returned on 2/11/96 after neurologic deterioration. She progressively developed more illogical behavior, anhedonia, anorexia and changes in sleep pattern. She became completely dependent and could not undergo repeat neuropsychologic assessment in 2/96. She was later transferred to another care facility against medical advice. The etiology for these changes became complicated by a newly discovered history of possible ETOH abuse and usual "anxiety" disorder. + +MRI brain, 2/14/96, revealed increased T2 signal within the periventricular white matter, bilaterally. EEG showed diffuse slowing without epileptiform activity. \ No newline at end of file diff --git a/3265_General Medicine.txt b/3265_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..ec14a6516280cdfa773ad633ac6c9ade3ded83ca --- /dev/null +++ b/3265_General Medicine.txt @@ -0,0 +1,91 @@ +ADMISSION DIAGNOSES: + +1. Seizure. + +2. Hypoglycemia. + +3. Anemia. + +4. Hypotension. + +5. Dyspnea. + +6. Edema. + +DISCHARGE DIAGNOSES: + +1. Colon cancer, status post right hemicolectomy. + +2. Anemia. + +3. Hospital-acquired pneumonia. + +4. Hypertension. + +5. Congestive heart failure. + +6. Seizure disorder. + +PROCEDURES PERFORMED: + +1. Colonoscopy. + +2. Right hemicolectomy. + +HOSPITAL COURSE: + + The patient is a 59-year-old female with multiple medical problems including diabetes mellitus requiring insulin for 26 years, previous MI and coronary artery disease, history of seizure disorder, GERD + + bipolar disorder, and anemia. She was admitted due to a seizure and myoclonic jerks as well as hypoglycemia and anemia. Regarding the seizure disorder, Neurology was consulted. Noncontrast CT of the head was negative. Neurology felt that the only necessary intervention at that time would be to increase her Lamictal to 150 mg in the morning and 100 mg in the evening with gradual increase of the dosage until she was on 200 mg b.i.d. Regarding the hypoglycemia, the patient has diabetic gastroparesis and was being fed on J-tube intermittent feedings throughout the night at the rate of 120 an hour. Her insulin pump had a basal rate of roughly three at night during the feedings. While in the hospital, the insulin pump rate was turned down to 1.5 and then subsequently decreased a few other times. She seemed to tolerate the insulin pump rate well throughout her hospital course. There were a few episodes of hypoglycemia as well as hyperglycemia, but the episode seem to be related to the patient's n.p.o. status and the changing rates of tube feedings throughout her hospital course. + +At discharge, her endocrinologist was contacted. It was decided to change her insulin pump rate to 3 units per hour from midnight till 6 a.m. + + from 0.8 units per hour from 6 a.m. until 8 a.m. + + and then at 0.2 units per hour from 8 a.m. until 6 p.m. The insulin was to be NovoLog. Regarding the anemia, the gastroenterologists were consulted regarding her positive Hemoccult stools. A colonoscopy was performed, which found a mass at the right hepatic flexure. General Surgery was then consulted and a right hemicolectomy was performed on the patient. The patient tolerated the procedure well and tube feeds were slowly restarted following the procedure, and prior to discharge were back at her predischarge rates of 120 per hour. Regarding the cancer itself, it was found that 1 out of 53 nodes were positive for cancer. CT of the abdomen and pelvis revealed no metastasis, a CT of the chest revealed possible lung metastasis. Later in hospital course, the patient developed a septic-like picture likely secondary to hospital-acquired pneumonia. She was treated with Zosyn, Levaquin, and vancomycin, and tolerated the medications well. Her symptoms decreased and serial chest x-rays were followed, which showed some resolution of the illness. The patient was seen by the Infectious Disease specialist. The Infectious Disease specialist recommended vancomycin to cover MRSA bacteria, which was found at the J-tube site. At discharge, the patient was given three additional days of p.o. Levaquin 750 mg as well as three additional days of Bactrim DS every 12 hours. The Bactrim was used to cover the MRSA at the J-tube site. It was found that MRSA was sensitive to Bactrim. Throughout her hospital course, the patient continued to receive Coreg 12.5 mg daily and Lasix 40 mg twice a day for her congestive heart failure, which remains stable. She also received Lipitor for her high cholesterol. Her seizure disorder remained stable and she was discharged on a dose of 100 mg in the morning and 150 mg at night. The dosage increases can begin on an outpatient basis. + +DISCHARGE INSTRUCTIONS/MEDICATIONS: + + The patient was discharged to home. She was told to shy away from strenuous activity. Her discharge diet was to be her usual diet of isotonic fiber feeding through the J-tube at a rate of 120 per hour throughout the night. The discharge medications were as follows: + +1. Coreg 12.5 mg p.o. b.i.d. + +2. Lipitor 10 mg p.o. at bedtime. + +3. Nitro-Dur patch 0.3 mg per hour one patch daily. + +4. Phenergan syrup 6.25 mg p.o. q.4h. p.r.n. + +5. Synthroid 0.175 mg p.o. daily. + +6. Zyrtec 10 mg p.o. daily. + +7. Lamictal 100 mg p.o. daily. + +8. Lamictal 150 mg p.o. at bedtime. + +9. Ferrous sulfate drops 325 mg, PEG tube b.i.d. + +10. Nexium 40 mg p.o. at breakfast. + +11. Neurontin 400 mg p.o. t.i.d. + +12. Lasix 40 mg p.o. b.i.d. + +13. Fentanyl 50 mcg patch transdermal q.72h. + +14. Calcium and vitamin D combination, calcium carbonate 500 mg/vitamin D 200 units one tab p.o. t.i.d. + +15. Bactrim DS 800mg/160 mg tablet one tablet q.12h. x3 days. + +16. Levaquin 750 mg one tablet p.o. x3 days. + +The medications listed above, one listed as p.o. are to be administered via the J-tube. + +FOLLOWUP: + +The patient was instructed to see Dr. X in approximately five to seven days. She was given a lab sheet to have a CBC with diff as well as a CMP to be drawn prior to her appointment with Dr. X. She is instructed to follow up with Dr. Y if her condition changes regarding her colon cancer. She was instructed to follow up with Dr. Z, her oncologist, regarding the positive lymph nodes. We were unable to contact Dr. Z, but his telephone number was given to the patient and she was instructed to make a followup appointment. She was also instructed to follow up with her endocrinologist, Dr. A, regarding any insulin pump adjustments, which were necessary and she was also instructed to follow up with Dr. B, her gastroenterologist, regarding any issues with her J-tube. + +CONDITION ON DISCHARGE: + + Stable. \ No newline at end of file diff --git a/3269_General Medicine.txt b/3269_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..53e2fc9c39feb1f89b5d2a31475b7b963e27ef57 --- /dev/null +++ b/3269_General Medicine.txt @@ -0,0 +1,43 @@ +HISTORY: + + Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath. Please see dictated ICU transfer note yesterday detailing the need for emergent transfer transfusion and EGD in this patient. Over the last 24 hours, the patient has received 2 units of packed red blood cells and his hematocrit and hemoglobin have returned to their baseline of approximately 11 appropriate for hemoglobin value. He also underwent EGD earlier today with Dr. X. I have discussed the case with him at length earlier this afternoon and the patient had symptoms of ulcerative esophagitis with no active bleeding. Dr. X recommended to increase the doses of his proton pump inhibitor and to avoid NSAIDs in the future. The patient today complains that he is still having issues with shortness of breath and wheezing and productive cough, now producing yellow-brown sputum with increasing frequency, but he has had no further episodes of melena since transfer to the ICU. He is also complaining of some laryngitis and some pharyngitis, but is denying any abdominal complaints, nausea, or diarrhea. + +PHYSICAL EXAMINATION + +VITAL SIGNS: Blood pressure is 100/54, heart rate 80 and temperature 98.8. Is and Os negative fluid balance of 1.4 liters in the last 24 hours. + +GENERAL: This is a somnolent 68-year-old male, who arouses to voice, wakes up, seems to have good appetite, has continuing cough. Pallor is improved. + +EYES: Conjunctivae are now pink. + +ENT: Oropharynx is clear. + +CARDIOVASCULAR: Reveals distant heart tones with regular rate and rhythm. + +LUNGS: Have coarse breath sounds with wheezes, rhonchi, and soft crackles in the bases. + +ABDOMEN: Soft and nontender with no organomegaly appreciated. + +EXTREMITIES: Showed no clubbing, cyanosis or edema. Capillary refill time is now normal in the fingertips. + +NEUROLOGICAL: Cranial nerves II through XII are grossly intact with no focal neurological deficits. + +LABORATORY DATA: + + Laboratories drawn at 1449 today, WBC 10, hemoglobin and hematocrit 11.5 and 33.1, and platelets 288,000. This is up from 8.6 and 24.7. Platelets are stable. Sodium is 134, potassium 4.0, chloride 101, bicarb 26, BUN 19, creatinine 1.0, glucose 73, calcium 8.4, INR 0.96, iron 13% + + saturations 4% + + TIBC 312, TSH 0.74, CEA elevated at 8.6, ferritin 27.5 and occult blood positive. EGD + + final results pending per Dr. X's note and conversation with me earlier, ulcerative esophagitis without signs of active bleeding at this time. + +IMPRESSION/PLAN + +1. Melena secondary to ulcerative esophagitis. We will continue to monitor the patient overnight to ensure there is no further bleeding. If there are no further episodes of melena and hemoglobin is stable or unchanged in the morning, the patient will be transferred back to medical floor for continuing treatment of his chronic obstructive pulmonary disease exacerbation. + +2. Chronic obstructive pulmonary disease exacerbation. The patient is doing well, taking PO. We will continue him on his oral Omnicef and azithromycin and continuing breathing treatments. We will add guaifenesin and N-acetyl-cysteine in a hope to mobilize some of his secretions. This does appear to be improving. His white count is normalized and I am hopeful we can discharge him on oral antibiotics within the next 24 to 48 hours if there are no further complications. + +3. Elevated CEA. The patient will need colonoscopy on an outpatient basis. He has refused this today. We would like to encourage him to do so. Of note, the patient when he came in was on bloodless protocol, but with urging did accept the transfusion. Similarly, I am hoping that with proper counseling, the patient will consent to further examination with colonoscopy given his guaiac-positive status, elevated CEA and risk factors. + +4. Anemia, normochromic normocytic with low total iron binding capacity. This appears to be anemia of chronic disease. However, this is likely some iron deficiency superimposed on top of this given his recent bleeding, with consider iron, vitamin C, folate and B12 supplementation and discharge given his history of alcoholic malnutrition and recent gastrointestinal bleeding. Total critical care time spent today discussing the case with Dr. X, examining the patient, reviewing laboratory trends, adjusting medications and counseling the patient in excess is 35 minutes. \ No newline at end of file diff --git a/3274_General Medicine.txt b/3274_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..95f6018d6e48523b8ab31519b45d904eec9649c7 --- /dev/null +++ b/3274_General Medicine.txt @@ -0,0 +1,53 @@ +CHIEF COMPLAINT: + + Itchy rash. + +HISTORY OF PRESENT ILLNESS: + + This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms. No facial swelling. No tongue or lip swelling. No shortness of breath, wheezing, or other associated symptoms. He cannot think of anything that could have triggered this off. There have been no changes in his foods, medications, or other exposures as far as he knows. He states a couple of days ago he did work and was removing some insulation but does not remember feeling itchy that day. + +PAST MEDICAL HISTORY: + + Negative for chronic medical problems. No local physician. Has had previous back surgery and appendectomy, otherwise generally healthy. + +REVIEW OF SYSTEMS: + + As mentioned denies any oropharyngeal swelling. No lip or tongue swelling. No wheezing or shortness of breath. No headache. No nausea. Notes itchy rash, especially on his torso and upper arms. + +SOCIAL HISTORY: + + The patient is accompanied with his wife. + +FAMILY HISTORY: + + Negative. + +MEDICATIONS: + + None. + +ALLERGIES: + + TORADOL + + MORPHINE + + PENICILLIN + + AND AMPICILLIN. + +PHYSICAL EXAMINATION: + + VITAL SIGNS: The patient was afebrile. He is slightly tachycardic, 105, but stable blood pressure and respiratory rate. GENERAL: The patient is in no distress. Sitting quietly on the gurney. HEENT: Unremarkable. His oral mucosa is moist and well hydrated. Lips and tongue look normal. Posterior pharynx is clear. NECK: Supple. His trachea is midline. There is no stridor. LUNGS: Very clear with good breath sounds in all fields. There is no wheezing. Good air movement in all lung fields. CARDIAC: Without murmur. Slight tachycardia. ABDOMEN: Soft, nontender. SKIN: Notable for a confluence erythematous, blanching rash on the torso as well as more of a blotchy papular, macular rash on the upper arms. He noted some on his buttocks as well. Remaining of the exam is unremarkable. + +ED COURSE: + + The patient was treated with epinephrine 1:1000, 0.3 mL subcutaneously along with 50 mg of Benadryl intramuscularly. After about 15-20 minutes he states that itching started to feel better. The rash has started to fade a little bit and feeling a lot more comfortable. + +IMPRESSION: + + ACUTE ALLERGIC REACTION WITH URTICARIA AND PRURITUS. + +ASSESSMENT AND PLAN: + + The patient has what looks to be some type of allergic reaction, although the underlying cause is difficult to assess. He will make sure he goes home to look around to see if there is in fact anything that changed recently that could have triggered this off. In the meantime, I think he can be managed with some antihistamine over-the-counter. He is responding already to Benadryl and the epinephrine that we gave him here. He is told that if he develops any respiratory complaints, shortness of breath, wheezing, or tongue or lip swelling he will return immediately for evaluation. He is discharged in stable condition. \ No newline at end of file diff --git a/3281_General Medicine.txt b/3281_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..7442a8841e0e810fba190683753334f0dacfb8dc --- /dev/null +++ b/3281_General Medicine.txt @@ -0,0 +1,91 @@ +PROBLEM: + + Probable Coumadin hypersensitivity. + +HISTORY OF PRESENT ILLNESS: + + The patient is an 82-year-old Caucasian female admitted to the Hospital for elective total left knee arthroplasty. At the time of admission, the patient has a normal prothrombin time and INR of 13.4 seconds and 1.09 respectively and postoperatively, she was placed on Coumadin which is the usual orthopedic surgery procedure for reducing the risk of postoperative thromboembolic activity. However, the patient's prothrombin time and INR rapidly rose to supratherapeutic levels. Even though Coumadin was discontinued on 01/21/09, the patient's prothrombin time and INR has continued to rise. Her prothrombin time is now 83.3 seconds with an INR of 6.52. Hematology/Oncology consult was requested for recommendation regarding further evaluation and management. + +SOCIAL HISTORY: + + The patient is originally from Maine. She has lived in Arizona for 4 years. She has had 2 children; however, only one is living. She had one child died from complications of ulcerative colitis. She has been predominantly a homemaker during her life, but has done some domestic cleaning work in the past. + +CHILDHOOD HISTORY: + + Negative for rheumatic fever. The patient has usual childhood illnesses. + +ALLERGIES: + +No known drug allergies. + +FAMILY HISTORY: + + The patient's mother died from gastric cancer. She had a brother who died from mesothelioma. He did have a positive asbestos exposure working in the shipyards. The patient's father died from motor vehicle accident. She had a sister who succumbed to pneumonia as a complication to Alzheimer disease. + +HABITS: + + No use of ethanol, tobacco, illicit, or recreational substances. + +ADULT MEDICAL PROBLEMS: + + The patient has a history of diabetes mellitus, hypertension, and hypercholesterolemia, which is all consistent with the metabolic syndrome X. In addition, the patient's husband, who is present, knows that she has early dementia and has problems with memory and difficulty in processing new information. + +SURGERIES: + + The patient's only surgery is the aforementioned left knee arthroplasty and bilateral cataract surgery, otherwise negative. + +MEDICATIONS: + + The patient's medications on admission include: + +1. Fosamax. + +2. TriCor. + +3. Gabapentin. + +4. Hydrochlorothiazide. + +5. Labetalol. + +6. Benicar. + +7. Crestor. + +8. Detrol. + +REVIEW OF SYSTEMS: + + Unable to obtain review of systems as the patient was given a dose of morphine for postoperative pain and she is a bit obtunded at this time. She is arousable, but not particularly conversant. + +OBSERVATIONS: + +GENERAL: The patient is a drowsy, but arousable, nonconversant, elderly Caucasian female. + +HEENT: Pupils were equal, round, and reactive to light and accommodation. Extraocular muscles are grossly intact. Oropharynx benign. + +NECK: Supple. Full range of motion without bruits or thyromegaly. + +LUNGS: Clear to auscultation and percussion. + +BACK: Without spine or CVA tenderness. + +HEART: Regular rate and rhythm without murmurs, rubs, thrills, or heaves. + +ABDOMEN: Soft and nontender. Positive bowel sounds without mass or visceromegaly. + +LYMPHATIC: No appreciable adenopathy. + +EXTREMITIES: The patient has some postoperative fullness involving her left knee. She has a dressing over the left knee. + +SKIN: Without lesions. + +NEURO: Unable to assess in light of post morphine obtunded state. + +ASSESSMENT: + + Hypersensitivity to Coumadin. + +PLAN: + + Gave the patient vitamin K at this time. Literature suggested oral vitamin K is actually more efficacious than parenteral. However, in light of the fact that the patient is obtunded and is not taking anything right now in the way of oral food or fluids, we will give this to her in an IM fashion. Repeat prothrombin time and INR in a.m. Once she has come down to a more therapeutic range, I would initiate low-molecular weight heparin in the form of Fragmin one time a day or Lovenox on a b.i.d. schedule for 4 to 6 weeks postoperatively. \ No newline at end of file diff --git a/3283_General Medicine.txt b/3283_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..70b964792fc4c18b3c5c1ad273cf8eb2f46312ee --- /dev/null +++ b/3283_General Medicine.txt @@ -0,0 +1,73 @@ +CHIEF COMPLAINT: + + Non-healing surgical wound to the left posterior thigh. + +HISTORY OF PRESENT ILLNESS: + + This is a 49-year-old white male who sustained a traumatic injury to his left posterior thighthis past year while in ABCD. He sustained an injury from the patellar from a boat while in the water. He was air lifted actually up to XYZ Hospital and underwent extensive surgery. He still has an external fixation on it for the healing fractures in the leg and has undergone grafting and full thickness skin grafting closure to a large defect in his left posterior thigh, which is nearly healed right in the gluteal fold on that left area. In several areas right along the graft site and low in the leg, the patient has several areas of hypergranulation tissue. He has some drainage from these areas. There are no signs and symptoms of infection. He is referred to us to help him get those areas under control. + +PAST MEDICAL HISTORY: + + Essentially negative other than he has had C. difficile in the recent past. + +ALLERGIES: + + None. + +MEDICATIONS: + + Include Cipro and Flagyl. + +PAST SURGICAL HISTORY: + + Significant for his trauma surgery noted above. + +FAMILY HISTORY: + + His maternal grandmother had pancreatic cancer. Father had prostate cancer. There is heart disease in the father and diabetes in the father. + +SOCIAL HISTORY: + + He is a non-cigarette smoker and non-ETOH user. He is divorced. He has three children. He has an attorney. + +REVIEW OF SYSTEMS: + +CARDIAC: He denies any chest pain or shortness of breath. + +GI: As noted above. + +GU: As noted above. + +ENDOCRINE: He denies any bleeding disorders. + +PHYSICAL EXAMINATION: + +GENERAL: He presents as a well-developed, well-nourished 49-year-old white male who appears to be in no significant distress. + +HEENT: Unremarkable. + +NECK: Supple. There is no mass, adenopathy, or bruit. + +CHEST: Normal excursion. + +LUNGS: Clear to auscultation and percussion. + +COR: Regular. There is no S3, S4, or gallop. There is no murmur. + +ABDOMEN: Soft. It is nontender. There is no mass or organomegaly. + +GU: Unremarkable. + +RECTAL: Deferred. + +EXTREMITIES: His right lower extremity is unremarkable. Peripheral pulse is good. His left lower extremity is significant for the split thickness skin graft closure of a large defect in the posterior thigh, which is nearly healed. The open areas that are noted above __________ hypergranulation tissue both on his gluteal folds on the left side. There is one small area right essentially within the graft site, and there is one small area down lower on the calf area. The patient has an external fixation on that comes out laterally on his left thigh. Those pin sites look clean. + +NEUROLOGIC: Without focal deficits. The patient is alert and oriented. + +IMPRESSION: + + Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg. + +PLAN: + + Plan would be for chemical cauterization of these areas. Series of treatment with chemical cauterization till these are closed. \ No newline at end of file diff --git a/3284_General Medicine.txt b/3284_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..9ec5c1bfcf8449a7c4aa1761b9503d094357c9a5 --- /dev/null +++ b/3284_General Medicine.txt @@ -0,0 +1,84 @@ +SUBJECTIVE: + + The patient is a 20-year-old Caucasian male admitted via ABCD Hospital Emergency Department for evaluation of hydrocarbon aspiration. The patient ingested "tiki oil" (kerosene, liquid paraffin, citronella oil) approximately two days prior to admission. He subsequently developed progressive symptoms of dyspnea, pleuritic chest pain, hemoptysis with nausea and vomiting. He was seen in the ABCD Hospital Emergency Department, toxic appearing with an abnormal chest x-ray demonstrating bilateral lower lobe infiltrates, greater on the right. He had a temperature of 38.3 with tachycardia approximating 130. White count was 59,300 with a marked left shift. Arterial blood gases showed pH 7.48, pO2 79, and pCO2 35. He was admitted for further medical management. + +PAST MEDICAL HISTORY: + + Aplastic crisis during childhood requiring splenectomy and a cholecystectomy at age 9. + +DRUG ALLERGIES: + + NONE KNOWN. + +CURRENT MEDICATIONS: + + None. + +FAMILY HISTORY: + +Noncontributory. + +SOCIAL HISTORY: + +The patient works at a local Christmas tree farm. He smokes cigarettes approximately one pack per day. + +REVIEW OF SYSTEMS: + + Ten-system review significant for nausea, vomiting, fever, hemoptysis, and pleuritic chest pain. + +PHYSICAL EXAMINATION + +GENERAL: A toxic-appearing 20-year-old Caucasian male, in mild respiratory distress. + +VITAL SIGNS: Blood pressure 122/74, pulse 130 and regular, respirations 24, temperature 38.3, and oxygen saturation 93%. + +SKIN: No rashes, petechiae or ecchymoses. + +HEENT: Within normal limits. Pupils are equally round and reactive to light and accommodation. Ears clean. Throat clean. + +NECK: Supple without thyromegaly. Lymph nodes are nonpalpable. + +CHEST: Decreased breath sounds bilaterally, greater on the right, at the right base. + +CARDIAC: No murmur or gallop rhythm. + +ABDOMEN: Mild direct diffuse tenderness without rebound. No detectable masses, pulsations or organomegaly. + +EXTREMITIES: No edema. Pulses are equal and full bilaterally. + +NEUROLOGIC: Nonfocal. + +DATABASE: + + Chest x-ray, bilateral lower lobe pneumonia, greater on the right. EKG + + sinus tachycardia, rate of 130, normal intervals, no ST changes. Arterial blood gases on 2 L of oxygen, pH 7.48, pO2 79, and pCO2 35. + +BLOOD STUDIES: + + Hematocrit is 43, WBC 59,300 with a left shift, and platelet count 394,000. Sodium is 130, potassium 3.8, chloride 97, bicarbonate 24, BUN 14, creatinine 0.8, random blood sugar 147, and calcium 9.4. + +IMPRESSION + +1. Hydrocarbon aspiration. + +2. Bilateral pneumonia with pneumonitis secondary to aspiration. + +3. Asplenic patient. + +PLAN + +1. ICU monitoring. + +2. O2 protocol. + +3. Hydration. + +4. Antiemetic therapy. + +5. Parenteral antibiotics. + +6. Prophylactic proton pump inhibitors. + +The patient will need ICU monitoring and Pulmonary Medicine evaluation pending clinical course. + diff --git a/3289_General Medicine.txt b/3289_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..5a61b894f1973056ed5f01f76889961d4b51f448 --- /dev/null +++ b/3289_General Medicine.txt @@ -0,0 +1,73 @@ +CHIEF COMPLAINT: + + Headache. + +HISTORY OF PRESENT ILLNESS: + + This is a 16-year-old white female who presents here to the emergency department in a private auto with her mother for evaluation of headache. She indicates intense constant right frontal headache, persistent since onset early on Monday, now more than 48 hours ago. Indicates pressure type of discomfort with throbbing component. It is as high as a 9 on a 0 to 10 scale of intensity. She denies having had similar discomfort in the past. Denies any trauma. + +Review of systems: No fever or chills. No sinus congestion or nasal drainage. No cough or cold symptoms. No head trauma. Mild nausea. No vomiting or diarrhea. Other systems reviewed and are negative. + +PMH: + + Acne. Psychiatric history is unremarkable. + +PSH: + + Right knee surgery. + +SH: + + The patient is single. Living at home. No smoking or alcohol. + +FH: + + Noncontributory. + +ALLERGIES: + +No drug allergies. + +MEDICATIONS: + + Accutane and Ovcon. + +PHYSICAL EXAMINATION: + +VITALS: Temperature of 97.8 degrees F. + + pulse of 80, respiratory rate of 16, and blood pressure is 131/96. + +GENERAL: This is a 16-year-old white female. She is awake, alert, and oriented x3. She does appear bit uncomfortable. + +HEAD: Normocephalic and atraumatic. + +EYES: The pupils were equal and reactive to light. Extraocular movements are intact. + +ENT: TMs are clear. Nose and throat are unremarkable. + +NECK: There is no evidence of nuchal rigidity. She does, however, have notable tenderness and spasm of the right trapezius and rhomboid muscles when she extends up to the right paracervical muscles. Palpation clearly causes having exacerbation of her discomfort. + +CHEST: Thorax is unremarkable. + +GI: Abdomen is nontender. + +MUSCLES: Extremities are unremarkable. + +NEURO: Cranial nerves II through XII are grossly intact. Motor and sensory are grossly intact. + +SKIN: Skin is warm and dry. + +ED COURSE: + + The patient was given IV Norflex 60 mg, Zofran 4 mg, and morphine sulfate 4 mg and with that has significant improvement in her discomfort. + +DIAGNOSES: + +1. Muscle tension cephalgia. + +2. Right trapezius and rhomboid muscle spasm. + +PLAN: + + Scripts were given for Darvocet-N 100 one every 4 to 6 hours #15, Soma one 4 times a day #20. She was instructed to apply warm compresses and perform gentle massage. Follow up with regular provider as needed. Return if any problems. \ No newline at end of file diff --git a/3293_General Medicine.txt b/3293_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..202eb80179ec6c7e9737ae7678b90f32107cf113 --- /dev/null +++ b/3293_General Medicine.txt @@ -0,0 +1,49 @@ +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. \ No newline at end of file diff --git a/3294_General Medicine.txt b/3294_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..1479fa665cdfc49f4e4a1488ff1612b4d0f4b9d3 --- /dev/null +++ b/3294_General Medicine.txt @@ -0,0 +1,61 @@ +CHIEF COMPLAINT: + + One-month followup. + +HISTORY OF PRESENT ILLNESS: + + The patient is an 88-year-old Caucasian female. She comes here today with a friend. The patient has no complaints. She states she has been feeling well. Her knees are not hurting her at all anymore and she is not needing Bextra any longer. I think the last steroid injection that she had with Dr. XYZ really did help. The patient denies any shortness of breath or cough. Has no nausea, vomiting, abdominal pain. No diarrhea or constipation. She states her appetite is good. She clears her plate at noon. She has had no fevers, chills, or sweats. The friend with her states she is doing very well. Seems to eat excellently at noontime, despite this, the patient continues to lose weight. When I asked her what she eats for breakfast and for supper, she states she really does not eat anything. Her only meal that she eats at the nursing home is the noon meal and then I just do not think she is eating much the rest of the time. She states she is really not hungry the rest of the time except at lunchtime. She denies any fevers, chills, or sweats. We did do some lab work at the last office visit and CBC was essentially normal. Comprehensive metabolic was essentially normal as was of the BUN of 32 and creatinine of 1.3. This is fairly stable for her. Liver enzymes were normal. TSH was normal. Free albumin was normal at 23. She is on different antidepressants and that may be causing some difficulties with unintentional weight loss. + +MEDICATIONS: + +Currently are Aricept 10 mg a day, Prevacid 30 mg a day, Lexapro 10 mg a day, Norvasc 2.5 mg a day, Milk of Magnesia 30 cc daily, and Amanda 10 mg b.i.d. + +ALLERGIES: + + No known drug allergies. + +PAST MEDICAL HISTORY: + + Reviewed from 05/10/2004 and unchanged other than the addition of paranoia, which is much improved on her current medications. + +SOCIAL HISTORY: + + The patient is widow. She is a nonsmoker, nondrinker. She lives at Kansas Christian Home independently, but actually does get a lot of help with medications, having a driver to bring her here, and going to the noon meal. + +REVIEW OF SYSTEMS: + + As above in HPI. + +PHYSICAL EXAM: + +General: This is a well-developed, pleasant Caucasian female, who appears thinner especially in her face. States are clothes are fitting more loosely. + +Vital Signs: Weight: 123, down 5 pounds from last month and down 11 pounds from May 2004. Blood pressure: 128/62. Pulse: 60. Respirations: 20. Temperature: 96.8. + +Neck: Supple. Carotids are silent. + +Chest: Clear to auscultation. + +Cardiovascular: Regular rate and rhythm. + +Abdomen: Soft and nontender, nondistended with positive bowel sounds. No organomegaly or masses are appreciated. + +Extremities: Free of edema. + +ASSESSMENT: + +1. Unintentional weight loss. I think this is more a problem of just not getting in any calories though does not appear to be a medical problem go on, although her dementia may make it difficult for her to remember to eat, and with her antidepressant medication she is on, she just may not have much of an appetite to eat unless food is prepared for her. + +2. Depression, doing well. + +3. Paranoia, doing well. + +4. Dementia, stable. + +5. Osteoarthritis of the knees, pain is much improved. + +PLAN: + +1. Continue on current medications. + +2. I did call and talk with doctor at hospital. We discussed different options. We have decided to have the patient eat the evening meal at the nursing home also and have her take a supplement drink such as Ensure at breakfast time. Connie will weigh the patient once a week and I will go ahead and see the patient in one month. We can see how she is doing at that time. If she continues to lose weight despite eating better, then I think we will need to do further evaluation. \ No newline at end of file diff --git a/3297_General Medicine.txt b/3297_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..4a45f65bb35230fc890fe5da32608a4eeab8c8bc --- /dev/null +++ b/3297_General Medicine.txt @@ -0,0 +1,53 @@ +SUBJECTIVE: + + The patient is in with several medical problems. He complains his mouth being sore since last week and also some "trouble with my eyes." He states that they feel "funny" but he is seeing okay. He denies any more diarrhea or abdominal pain. Bowels are working okay. He denies nausea or diarrhea. Eating is okay. He is emptying his bladder okay. He denies dysuria. His back is hurting worse. He complains of right shoulder pain and neck pain over the last week but denies any injury. He reports that his cough is about the same. + +CURRENT MEDICATIONS: + + Metronidazole 250 mg q.i.d. + + Lortab 5/500 b.i.d. + + Allegra 180 mg daily, Levothroid 100 mcg daily, Lasix 20 mg daily, Flomax 0.4 mg at h.s. + + aspirin 81 mg daily, Celexa 40 mg daily, verapamil SR 180 mg one and a half tablet daily, Zetia 10 mg daily, Feosol b.i.d. + +ALLERGIES: + + Lamisil, Equagesic, Bactrim, Dilatrate, cyclobenzaprine. + +OBJECTIVE: + +General: He is a well-developed, well-nourished, elderly male in no acute distress. + +Vital Signs: His age is 66. Temperature: 97.7. Blood pressure: 134/80. Pulse: 88. Weight: 201 pounds. + +HEENT: Head was normocephalic. Examination of the throat reveals it to be clear. He does have a few slight red patches on his upper inner lip consistent with yeast dermatitis. + +Neck: Supple without adenopathy or thyromegaly. + +Lungs: Clear. + +Heart: Regular rate and rhythm. + +Extremities: He has full range of motion of his shoulders but some tenderness to the trapezius over the right shoulder. Back has limited range of motion. He is nontender to his back. Deep tendon reflexes are 2+ bilaterally in lower extremities. Straight leg raising is positive for back pain on the right side at 90 degrees. + +Abdomen: Soft, nontender without hepatosplenomegaly or mass. He has normal bowel sounds. + +ASSESSMENT: + +1. Clostridium difficile enteritis, improved. + +2. Right shoulder pain. + +3. Chronic low back pain. + +4. Yeast thrush. + +5. Coronary artery disease. + +6. Urinary retention, which is doing better. + +PLAN: + + I put him on Diflucan 200 mg daily for seven days. We will have him stop his metronidazole little earlier at his request. He can drop it down to t.i.d. until Friday of this week and then finish Friday’s dose and then stop the metronidazole and that will be more than a 10-day course. I ordered physical therapy to evaluate and treat his right shoulder and neck as indicated x 6 visits and he may see Dr. XYZ p.r.n. for his eye discomfort and his left eye pterygium which is noted on exam (minimal redness is noted to the conjunctiva on the left side but no mattering was seen.) Recheck with me in two to three weeks. \ No newline at end of file diff --git a/3298_General Medicine.txt b/3298_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..6cc27fa139c278a05bf562bca5055dcb8f0fb3ce --- /dev/null +++ b/3298_General Medicine.txt @@ -0,0 +1,27 @@ +S: + + XYZ is in today not feeling well for the last three days. She is a bit sick with bodyaches. She is coughing. She has a sore throat, especially when she coughs. Her cough is productive of green colored sputum. She has had some chills. No vomiting. No diarrhea. She is sleeping okay. She does not feel like she needs anything for the cough. She did call in yesterday, and got a refill of her Keflex. She took two Keflex this morning and she is feeling a little bit better now. She is tearful, just tired of feeling ran down. + +O: + + Vital signs as per chart. Respirations 15. Exam: Nontoxic. No acute distress. Alert and oriented. HEENT: TMs are clear bilaterally without erythema or bulging. Clear external canals. Clear tympanic. Conjunctivae are clear. Clear nasal mucosa. Clear oropharynx with moist mucous membranes. NECK is soft and supple without lymphadenopathy. LUNGS are coarse with no severe rhonchi or wheezes. HEART is regular rate and rhythm without murmur. ABDOMEN is soft and nontender. + +Chest x-ray reveals no obvious consolidation or infiltrates. We will send the x-ray for over-read. + +Influenza test is negative. Rapid strep screen is negative. + +A: + + Bronchitis/URI. + +P: + + + +1. Motrin as needed for fever and discomfort. + +2. Push fluids. + +3. Continue on the Keflex. + +4. Follow up with Dr. ABC if symptoms persist or worsen, otherwise as needed. \ No newline at end of file diff --git a/3300_General Medicine.txt b/3300_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..282b24cdb008954ac0129c63a72567eac8885809 --- /dev/null +++ b/3300_General Medicine.txt @@ -0,0 +1,21 @@ +SUBJECTIVE: + + The patient has recently had an admission for pneumonia with positive blood count. She was treated with IV antibiotics and p.o. antibiotics; she improved on that. She was at home and doing quite well for approximately 10 to 12 days when she came to the ER with a temperature of 102. She was found to have strep. She was treated with penicillin and sent home. She returned about 8 o'clock after vomiting and a probable seizure. Temperature was 104.5; she was lethargic after that. She had an LP + + which was unremarkable. She had blood cultures, which have not grown anything. The CSF has not grown anything at this point. + +PHYSICAL EXAMINATION: + + She is alert, recovering from anesthesia. Head, eyes, ears, nose and throat are unremarkable. Chest is clear to auscultation and percussion. Abdomen is soft. Extremities are unremarkable. + +LAB STUDIES: + + White count in the emergency room was 9.8 with a slight shift. CSF glucose was 68, protein was 16, and there were no cells. The Gram-stain was unremarkable. + +ASSESSMENT: + + I feel that this patient has a febrile seizure. + +PLAN: + + My plan is to readmit the patient to control her temperature and assess her white count. I am going to observe her overnight. \ No newline at end of file diff --git a/3303_General Medicine.txt b/3303_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..aaa83e628287001e4c84130e630731a8e8b027ce --- /dev/null +++ b/3303_General Medicine.txt @@ -0,0 +1,41 @@ +SUBJECTIVE: + + The patient has NG tube in place for decompression. She says she is feeling a bit better. + +PHYSICAL EXAMINATION: + +VITAL SIGNS: She is afebrile. Pulse is 58 and blood pressure is 110/56. + +SKIN: There is good skin turgor. + +GENERAL: She is not in acute distress. + +CHEST: Clear to auscultation. There is good air movement bilaterally. + +CARDIOVASCULAR: First and second sounds are heard. No murmurs appreciated. + +ABDOMEN: Less distended. Bowel sounds are absent. + +EXTREMITIES: She has 3+ pedal swelling. + +NEUROLOGICAL: The patient is alert and oriented x3. Examination is nonfocal. + +LABORATORY DATA: + + White count is down from 20,000 to 12.5, hemoglobin is 12, hematocrit 37, and platelets 199,000. Glucose is 157, BUN 14, creatinine 0.6, sodium is 131, potassium is 4.0, and CO2 is 31. + +ASSESSMENT AND PLAN: + +1. Small bowel obstruction/paralytic ileus, rule out obstipation. Continue with less aggressive decompression. Follow surgeon's recommendation. + +2. Pulmonary fibrosis, status post biopsy. Manage as per pulmonologist. + +3. Leukocytosis, improving. Continue current antibiotics. + +4. Bilateral pedal swelling. Ultrasound of the lower extremity negative for DVT. + +5. Hyponatremia, improving. + +6. DVT prophylaxis. + +7. GI prophylaxis. \ No newline at end of file diff --git a/3304_General Medicine.txt b/3304_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..ad2d76e8e286ac58802140da847fe7bbc8b3fe1a --- /dev/null +++ b/3304_General Medicine.txt @@ -0,0 +1,59 @@ +SUBJECTIVE: + + The patient is an 89-year-old lady. She actually turns 90 later this month, seen today for a short-term followup. Actually, the main reasons we are seeing her back so soon which are elevated blood pressure and her right arm symptoms are basically resolved. Blood pressure is better even though she is not currently on the higher dose Mavik likely recommended. She apparently did not feel well with the higher dose, so she just went back to her previous dose of 1 mg daily. She thinks, she also has an element of office hypertension. Also, since she is on Mavik plus verapamil, she could switch over to the combined drug Tarka. However, when we gave her samples of that she thought they were too big for her to swallow. Basically, she is just back on her previous blood pressure regimen. However, her blood pressure seems to be better today. Her daughter says that they do check it periodically and it is similar to today’s reading. Her right arm symptoms are basically resolved and she attributed that to her muscle problem back in the right shoulder blade. We did do a C-spine and right shoulder x-ray and those just mainly showed some degenerative changes and possibly some rotator cuff injury with the humeral head quite high up in the glenoid in the right shoulder, but this does not seem to cause her any problems. She has some vague “stomach problems” + + although apparently it is improved when she stopped Aleve and she does not have any more aches or pains off Aleve. She takes Tylenol p.r.n. + + which seems to be enough for her. She does not think she has any acid reflux symptoms or heartburn. She does take Tums t.i.d. and also Mylanta at night. She has had dentures for many, many years and just recently I guess in the last few months, although she was somewhat vague on this, she has had some sores in her mouth. They do heal up, but then she will get another one. She also thinks since she has been on the Lexapro, she has somewhat of a tremor of her basically whole body at least upper body including the torso and arms and had all of the daughters who I not noticed to speak of and it is certainly difficult to tell her today that she has much tremor. They do think the Lexapro has helped to some extent. + +ALLERGIES: + + None. + +MEDICATION: + + Verapamil 240 mg a day, Mavik 1 mg a day, Lipitor 10 mg one and half daily, vitamins daily, Ocuvite daily, Tums t.i.d. + + Tylenol 2-3 daily p.r.n. + + and Mylanta at night. + +REVIEW OF SYSTEMS: + + Mostly otherwise as above. + +OBJECTIVE: + +General: She is a pleasant elderly lady. She is in no acute distress, accompanied by daughter. + +Vital signs: Blood pressure: 128/82. Pulse: 68. Weight: 143 pounds. + +HEENT: No acute changes. Atraumatic, normocephalic. On mouth exam, she does have dentures. She removed her upper denture. I really do not see any sores at all. Her mouth exam was unremarkable. + +Neck: No adenopathy, tenderness, JVD + + bruits, or mass. + +Lungs: Clear. + +Heart: Regular rate and rhythm. + +Extremities: No significant edema. Reasonable pulses. No clubbing or cyanosis, may be just a minimal tremor in head and hands, but it is very subtle and hardly noticeable. No other focal or neurological deficits grossly. + +IMPRESSION: + +1. Hypertension, better reading today. + +2. Right arm symptoms, resolved. + +3. Depression probably somewhat improved with Lexapro and she will just continue that. She only got up to the full dose 10 mg pill about a week ago and apparently some days does not need to take it. + +4. Perhaps a very subtle tremor. I will just watch that. + +5. Osteoporosis. + +6. Osteoarthritis. + +PLAN: + + I think I will just watch everything for now. I would continue the Lexapro, we gave her more samples plus a prescription for the 20 mg that she can cut in half. I offered to see her for again short-term followup. However, they both preferred just to wait until the annual check up already set up for next April and they know they can call sooner. She might get a flu shot here in the next few weeks. Daughter mentioned here today that she thinks her mom is doing pretty well, especially given that she is turning 90 here later this month and I would tend to agree with that. \ No newline at end of file diff --git a/3316_General Medicine.txt b/3316_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..238fc14ca9489130821c9ad3a1fe4eabdf1094a0 --- /dev/null +++ b/3316_General Medicine.txt @@ -0,0 +1,35 @@ +SUBJECTIVE: + + The patient states that he feels sick and weak. + +PHYSICAL EXAMINATION: + +VITAL SIGNS: Highest temperature recorded over the past 24 hours was 101.1, and current temperature is 99.2. + +GENERAL: The patient looks tired. + +HEENT: Oral mucosa is dry. + +CHEST: Clear to auscultation. He states that he has a mild cough, not productive. + +CARDIOVASCULAR: First and second heart sounds were heard. No murmur was appreciated. + +ABDOMEN: Soft and nontender. Bowel sounds are positive. Murphy's sign is negative. + +EXTREMITIES: There is no swelling. + +NEURO: The patient is alert and oriented x 3. Examination is nonfocal. + +LABORATORY DATA: + + White count is normal at 6.8, hemoglobin is 15.8, and platelets 257,000. Glucose is in the low 100s. Comprehensive metabolic panel is unremarkable. UA is negative for infection. + +ASSESSMENT AND PLAN: + +1. Fever of undetermined origin, probably viral since white count is normal. Would continue current antibiotics empirically. + +2. Dehydration. Hydrate the patient. + +3. Prostatic hypertrophy. Urologist, Dr. X. + +4. DVT prophylaxis with subcutaneous heparin. \ No newline at end of file diff --git a/3317_General Medicine.txt b/3317_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..15fe5439096ca6837766803e9d16fb2fe69417fc --- /dev/null +++ b/3317_General Medicine.txt @@ -0,0 +1,45 @@ +CHIEF COMPLAINT: + + Followup on diabetes mellitus, status post cerebrovascular accident. + +SUBJECTIVE: + + This is a 70-year-old male who has no particular complaints other than he has just discomfort on his right side. We have done EMG studies. He has noticed it since his stroke about five years ago. He has been to see a neurologist. We have tried different medications and it just does not seem to help. He checks his blood sugars at home two to three times a day. He kind of adjusts his own insulin himself. Re-evaluation of symptoms is essentially negative. He has a past history of heavy tobacco and alcohol usage. + +MEDICATIONS: + + Refer to chart. + +ALLERGIES: + + Refer to chart. + +PHYSICAL EXAMINATION: + +Vitals: Wt; 118 lbs, B/P; 108/72, T; 96.5, P; 80 and regular. + +General: A 70-year-old male who does not appear to be in acute distress but does look older than his stated age. He has some missing dentition. + +Skin: Dry and flaky. + +CV: Heart tones are okay, adequate carotid pulsations. He has 2+ pedal pulse on the left and 1+ on the right. + +Lungs: Diminished but clear. + +Abdomen: Scaphoid. + +Rectal: His prostate check was normal per Dr. Gill. + +Neuro: Sensation with monofilament testing is better on the left than it is on the right. + +IMPRESSION: + +1. Diabetes mellitus. + +2. Neuropathy. + +3. Status post cerebrovascular accident. + +PLAN: + + Refill his medications x 3 months. We will check an A1c and BMP. I have talked to him several times about a colonoscopy, which he has refused, and so we have been doing stools for occult blood. We will check a PSA. Continue with yearly eye exams, foot exams, Accu-Cheks, and we will see him in three months and p.r.n. \ No newline at end of file diff --git a/3318_General Medicine.txt b/3318_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..2af1867d3c5ace565a804605a274da29e830ea8f --- /dev/null +++ b/3318_General Medicine.txt @@ -0,0 +1,29 @@ +CHIEF COMPLAINT: + + Followup on diabetes mellitus, hypercholesterolemia, and sinusitis. + +SUBJECTIVE: + + A 70-year-old female who was diagnosed with diabetes mellitus last fall. She has been checking her Accu-Cheks generally once a day, and they range from 82 to a high of 132. She feels well. She walks 1-2 miles most days. If the weather is bad, they go to a local mall. Otherwise they walk outside. She does complain of some sinus congestion and drainage for the last several days. She is up-to-date on her mammogram that she had at the Baylis Building. She sees Dr. Cheng for her gynecological care. She is a nonsmoker. Denies abdominal pain, nausea, vomiting, diarrhea, constipation, blood in her urine, blood in her stools. She has nocturia x 1. Denies swelling in her ankles. She checks her feet regularly. + + + +PAST MEDICAL HISTORY: + + Refer to chart. + +MEDICATIONS: + + Refer to chart. + +ALLERGIES: + + Refer to chart. + +PHYSICAL EXAMINATION: + +Vitals: Wt: 185 B/P: 142/70. When she checks it at the mall and other places, it is usually about 120/56. T: 96.5 P: 84 and regular. + +General: A 70-year-old female who does not appear to be in acute distress. + +HEENT: She has frontal and maxillary sinus tenderness on the right to palpation. The right TM is slightly dull. \ No newline at end of file diff --git a/3322_General Medicine.txt b/3322_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..1246552ac823d00319d7e896be3a186e6381fa88 --- /dev/null +++ b/3322_General Medicine.txt @@ -0,0 +1,57 @@ +SUBJECTIVE: + + The patient comes in today for a comprehensive evaluation. She is well-known to me. I have seen her in the past multiple times. + +PAST MEDICAL HISTORY/SOCIAL HISTORY/FAMILY HISTORY: + + Noted and reviewed today. They are on the health care flow sheet. She has significant anxiety which has been under fair control recently. She has a lot of stress associated with a son that has some challenges. There is a family history of hypertension and strokes. + +CURRENT MEDICATIONS: + + Currently taking Toprol and Avalide for hypertension and anxiety as I mentioned. + +REVIEW OF SYSTEMS: + + Significant for occasional tiredness. This is intermittent and currently not severe. She is concerned about the possibly of glucose abnormalities such diabetes. We will check a glucose, lipid profile and a Hemoccult test also and a mammogram. Her review of systems is otherwise negative. + +PHYSICAL EXAMINATION: + +VITAL SIGNS: As above. + +GENERAL: The patient is alert, oriented, in no acute distress. + +HEENT: PERRLA. EOMI. TMs clear bilaterally. Nose and throat clear. + +NECK: Supple without adenopathy or thyromegaly. Carotid pulses palpably normal without bruit. + +CHEST: No chest wall tenderness. + +BREAST EXAM: No asymmetry, skin changes, dominant masses, nipple discharge, or axillary adenopathy. + +HEART: Regular rate and rhythm without murmur, clicks, or rubs. + +LUNGS: Clear to auscultation and percussion. + +ABDOMEN: Soft, nontender, bowel sounds normoactive. No masses or organomegaly. + +GU: External genitalia without lesions. BUS normal. Vulva and vagina show just mild atrophy without any lesions. Her cervix and uterus are within normal limits. Ovaries are not really palpable. No pelvic masses are appreciated. + +RECTAL: Negative. + +BREASTS: No significant abnormalities. + +EXTREMITIES: Without clubbing, cyanosis, or edema. Pulses within normal limits. + +NEUROLOGIC: Cranial nerves II-XII intact. Strength, sensation, coordination, and reflexes all within normal limits. + +SKIN: Noted to be normal. No subcutaneous masses noted. + +LYMPH SYSTEM: No lymphadenopathy. + +ASSESSMENT: + + Generalized anxiety and hypertension, both under fair control. + +PLAN: + + We will not make any changes in her medications. I will have her check a lipid profile as mentioned, and I will call her with that. Screening mammogram will be undertaken. She declined a sigmoidoscopy at this time. I look forward to seeing her back in a year and as needed. \ No newline at end of file diff --git a/3326_General Medicine.txt b/3326_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..bf9000de64f6ead5167b9401f91caf9b930a5c67 --- /dev/null +++ b/3326_General Medicine.txt @@ -0,0 +1,61 @@ +HISTORY OF PRESENT ILLNESS: + + Goes back to yesterday, the patient went out for dinner with her boyfriend. The patient after coming home all the family members had some episodes of diarrhea; it is unclear how many times the patient had diarrhea last night. She was found down on the floor this morning, soiled her bowel movements. Paramedics were called and the patient was brought to the emergency room. The patient was in the emergency room noted to be in respiratory failure, was intubated. The patient was in septic shock with metabolic acidosis and no blood pressure and very rapid heart rate with acute renal failure. The patient was started on vasopressors. The patient was started on IV fluids as well as IV antibiotic. The CT of the abdomen showed ileus versus bowel distention without any actual bowel obstruction or perforation. A General Surgery consultation was called who did not think the patient was a surgical candidate and needed an acute surgical procedure. The patient underwent an ultrasound of the abdomen, which did not show any evidence of cholecystitis or cholelithiasis. The patient was also noted to have acute rhabdomyolysis on the workup in the emergency room. + +PAST MEDICAL HISTORY: + +Significant for history of osteoporosis, hypertension, tobacco dependency, anxiety, neurosis, depression, peripheral arterial disease, peripheral neuropathy, and history of uterine cancer. + +PAST SURGICAL HISTORY: + +Significant for hysterectomy, bilateral femoropopliteal bypass surgeries as well as left eye cataract surgery and appendicectomy. + +SOCIAL HISTORY: + + She lives with her boyfriend. The patient has a history of heavy tobacco and alcohol abuse for many years. + +FAMILY HISTORY: + + Not available at this current time. + +REVIEW OF SYSTEMS: + + As mentioned above. + +PHYSICAL EXAMINATION: + +GENERAL: She is intubated, obtunded, gangrenous ears with gangrenous fingertips. + +VITAL SIGNS: Blood pressure is absent, heart rate of 138 per minute, and the patient is on the ventilator. + +HEENT: Examination shows head is atraumatic, pupils are dilated and very, very sluggishly reacting to light. No oropharyngeal lesions noted. + +NECK: Supple. No JVD + + distention or carotid bruit. No lymphadenopathy. + +LUNGS: Bilateral crackles and bruits. + +ABDOMEN: Distended, unable to evaluate if this is tender. No hepatosplenomegaly. Bowel sounds are very hyperactive. + +LOWER EXTREMITIES: Show no edema. Distal pulses are decreased. + +OVERALL NEUROLOGICAL: Examination cannot be assessed. + +LABORATORY DATA: + + The database was available at this point of time. WBC count is elevated at 19,000 with the left shift, hemoglobin of 17.7, and hematocrit of 55.8 consistent with severe dehydration. PT INR is prolonged at 1.7 and aPTT is prolonged at 60. Sodium was 143, BUN of 36, and creatinine of 2.5. The patient's blood gas shows pH of 7.05, pO2 of 99.6, and pCO2 of 99.6. Bicarb is 16.5. + +ASSESSMENT AND EVALUATION: + +1. Septicemia with septic shock. + +2. Metabolic acidosis. + +3. Respiratory failure. + +4. Anuria. + +5. Acute renal failure. + +The patient has no blood pressure at this point in time. The patient is on IV fluids. The patient is on vasopressors due to ventilator support, bronchodilators as well as IV antibiotics. Her overall prognosis is extremely poor. This was discussed with the patient's niece who is at bedside and will become indicated with her daughter when she arrives who is on the plane right now from Iowa. The patient will be maintained on these supports at this point in time, but prognosis is poor. \ No newline at end of file diff --git a/3331_General Medicine.txt b/3331_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..ceae060b241d0443c8fab8bd5cfe9ea94c1a6163 --- /dev/null +++ b/3331_General Medicine.txt @@ -0,0 +1,47 @@ +CHIEF COMPLAINT: + + Anxiety, alcohol abuse, and chest pain. + +HISTORY OF PRESENT ILLNESS: + + This is a pleasant 40-year-old male with multiple medical problems, basically came to the hospital yesterday complaining of chest pain. The patient states that he complained of this chest pain, which is reproducible, pleuritic in both chest radiating to the left back and the jaw, complaining of some cough, nausea, questionable shortness of breath. The patient describes the pain as aching, sharp and alleviated with pain medications, not alleviated with any nitrates. Aggravated by breathing, coughing, and palpation over the area. The pain was 9/10 in the emergency room and he was given some pain medications in the ER and was basically admitted. Labs were drawn, which were essentially, potassium was about 5.7 and digoxin level was drawn, which was about greater than 5. The patient said that he missed 3 doses of digoxin in the last 3 days after being discharged from Anaheim Memorial and then took 3 tablets together. The patient has a history prior digoxin overdose of the same nature. + +MEDICATIONS: + + Digoxin 0.25 mg, metoprolol 50 mg, Naprosyn 500 mg, metformin 500 mg, lovastatin 40 mg, Klor-Con 20 mEq, Advair Diskus, questionable Coreg. + +PAST MEDICAL HISTORY: + + MI in the past and atrial fibrillation, he said that he has had one stent put in, but he is not sure. The last cardiologist he saw was Dr. X and his primary doctor is Dr. Y. + +SOCIAL HISTORY: + + History of alcohol use in the past. + +He is basically requesting for more and more pain medications. He states that he likes Dilaudid and would like to get the morphine changed to Dilaudid. His pain is tolerable. + +PHYSICAL EXAMINATION: + +VITAL SIGNS: Stable. + +GENERAL: Alert and oriented x3, no apparent distress. + +HEENT: Extraocular muscles are intact. + +CVS: S1, S2 heard. + +CHEST: Clear to auscultation bilaterally. + +ABDOMEN: Soft and nontender. + +EXTREMITIES: No edema or clubbing. + +NEURO: Grossly intact. Tender to palpate over the left chest, no obvious erythema or redness, or abnormal exam is found. + +EKG basically shows atrial fibrillation, rate controlled, nonspecific ST changes. + +ASSESSMENT AND PLAN: + +1. This is a 40-year-old male with digoxin toxicity secondary to likely intentional digoxin overuse. Now, he has had significant block with EKG changes as stated. Continue to follow the patient clinically at this time. The patient has been admitted to ICU and will be changed to DOU. + +2. Chronic chest pain with a history of myocardial infarction in the past, has been ruled out with negative cardiac enzymes. The patient likely has opioid dependence and requesting more and more pain medications. He is also bargaining for pain medications with me. The patient was advised that he will develop more opioid dependence and I will stop the pain medications for now and give him only oral pain medications in the anticipation of the discharge in the next 1 or 2 days. The patient was likely advised to also be seen by a pain specialist as an outpatient after being referred. We will try to verify his pain medications from his primary doctor and his pharmacy. The patient said that he has been on Dilaudid and Vicodin ES and Norco and all these medications in the past. \ No newline at end of file diff --git a/3334_General Medicine.txt b/3334_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..a3469298b3bb3ab7bf103b941326fa0cb72275bf --- /dev/null +++ b/3334_General Medicine.txt @@ -0,0 +1,71 @@ +REASON FOR CONSULT: + + For evaluation of left-sided chest pain, 5 days post abdominal surgery. + +PAST MEDICAL HISTORY: + + None. + +HISTORY OF PRESENT COMPLAINT: + + This 87-year-old patient has been admitted in this hospital on 12/03/08. The patient underwent laparoscopic appendicectomy by Dr. X. The patient had postoperative paralytic ileus, which has resolved. The patient had developed left-sided chest pain yesterday. In the postoperative period, the patient has had fluid retention, had gain about 25 pounds, and he had swelling of the lower extremities. + +REVIEW OF SYSTEMS: + +CONSTITUTIONAL SYMPTOMS: No recent fever. + +ENT: Unremarkable. + +RESPIRATORY: He denies cough but develop this left-sided chest pain, which does not increase with inspiration, pain is located on the left posterior axillary line and over the fourth and fifth rib. + +CARDIOVASCULAR: No known heart problems. + +GASTROINTESTINAL: The patient denies nausea or vomiting. He is status post laparoscopic appendicectomy, and he is tolerating oral diet. + +GENITOURINARY: No dysuria, no hematuria. + +ENDOCRINE: Negative for diabetes or thyroid problems. + +NEUROLOGIC: No history of CVA or TIA. + +Rest of review of systems unremarkable. + +SOCIAL HISTORY: + +The patient is a nonsmoker. He denies use of alcohol. + +FAMILY HISTORY: + + Noncontributory. + +PHYSICAL EXAMINATION: + +GENERAL: An 87-year-old gentleman, not toxic looking. + +HEAD AND NECK: Oral mucosa is moist. + +CHEST: Clear to auscultation. No wheezing. No crepitations. There is reproducible tenderness over the left posterior-lateral axis. + +CARDIOVASCULAR: First and second heart sounds were heard. No murmurs appreciated. + +ABDOMEN: Slightly distended. Bowel sounds are positive. + +EXTREMITIES: He has 2+ to 3+ pedal swelling. + +NEUROLOGIC: The patient is alert and oriented x3. Examination is nonfocal. + +LABORATORY DATA: + + White count is 12,500, hemoglobin is 13, hematocrit is 39, and platelets 398,000. Glucose is 123, total protein is 6, and albumin is 2.9. + +ASSESSMENT AND PLAN: + +1. Ruptured appendicitis. The patient is 6 days post surgery. He is tolerating oral fluids and moving bowels. + +2. Left-sided chest pain, need to rule out PE by distance of pretty low probability. The patient, however, has low-oxygen saturation. We will do ultrasound of the lower extremity and if this is positive we would proceed with the CT angiogram. + +3. Fluid retention, manage as per surgeon. + +4. Paralytic ileus, resolving. + +5. Leukocytosis, we will monitor. \ No newline at end of file diff --git a/3337_General Medicine.txt b/3337_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..1626cbfe5607bd5bca46a58f2ea07e3c178f4c61 --- /dev/null +++ b/3337_General Medicine.txt @@ -0,0 +1,83 @@ +PAST MEDICAL HISTORY: Include: + +1. Type II diabetes mellitus. + +2. Hypertension. + +3. Hyperlipidemia. + +4. Gastroesophageal reflux disease. + +5. Renal insufficiency. + +6. Degenerative joint disease, status post bilateral hip and bilateral knee replacements. + +7. Enterocutaneous fistula. + +8. Respiratory failure. + +9. History of atrial fibrillation. + +10. Obstructive sleep apnea. + +11. History of uterine cancer, status post total hysterectomy. + +12. History of ventral hernia repair for incarcerated hernia. + +SOCIAL HISTORY: The patient has been admitted to multiple hospitals over the last several months. + +FAMILY HISTORY: Positive for diabetes mellitus type 2 in both mother and her sister. + +MEDICATIONS: Currently include, + +1. Albuterol inhaler q.4 h. + +2. Paradox swish and spit mouthwash twice a day. + +3. Digoxin 0.125 mg daily. + +4. Theophylline 50 mg q.6 h. + +5. Prozac 20 mg daily. + +6. Lasix 40 mg daily. + +7. Humulin regular high dose sliding scale insulin subcu. q.6 h. + +8. Atrovent q.4 h. + +9. Lantus 12 units subcu. q.12 h. + +10. Lisinopril 10 mg daily. + +11. Magnesium oxide 400 mg three times a day. + +12. Metoprolol 25 mg twice daily. + +13. Nitroglycerin topical q.6 h. + +14. Zegerid 40 mg daily. + +15. Simvastatin 10 mg daily. + +ALLERGIES: Percocet, Percodan, oxycodone, and Duragesic. + +REVIEW OF SYSTEMS: The patient currently denies any pain, denies any headache or blurred vision. Denies chest pain or shortness of breath. She denies any nausea or vomiting. Otherwise, systems are negative. + +PHYSICAL EXAM: + +General: The patient is awake, alert, and oriented. She is in no apparent respiratory distress. + +Vital Signs: Temperature 97.6, blood pressure is 139/53, pulse 100, respirations 24. The patient has a tracheostomy in place. She will also have an esophageal gastric tube in place. + +Cardiac: Regular rate and rhythm without audible murmurs, rubs or gallops. Lungs are clear to auscultation bilaterally with slightly diminished breath sounds on the bases. No adventitious sounds are noted. + +Abdomen: Obese. There is an open wound on the ventral abdomen overlying the midline abdominal incision from previous surgery. The area is covered with bandage with serosanguineous fluid. Abdomen is nontender to palpation. Bowel sounds are heard in all 4 quadrants. + +Extremities: Bilateral lower extremities are edematous and very cool to touch. + +LABORATORY DATA: Pending. Capillary blood sugars thus far have been 132 and 135. + +ASSESSMENT: This is an 80-year-old female with an unfortunate past medical history with recent complications of sepsis and respiratory failure who is now receiving tube feeds. + +PLAN: For her diabetes mellitus, we will continue the patient on her current regimen of Lantus 12 units subcu. q.12 h. and Regular Insulin at a high dose sliding scale every 6 hours. The patient had been previously controlled on this. We will continue to check her sugars every 6 hours and adjust insulin as necessary. \ No newline at end of file diff --git a/3338_General Medicine.txt b/3338_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..abefa989cb31ce4337ff6ac5469f72d8a0d7b91a --- /dev/null +++ b/3338_General Medicine.txt @@ -0,0 +1,47 @@ +HISTORY: + + A 69-year-old female with past history of type II diabetes, atherosclerotic heart disease, hypertension, carotid stenosis. The patient was status post coronary artery bypass surgery aortic valve repair at Shadyside Hospital. The patient subsequently developed CVA. She also developed thrombosis of the right arm, which ultimately required right hand amputation. She was stabilized and eventually transferred to HealthSouth for further management. + +PHYSICAL EXAMINATION: + +Vital Signs: Pulse of 90 and blood pressure 150/70. + +Heart: Sounds were heard, grade 2/6 systolic murmur at the precordium. + +Chest: Clinically clear. + +Abdomen: Some suprapubic tenderness. Evidence of right lower arm amputation. + +The patient was started on Prevacid 30 mg daily, levothyroxine 75 mcg a day, Toprol 25 mg twice a day, Zofran 4 mg q.6 h, Coumadin dose at 5 mg and was adjusted. She was given a pain control using Vicodin and Percocet, amiodarone 200 mg a day, Lexapro 20 mg a day, Plavix 75 mg a day, fenofibrate 145 mg, Lasix 20 mg IV twice a day, Lantus 50 units at bedtime and Humalog 10 units a.c. and sliding scale insulin coverage. Wound care to the right heel was supervised by Dr. X. The patient initially was fed through NG tube, which was eventually discontinued. Physical therapy was ordered. The patient continued to do well. She was progressively ambulated. Her meds were continuously adjusted. The patient's insulin was eventually changed from Lantus to Levemir 25 units twice a day. Dr. Y also followed the patient closely for left heel ulcer. + +LABORATORY DATA: + + The latest cultures from left heel are pending. Her electrolytes revealed sodium of 135 and potassium of 3.2. Her potassium was switched to K-Dur 40 mEq twice a day. Her blood chemistries are otherwise closely monitored. INRs were obtained and were therapeutic. Throughout her hospitalization, multiple cultures were also obtained. Urine cultures grew Klebsiella. She was treated with appropriate antibiotics. Her detailed blood work is as in the chart. Detailed radiological studies are as in the chart. The patient made a steady progress and eventually plans were made to transfer the patient to ABC furthermore aggressive rehabilitation. + +FINAL DIAGNOSES: + +1. Atherosclerotic heart disease, status post coronary artery bypass graft. + +2. Valvular heart disease, status post aortic valve replacement. + +3. Right arm arterial thrombosis, status post amputation right lower arm. + +4. Hypothyroidism. + +5. Uncontrolled diabetes mellitus, type 2. + +6. Urinary tract infection. + +7. Hypokalemia. + +8. Heparin-induced thrombocytopenia. + +9. Peripheral vascular occlusive disease. + +10. Paroxysmal atrial fibrillation. + +11. Hyperlipidemia. + +12. Depression. + +13. Carotid stenosis. \ No newline at end of file diff --git a/3340_General Medicine.txt b/3340_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..67967c65dcf69db6785a5cd20cfe416c427e0d36 --- /dev/null +++ b/3340_General Medicine.txt @@ -0,0 +1,65 @@ +Chief Complaint: + + Abdominal pain, nausea and vomiting. + +History of Present Illness: + + A 50-year-old Asian female comes to The Methodist Hospital on January 2, 2001, complaining of a 3-day history of abdominal pain. The pain is described as crampy in the central part of her abdomen, and is associated with nausea and vomiting during the previous 24 hours. The patient denied passing any stool or gas per rectum for the previous 24 hours. She had been admitted recently to the hospital from December 19 to December 23, 2000, with a three-week history of fevers to 101.8, diaphoresis, anorexia, malaise and skin "lumps". She described a total of three "lumps". The first one started as a pin-sized lesion that grew up and then disappeared, the other two didn't resolve. They were described as "erythematous nodular lesions on the extensor surface of the left arm." A punch biopsy was obtained from these skin lesions, showing deep dermis and subcutaneous adipose tissue that contained "multiple granulomas composed of histiocytes and multinucleated giant cells without caseating necrosis". However, one granuloma in the deep dermis, showed a hint of central necrosis. Special stains for acid - fast bacilli and fungi were reported as negative. No atypia or malignancy was noted. A CT scan of the chest was obtained on December 19, 2000 and showed numerous masses with spiculated borders bilaterally, predominately in the upper lobes and superior segments of the lower lobes. No cavitary lesions, mediastinal masses or definite hilar adenopathy were reported. The patient underwent bronchoscopy and transbronchial biopsy which showed fragments of bronchial mucosa and wall with underlying lung parenchyma. Minimal to mild interstitial lymphocytes with a few microfoci of neutrophils were seen. They were also able to appreciate intra-alveolar fibrinous exudates. One of the blood cultures drawn on December 19, 2000 grew Streptococcus mitis. + +The patient was discharged on ethambutol 1200 mg po qd, clarithromycin 500 mg po bid, ampicillin 500 mg po q 6h and fluconazole 200 mg po qd. + +Past Medical History: + +1. Post-streptococcal glomerulonephritis at age 10. + +2. End stage renal disease diagnosed in 1994, on peritoneal dialysis until 1996. + +3. Cadaveric transplant in October 1996,4. Steroid induced diabetes mellitus,5. Hypertension,Past Surgical History: + +1. Total abdominal hysterectomy in January 1996,2. Cesarean section X2 in 1996 and 1997,3. Appendectomy in 1971,4. Insertion of peritoneal dialysis catheter in 1994,5. Cadaveric transplant in October 1996,Social History: + +The patient denies a history of smoking, drinking or intravenous drug use. She came to the United States in 1973. She works as a nurse in a newborn nursery. Her hobby is gardening. She traveled to Las Vegas on May 2000 and stayed for 6 months. She denied ill contacts or pets. + +Allergies: + + Ciprofloxacin and Enteric coated aspirin,Medications: + + prednisone 20 mg po qd, enalapril 2.5 mg po qd, clonidine patch TTS 3 1/week, Prograf 5 mg po bid, ranitidine 150 mg po bid, furosemide 40 mg po bid, atorvastatin 10 mg po qd, multivitamins 1 tab po qd, estrogen patch, fluconazole 200 mg po qd, metformin 500 mg po bid, glyburide 10 mg po qd, clarithromycin 500 mg po bid, ethambutol 1200 mg po qd, ampicillin 500 mg po q 6h. + +Family History: + + She described a family history of hypertension. Her mother died after a myocardial infarction at age 59. Her father was diagnosed with congestive heart failure and had a pacemaker placed. + +Review of systems: + + Non-contributory. The patient denied fever, chills, ulcers, liver disease or history of gallstones. + +Vaccines: The patient was vaccinated with BCG before starting elementary school in the Philippines. + +Physical Examination: + + At the time of the examination the patient was alert and oriented times three and in no acute distress. She was well nourished. + +BP 106/60 lying down; HR 86; RR 12; T 96.1° F; Hgt. =5' 2"; Wgt. =121 lbs. + +SKIN: There was no rash or skin lesions. + +HEENT: She had no oral lesions and moist mucous membranes. No icterus was noted. + +NECK: Her neck was supple without lymphadenopathy or thyromegaly. + +LUNGS: Crackles at the right lower base with normal respiratory excursion and no dullness to percussion. + +HEART: IV/VI crescendo - decrescendo systolic murmur was heard at the second intercostal space with radiation to the neck. + +ABDOMEN: The abdomen was distended. Bowel sounds were normal. No hepatosplenomegaly, tenderness or rebound tenderness could be detected during the examination. + +EXTREMITIES: No cyanosis, clubbing or edema was noted. + +RECTAL: Normal rectal exam. Guaiac negative. + +NEUROLOGIC: Normal and non-focal. + +Hospital Course: + + The patient was admitted and a nasogastric tube was placed. IV fluids were started. A KUB was obtained showing an abnormal bowel gas pattern. Multiple loops of distended bowel were noted in the mid abdomen. Air and feces were noted within the colon in the right side. An Abdominal CT scan was obtained. There was a small amount of perihepatic fluid noted. The liver and spleen were normal. The kidneys were atrophic. The gallbladder was moderately distended. There was marked dilatation of the small bowel proximally and distally. There was gas and contrast material in the colon. A diagnostic procedure was performed. \ No newline at end of file diff --git a/3341_General Medicine.txt b/3341_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..7f02162aad9d4e638aa057503aa50f91251523b3 --- /dev/null +++ b/3341_General Medicine.txt @@ -0,0 +1,45 @@ +SUBJECTIVE: + + The patient complains of backache, stomachache, and dysuria for the last two days. Fever just started today and cough. She has history of kidney stones less than a year ago and had a urinary tract infection at that time. Her back started hurting last night. + +PAST MEDICAL HISTORY: + + She denies sexual activities since two years ago. Her last menstrual period was 06/01/2004. Her periods have been irregular. She started menarche at 10 years of age and she is still irregular and it runs in Mom’s side of the family. Mom and maternal aunt have had total hysterectomies. She also is diagnosed with abnormal valve has to be on SBE prophylaxis, sees Dr. XYZ Allen. She avoids decongestants. She is limited on her activity secondary to her heart condition. + +MEDICATION: + + Cylert. + +ALLERGIES: + + No known drug allergies. + +OBJECTIVE: + +Vital Signs: Blood pressure is 124/72. Temperature 99.2. Respirations 20 unlabored. Weight: 137 pounds. + +HEENT: Normocephalic. Conjunctivae noninjected. No mattering noted. Her TMs are bilaterally clear, nonerythematous. Throat clear, good mucous membrane moisture, but she did have erythema and edema at her posterior soft palate. + +Neck: Supple. Increased lymphadenopathy noted in the submandibular nodes, but no axillary nodes and no hepatosplenomegaly. + +Respiratory: Clear. No wheezes, no crackles, no tachypnea, and no retractions. + +Cardiovascular: Regular rate and rhythm. S1 and S2 normal, no murmur. + +Abdomen: Soft. No organomegaly. She did have exquisite tenderness to palpation of the left upper quadrant and flank area, but the spleen was not palpable. She has no suprapubic tenderness. + +Extremities: She has good range of motion of upper and lower extremities. Good ambulation. + +Her UA was positive for 2+ leukocyte esterase, positive nitrites, 1+ protein, 2+ ketones, 4+ blood, greater than 50 white blood cells, 10-20 rbc’s, and 1+ bacteria. Culture and sensitivity is pending. Her Strep test is negative. Culture is pending. + +ASSESSMENT: + +1. Urinary dysuria. + +2. Left flank pain. + +3. Pharyngitis. + +PLAN: + + A 1 g of Rocephin IM was given. Call Dr. B's office tomorrow morning incase a second IM dose is needed. If not then she will fill a prescription for Omnicef 300 mg capsule 1 p.o. b.i.d. for 10 days total and then we will await the culture and sensitivity results to see if this is appropriate drug. Push fluids. Await strep culture report. Follow up with Dr. XYZ if no better or symptoms worsen. \ No newline at end of file diff --git a/3343_General Medicine.txt b/3343_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..5992373f5909a1d25ab086d555452ef89d99dd96 --- /dev/null +++ b/3343_General Medicine.txt @@ -0,0 +1,81 @@ +Chief Complaint: + + Confusion and hallucinations. + +History of Present Illness: + + The patient was a 27-year-old Hispanic man who presented to St. Luke's Episcopal Hospital with a five day history of confusion and hallucinations. The patient was doing well until three months prior to admission when he developed wheezing and shortness of breath upon exertion. He was seen by his primary care physician and was prescribed Salmeterol and Fluticasone nasal inhaler for presumed asthma. His wheezing improved with treatment. + +Over the five days prior to admission, his family noticed the patient's increasing confusion and bizarre behavior. The patient was intermittently unable to recognize his family members or surroundings. He was restless and anxious, paced the floor at night, and complained of insomnia. He stated he was unable to sleep because he feared his family was trying to hurt him. When he did sleep, he described night terrors. He also complained of both auditory and visual hallucinations. He stated the voices "told him to do good things". He denied any previous history of depression or manic episodes. The patient denied suicidal or homicidal ideation. He admitted he had recently lost weight although he was unable to quantify how much. He stated his appetite was good, but he had not been eating for fear of being poisoned. + +The patient denied having headaches or a history of trauma. He denied fevers or chills but he complained of recent night sweats. He denied nausea, vomiting, diarrhea, or dysuria. He denied chest pain, palpitations, or episodic flushing; but he complained of lightheadedness. He denied orthopnea or paroxysmal nocturnal dyspnea. The shortness of breath symptoms had resolved. + +Past Medical History: + + None. No history of hypertension or of cardiac, renal, lung, or liver disease. + +Past Surgical History: + + None,Past Psychological History: None,Social History: + + The patient was from Brazil. He moved to the United States one year ago. He denied any history of tobacco, alcohol, or illicit drug use. He was married and monogamous. He worked as an engineer/manager, and stated that his job was "very stressful". He had recently been admitted to an MBA program. The patient denied recent travel or exposures of any kind. + +Family History: + + The patient had a second-degree relative with a history of depression and "nervous breakdown". + +Allergies: + + There were no known drug allergies. + +Medications: + + Prescribed medications were Salmeterol inhaler, prn; and Fluticasone nasal inhaler. The patient was taking no over the counter or alternative medicines. + +Physical Examination: + + The patient was a 27-year-old Hispanic man who presented with symptoms of confusion and hallucinations. He was a thin man but appeared to be well developed and well nourished. The patient paced the room during the examination. He appeared anxious and distracted. He was coherent, yet he had poor concentration and was unable to cooperate fully with the examination. The patient had a pulse rate of 110 beats per minute and blood pressure of 186/101 mm Hg when reclining; and a pulse rate of 122 beats per minute and blood pressure of 166/92 mm Hg when standing. His oral temperature was 100.8 degrees Fahrenheit, and his respiratory rate was 12 breaths per minute. + +HEENT: Conjunctivae were pink; sclerae anicteric; mucous membranes moist and pink without lesions. + +NECK: The neck was supple, normal jugular venous pressure, no carotid bruits, no thyromegaly. + +LUNGS: The lungs were clear to auscultation bilaterally; no wheezes, rales or rhonchi. + +HEART: The heart had a regular rhythm, tachycardic, II/VI systolic ejection murmur LUSB + + no rubs or gallops, PMI nondisplaced, hyperdynamic precordium. + +ABDOMEN: The abdomen was soft, nontender and nondistended; normoactive bowel sounds, no hepatosplenomegaly, no masses; positive bruit heard throughout mid-abdomen, positive bilateral femoral bruits. + +EXTREMITIES: No clubbing, cyanosis, or edema; 2+ pulses. + +GENITOURINARY: Normal male phallus, no testicular masses. + +RECTAL: Guaiac negative, no masses. + +LYMPH NODES: Negative in the anterior and posterior clavicular, supraclavicular, axillary, and inguinal regions. + +SKIN: Acneiform eruption over back and trunk, no papules or vesicles. + +NEUROLOGICAL EXAMINATION: The patient was alert and oriented to self and year, but not to month or place. He had difficulty with mathematics and following commands (when asked to stand on his heels, the patient stood on his toes and turned on the television). Cranial nerves II-XII intact, motor 5/5 throughout all extremities; reflexes 2+ and symmetrical throughout. Sensory: Intact to light touch, vibration, proprioception, and temperature. Cerebellar: intact finger to nose, no ataxia. Romberg negative. + +PSYCHOLOGICAL EXAMINATION: The patient's mood was elevated and euphoric; affect was appropriate; his speech was normal in rate, volume, and tone. + +Hospital Course: + + The patient was admitted to St. Luke's Episcopal Hospital and a workup for his altered mental status was begun. The following studies were performed: + +Twelve-lead EKG: sinus tachycardia. + +CXR (PA/lat): normal cardiac silhouette and normal lung fields. + +CT scan of head without contrast: ventricles were normal in size and position. There was no evidence of mass or hemorrhage. + +Lumbar puncture: clear, colorless; WBC--0; RBC--56; protein--45; glucose--126; VDRL--negative; cryptococcal Ag--negative; cultures--negative. + +MRI with gadolinium: no discrete areas of abnormal signal intensity. + +EEG: no focal or epileptiform activity. + +The patient was treated with haldol and risperidone for his agitation, and further diagnostic testing was performed. \ No newline at end of file diff --git a/3344_General Medicine.txt b/3344_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..d443bf42c17b7f396f738b35e192c9d76331b5b7 --- /dev/null +++ b/3344_General Medicine.txt @@ -0,0 +1,77 @@ +Chief Complaint: + + Abdominal pain, nausea, vomiting, fever, altered mental status. + +History of Present Illness: + + 55 yo WM with reactive airways disease, allergic rhinitis who was in his usual state of health until he underwent a dental extraction with administration of cephalexin 1 week prior to admission. Approximately one day after the dental procedure, he began having nausea, and abdominal pain along with fatigue. The abdominal pain was described as pressure-like and was located in the epigastrium and periumbilical regions. He initially attributed the symptoms to a side effect of the antibiotic he was taking. However, with worsening of his symptoms, he presented to the ER 5 days after dental extraction. + +At that time his vitals were T 99.9 ° HR 115 RR 18 BP 182/101. His exam was notable for mild tenderness in the central abdomen. Laboratory evaluation was notable for WBC 15.6, Hgb 13.1, Plt 189, 16% bands, 68% PMNs. Na 127, K4.7, Cl 88, CO2 29, BUN 19, Cr 1.5, Glucose 155, Ca 9.6, alk phos 125, t bili 0.7, ALT 29, nl amylase and lipase. UA with 100 protein, lg blood, 53 RBC + + 2 WBC. Plain films done at that time revealed dilation of small bowel loops in mid-abdomen up to 3.5cm in diameter, thought to be most consistent with a paralytic ileus. The patient was discharged home with diagnosis of medication-induced gastroenteritis vs. UTI. He was instructed to stop his current antibiotic but start Levaquin, and he was given Vicodin, and phenergan for symptomatic relief. + +Over the next 2 days, the patient began having fevers, non-bloody emesis, diarrhea, and confusion in addition to his persistent nausea, and abdominal pain. On the night of presentation, the patient was found by a cousin in his bathroom lethargic and disoriented. EMS was called and patient was taken to the ER. In the ER + + the pt was diaphoretic, unable to answer questions appropriately, hypotensive, and febrile, with some response of bp to multiple IVF boluses (4L). He received acetaminophen, and ceftriaxone 2g IV after blood cultures were obtained and an LP was performed in the ER. He was then admitted to the ICU for further evaluation and management. + +Past Medical History: + +Asthma,Allergic Rhinitis,Medications: + +loratadine,beclomethasone nasal,fluticasone/salmeterol inhaled,Montelukast,cephalexin,hydrocodone,Allergies: + + PCN + + but has tolerated cephalosporins in the past. + +Social History: + + No tobacco use, occasional EtOH + + no known drug use, works as a real estate agent. + +Family History: + + HTN + + father with SLE + + uncle with Addison’s Disease. + +Physical Exam: + +T 102.9 ° HR 145 RR 22 BP 99/50 98% on room air, (orthostatics were not performed due to patient’s mental status) + +I/O: minimal urine output after Foley insertion,Gen: lethargic, mild tachypnea,HEENT: no evidence of trauma, sclerae anicteric, pupils are equal round and reactive to light, oropharynx clear, MM dry. + +Neck: supple, without increased JVP + + lymphadenopathy or bruits. No thyromegaly,Chest: coarse rhonchi bilaterally,CV: tachycardia, regular, no murmurs, gallops, rubs,Abd: hypoactive bowel sounds, soft, slightly distended, mild tenderness throughout. No rebound, no masses or hepatosplenomegaly. + +Ext: no cyanosis, clubbing, or edema. 2+ pulses bilateral distal extremities, no petechiae or splinter hemorrhages. + +Neuro: lethargic, but arousable, oriented to person, but not to place, or time. He was not able to answer questions appropriately. Moved all extremities equally but was uncooperative with exam. 2+ DTRs bilaterally, no Babinski reflex. + +Skin: no rash, ecchymosis, or petechiae,STUDIES: + +EKG: sinus tachycardia, normal axis, isolated Q in III + + no TWI or ST elevations or depressions,CXR: Heart normal in size, pulmonary vasculature unremarkable, subsegmental atelectasis in the lower lobes. Acromioclavicular osteoarthritis bilaterally. Lucent lesion in the subchondral bone of the R humeral head, likely a degenerative subchondral cyst. + +AXR: Minimal dilation of the small bowel loops in the mid abdomen measuring up to 3cm, no mass lesion or free air visible. + +MRI brain pre and post gadolinium: No evidence of hemorrhage, abnormal enhancement, mass lesions, mass effect or edema. The ventricles, sulci, and cisterns are age appropriate in size and configuration. There is no evidence for restricted diffusion. There is mucosal thickening lining the walls of the left maxillary sinus, also containing an air fluid level with two different levels within it, most likely from proteinaceous differences. There is mucosal thickening along the posterior wall of the right maxillary sinus. Mucosal thickening is identified along the walls of the sphenoid sinus, ethmoid sinuses and frontal sinus. Sinusitis with chronic and acute features. + +Echo: EF 50% + + mild LV concentric hypertrophy, otherwise normal chamber sizes and function,TEE: Normal valves, no thrombi, PFO with R to L shunt, trivial MR + + trivial TR + +RLE Ultrasound with Dopplers – total deep venous obstruction in distal external iliac, common femoral, profunda femoral, and femoral vein, partial DVT in popliteal and posterior tibial veins, and total DVT greater saphenous vein. No venous obstruction on the L LE. R calf 34cm, R thigh 42 cm, L calf 31cm, L thigh 39cm. + +CT Abdomen (initial ER visit): Trace bilateral pleural fluid, findings in liver compatible with diffuse fatty infiltration, 3.5cm non calcified R adrenal mass was noted, along with an edematous L adrenal with no discrete mass. There was retroperitoneal edema around the lower abdominal aorta with perinephric stranding, no stone or obstruction. Moderate fullness of small bowel loops was noted, most consistent with a paralytic ileus. + +Hospital Course: + + The patient developed right lower extremity swelling and was diagnosed with deep venous thrombosis. Diagnostic studies were performed. \ No newline at end of file diff --git a/3345_General Medicine.txt b/3345_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..feefd03a6126135158ac462b3ec88436b9d8fd64 --- /dev/null +++ b/3345_General Medicine.txt @@ -0,0 +1,65 @@ +Chief Complaint: + + Chronic abdominal pain. + +History of Present Illness: + + 23-year-old Hispanic male who presented for evaluation of chronic abdominal pain. Patient described the pain as dull, achy, constant and located at the epigastric area with some radiation to the back. There are also occasional episodes of stabbing epigastric pain unrelated to meals lasting only minutes. Patient noted that the pain started approximately six months prior to this presentation. He self medicated "with over the counter" antacids and obtained some relief so he did not seek medical attention at that time. + +Two months prior to current presentation, he had worsening of his pain as well as occasional nausea and vomiting. At this time the patient was found to be H. pylori positive by serology and was treated with triple therapy for two weeks and continued on omeprazole without relief of his pain. + +The patient felt he had experienced a twenty-pound weight loss since his symptoms began but he also admitted to poor appetite. He stated that he had two to three loose bowel movements a day but denied melena or bright red blood per rectum. Patient denied NSAID use, ethanol abuse or hematemesis. Position did not affect the quality of the pain. Patient denied fever or flushing. He stated he was a very active and healthy individual prior to these recent problems. + +Past Medical History: + + No significant past medical history. + +Past Surgical History: + + No prior surgeries. + +Allergies: + + No known drug allergies. + +Medications: + + Omeprazole 40 mg once a day. Denies herbal medications. + +Family History: + + Mother, father and siblings were alive and well. + +Social History: + + He is employed as a United States Marine officer, artillery repair specialist. He was a social drinker in the past but quit altogether two years ago. He never used tobacco products or illicit/intravenous drugs. + +Physical Examination: + + The patient was a thin male in no apparent distress. His oral temperature was 98.2 Fahrenheit, blood pressure was 114/67 mmHg, pulse rate of 91 beats per minute and regular, respiratory rate was 14 and his pulse oximetry on room air was 98%. Patient was 52 kg in weight and 173 cm height. + +SKIN: No skin rashes, lesions or jaundice. He had one tattoo on each upper arm. + +HEENT: Head was normocephalic and atraumatic. Pupils were equal, round and reactive. Anicteric sclerae. Tympanic membranes had a normal appearance. Normal funduscopic examination. Oral mucosa was moist and pink. Oral/pharynx was clear. + +NECK: No lymphadenopathy. No carotid bruits. Trachea midline. Thyroid non-palpable. No jugular venous distension. + +CHEST: Lungs were clear bilaterally with good air movement. + +HEART: Regular rate and rhythm. Normal S1 and S2 with no murmurs, gallops or rubs. PMI was non-displaced. + +ABDOMEN: Abdomen was flat. Normal active bowel sounds. Liver span percussed sixteen centimeters, six centimeters below R costal margin with irregular border that was mildly tender to palpation. Slightly tender to palpation in epigastric area. There was no splenomegaly. No abdominal masses were appreciated. No CVA tenderness was noted. + +RECTAL: No perirectal lesions were found. Normal sphincter tone and no rectal masses. Prostate size was normal without nodules. Guaiac positive. + +GENITALIA: Testes descended bilaterally, no penile lesions or discharge. + +EXTREMITIES: No clubbing, cyanosis, or edema. No peripheral lymphadenopathy was noted. + +NEUROLOGIC: Alert and oriented times three. Cranial nerves II to XII appeared intact. No muscle weakness or sensory deficits. DTRs equal and normal. + +Radiology/Studies: 2 view CXR: Mild elevation right diaphragm. + +CT of abdomen and pelvis: Too numerous to count bilobar liver masses up to about 8 cm. Extensive mass in the pancreatic body and tail, peripancreatic region and invading the anterior aspect of the left kidney. Question of vague splenic masses. No definite abnormality of the moderately distended gallbladder, bile ducts, right kidney, poorly seen adrenals, bowel or bladder. Evaluation of the retroperitoneum limited by paucity of fat. + +Patient underwent several diagnostic procedures and soon after he was transferred to Houston Veterans Administration Medical Center to be near family and to continue work-up and treatment. At the HVAMC these diagnostic procedures were reviewed. \ No newline at end of file diff --git a/3346_General Medicine.txt b/3346_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..c3081481d96043e130d71209fa11ce2b749f0dfc --- /dev/null +++ b/3346_General Medicine.txt @@ -0,0 +1,59 @@ +Chief Complaint: + + Dark urine and generalized weakness. + +History of Present Illness: + +40 year old Hispanic male presented to the emergency room complaining of generalized weakness, fatigue and dark urine for one week. In addition, he stated that his family had noticed yellowing of his skin and eyes, though he himself had not noticed. + +He did complain of subjective fever and chills along with occasional night sweats during the prior week or so and he noted anorexia for 3-4 weeks leading to 26 pound weight loss (213 lbs. to 187 lbs.). He was nauseated but denied vomiting. He did admit to intermittent abdominal discomfort which he could not localize. In addition, he denied any history of liver disease, but had undergone cholecystectomy many years previous. + +Past Medical History: + + DM II-HbA1c unknown,Past Surgical History: + + Cholecystectomy without complication,Family History: + + Mother with diabetes and hypertension. Father with diabetes. Brother with cirrhosis (etiology not documented). + +Social History: + + He was unemployed and denied any alcohol or drug use. He was a prior “mild” smoker, but quit 10 years previous. + +Medications: + + Insulin (unknown dosage) + +Allergies: + + No known drug allergies. + +Physical Exam: + +Temperature: 98.2,Blood pressure:118/80,Heart rate: 95,Respiratory rate: 18,GEN: Middle age Latin-American Male, jaundice, alert and oriented to person/place/time. + +HEENT: Normocephalic, atraumatic. Icteric sclerae, pupils equal, round and reactive to light. Clear oropharynx. + +NECK: Supple, without jugular venous distension, lymphadenopathy, thyromegaly or carotid bruits. + +CV: Regular rate and rhythm, normal S1 and S2. No murmurs, gallops or rubs,PULM: Clear to auscultation bilaterally without rhonchi, rales or wheezes,ABD: Soft with mild RUQ tenderness to deep palpation, Murphy’s sign absent. Bowel sounds present. Hepatomegaly with liver edge 3 cm below costal margin. Splenic tip palpable. + +RECTAL: Guaiac negative,EXT: Shotty inguinal lymphadenopathy bilaterally, largest node 2cm,NEURO: Strength 5/5 throughout, sensation intact, reflexes symmetric. No focal abnormality identified. No asterixis,SKIN: Jaundice, no rash. No petechiae, gynecomastia or spider angiomata. + +Hospital Course: + +The patient was admitted to the hospital to begin workup of liver failure. Initial labs were considered to be consistent with an obstructive pattern, so further imaging was obtained. A CT scan of the abdomen and pelvis revealed lymphadenopathy and a markedly enlarged liver. His abdominal pain was controlled with mild narcotics and he was noted to have decreasing jaundice by hospital day 4. An US guided liver biopsy revealed only acute granulomatous inflammation and fibrosis. The overall architecture of the liver was noted to be well preserved. + +Gastroenterology was consulted for EGD and ERCP. The EGD was normal and the ERCP showed normal biliary anatomy without evidence of obstruction. In addition, they performed an endoscopic ultrasound-guided fine needle aspiration of two lymph-nodes, one in the subcarinal region and one near the celiac plexus. Again, pathologic results were insufficient to make a tissue diagnosis. + +By the second week of hospitalization, the patient was having intermittent low-grade fevers and again experiencing night-sweats. He remained jaundice. Given the previous negative biopsies, surgery was consulted to perform an excisional biopsy of the right groin lymph node, which revealed no evidence of carcinoma, negative AFB and GMS stains and a single noncaseating granuloma. + +By his fourth week of hospitalization, he remained ill with evidence of ongoing liver failure. Surgery performed an open liver biopsy and lymph node resection. + +STUDIES (HISTORICAL): + +CT abdomen: Multiple enlarged lymph nodes near the porta hepatis and peri-pancreatic regions. The largest node measures 3.5 x 3.0 cm. The liver is markedly enlarged (23cm) with a heterogenous pattern of enhancement. The spleen size is at the upper limit of normal. Pancreas, adrenal glands and kidneys are within normal limits. Visualized portions of the lung parenchyma are grossly normal. + +CT neck: No abnormalities noted,CT head: No intracranial abnormalities,RUQ US (for biopsy): Heterogenous liver with lymphadenopathy. + +ERCP: No filling defect noted; normal pancreatic duct visualized. Normal visualization of the biliary tree, no strictures. Normal exam. \ No newline at end of file diff --git a/3355_General Medicine.txt b/3355_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..a764f32257e48635050c3b414e503d0aa6735570 --- /dev/null +++ b/3355_General Medicine.txt @@ -0,0 +1,75 @@ +CHIEF COMPLAINT: + + Abdominal pain and discomfort for 3 weeks. + +HISTORY OF PRESENT ILLNESS: + + + +The patient is a 38 year old white female with no known medical problems who presents complaining of abdominal pain and discomfort for 3 weeks. She had been in her normal state of health when she started having this diffuse abdominal pain and discomfort which is mostly located in the epigastrium and right upper quadrant. She also complains of indigestion and right scapular pain during this same period. None of these complaints are alleviated or aggravated by food. She denies any NSAIDs use. The patient went to an outside hospital where a right upper quadrant ultrasound showed no gallbladder disease, but was suspicious for a liver mass. A CT and MRI of the abdomen and pelvis showed a 12.5 X 10.9 X 11.1 cm right suprarenal mass and a 7.1 X 5.4 X 6.5 cm intrahepatic mass in the region of the dome of the liver. CT of the chest revealed multiple small (<5 mm) bilateral lung nodules. Total body bone scan had no abnormal uptake. She was transferred to Methodist for further care. + +The patient reports having a good appetite and denies any weight loss. She denies having any fever or chills. She has noticed increasing dyspnea with moderate exercise, but not at rest. She denies having palpitations. She occasionally has nausea, but no vomiting, constipation, or diarrhea. Over the last 2 months, she has noticed increasing facial hair and a mustache. + +There is an extensive family history of colon and other cancers in her family. She was told there is a genetic defect in her family but cannot recall the name of the syndrome. She had a colonoscopy and a polyp removed at the age of 14 years old. Her last colonoscopy was 2 months ago and was unremarkable. + +PAST MEDICAL HISTORY : + + None. No history of hypertension, diabetes, heart disease, liver disease or cancer. + +PAST SURGICAL HISTORY: + + Bilateral tubal ligation in 2001, colon polyp removed at 14 years old. + +GYN HISTORY: + + Gravida 2, Para 2, Ab 0. Menstrual periods have been regular, last menstrual period almost 1 month ago. No menorrhagia. Never had a mammogram. Has yearly Pap smears which have all been normal. + +FAMILY HISTORY: + + Mother is 61 years old and brother is 39 years old, both alive and well. Father died at 48 of colon cancer and questionable pancreatic cancer. One paternal uncle died at 32 of colon cancer and bile duct cancer. One paternal uncle had colon cancer in his 40s. Thirty cancers are noted on the father’s side of the family, many are colon; two women had breast cancer. The family was told that there is a genetic syndrome in the family, but no one remembers the name of the syndrome. + +SOCIAL HISTORY: + + No tobacco, alcohol or illicit drug use. Patient is born and raised in Oklahoma . No known exposures. Married with 2 children. + +MEDICATION: + + None. + +REVIEW OF SYSTEMS: + + No headaches. No visual, hearing, or swallowing difficulties. No cough or hemoptysis. No chest pain, PND + + orthopnea. No changes in bowel or urinary habits. Otherwise, as stated in HPI. + +PHYSICAL EXAM: + +VS: T 97.6 BP 121/85 P 84 R 18 O2 Sat 100% on room air,GEN: Pleasant, thin woman in mild distress secondary to abdominal pain and discomfort. + +HEENT: Pupils equally round and reactive to light. Extra-ocular movements intact. Anicteric. Sclerae clear. Pink conjunctiva. Moist mucous membranes. No oropharyngeal lesions. + +NECK: Supple, no masses, jugular venous distention or bruits. + +LUNGS: Clear to auscultation bilaterally. + +HEART: Regular rate and rhythm. No murmurs, gallops, rubs. + +BREASTS: Symmetric, no skin changes, no discharge, no masses,ABDOMEN: Soft with active bowel sounds. There is minimal diffuse tenderness on examination. No masses palpated. There is fullness in the right upper quadrant with negative Murphy’s sign. No rebound or guarding. The liver span is 12 cm by percussion, but not palpable below the costal margin. No splenomegaly. + +PELVIC: not done,EXT: No clubbing, cyanosis, or edema. 2+ pulses bilaterally. + +NEURO: Cranial nerves intact. 2+ DTRs bilaterally and symmetrically. Motor strength and sensation within the normal limits. + +LYMPH: No cervical, axillary, or inguinal lymph nodes palpated,SKIN: warm, no rashes, no lesions; no tattoos,STUDIES: + +CT Chest: Multiple bilateral small (<5 mm) pulmonary nodules, no mediastinal mass or hilar adenopathy. + +MRI Abdomen: 12.5 x 10.9 x 11.1 cm suprarenal mass, 7.1 x 5.4 x 6.5 cm intrahepatic lesion in the region of the dome of the liver, abnormal signal intensity within the inferior vena cava at the level of porta hepatic worrisome for thrombus. + +Total Body Bone Scan: No abnormal uptake. + +HOSPITAL COURSE: + + + +The patient was transferred from an outside hospital for further workup and management. She was taken to the Operating Room for abdominal exploration. A liver biopsy was done. \ No newline at end of file diff --git a/3356_General Medicine.txt b/3356_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..6799d0bff03c8cd43eeeb10c556e7de87bcd58a6 --- /dev/null +++ b/3356_General Medicine.txt @@ -0,0 +1,58 @@ +CHIEF COMPLAINT: + + Nausea, vomiting, diarrhea, and fever. + +HISTORY OF PRESENT ILLNESS: + + This patient is a 76-year-old woman who was treated with intravenous ceftriaxone and intravenous clindamycin at a care facility for pneumonia. She has developed worsening confusion, fever, and intractable diarrhea. She was brought to the emergency department for evaluation. Diagnostic studies in the emergency department included a CBC + + which revealed a white blood cell count of 23,500, and a low potassium level of 2.6. She was admitted to the hospital for treatment of profound hypokalemia, dehydration, intractable diarrhea, and febrile illness. + +PAST MEDICAL HISTORY: + + Recent history of pneumonia, urosepsis, dementia, amputation, osteoporosis, and hypothyroidism. + +MEDICATIONS: + +Synthroid, clindamycin, ceftriaxone, Remeron, Actonel, Zanaflex, and hydrocodone. + +SOCIAL HISTORY: + + The patient has been residing at South Valley Care Center. + +REVIEW OF SYSTEMS: + + The patient is unable answer review of systems. + +PHYSICAL EXAMINATION: + +GENERAL: This is a very elderly, cachectic woman lying in bed in no acute distress. + +HEENT: Examination is normocephalic and atraumatic. The pupils are equal, round and reactive to light and accommodation. The extraocular movements are full. + +NECK: Supple with full range of motion and no masses. + +LUNGS: There are decreased breath sounds at the bases bilaterally. + +CARDIOVASCULAR: Regular rate and rhythm with normal S1 and S2, and no S3 or S4. + +ABDOMEN: Soft and nontender with no hepatosplenomegaly. + +EXTREMITIES: No clubbing, cyanosis or edema. + +NEUROLOGIC: The patient moves all extremities but does not communicate. + +DIAGNOSTIC STUDIES: + + The CBC shows a white blood cell count of 23,500, hemoglobin 13.0, hematocrit 36.3, and platelets 287,000. The basic chemistry panel is remarkable for potassium 2.6, calcium 7.5, and albumin 2.3. + +IMPRESSION/PLAN: + +1. Elevated white count. This patient is admitted to the hospital for treatment of a febrile illness. There is concern that she has a progression of pneumonia. She may have aspirated. She has been treated with ceftriaxone and clindamycin. I will follow her oxygen saturation and chest x-ray closely. She is allergic to penicillin. Therefore, clindamycin is the appropriate antibiotic for possible aspiration. + +2. Intractable diarrhea. The patient has been experiencing intractable diarrhea. I am concerned about Clostridium difficile infection with possible pseudomembranous colitis. I will send her stool for Clostridium difficile toxin assay. I will consider treating with metronidazole. + +3. Hypokalemia. The patient's profound hypokalemia is likely secondary to her diarrhea. I will treat her with supplemental potassium. + +4. DNR status: I have ad a discussion with the patient's daughter, who requests the patient not receive CPR or intubation if her clinical condition or of the patient does not respond to the above therapy. + diff --git a/3359_General Medicine.txt b/3359_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..cfa83ff5d1d44921a580269dd62fa6ba0fbf2ba7 --- /dev/null +++ b/3359_General Medicine.txt @@ -0,0 +1,23 @@ +HISTORY OF PRESENT ILLNESS: + + The patient is an 85-year-old male who was brought in by EMS with a complaint of a decreased level of consciousness. The patient apparently lives with his wife and was found to have a decreased status since the last one day. The patient actually was seen in the emergency room the night before for injuries of the face and for possible elderly abuse. When the Adult Protective Services actually went to the patient's house, he was found to be having decreased consciousness for a whole day by his wife. Actually the night before, he fell off his wheelchair and had lacerations on the face. As per his wife, she states that the patient was given an entire mg of Xanax rather than 0.125 mg of Xanax, and that is why he has had decreased mental status since then. The patient's wife is not able to give a history. The patient has not been getting Sinemet and his other home medications in the last 2 days. + +PAST MEDICAL HISTORY: + +Parkinson disease. + +MEDICATIONS: + + Requip, Neurontin, Sinemet, Ambien, and Xanax. + +ALLERGIES: + + No known drug allergies. + +SOCIAL HISTORY: + + The patient lives with his wife. + +PHYSICAL EXAMINATION: + +GENERAL: \ No newline at end of file diff --git a/3360_General Medicine.txt b/3360_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..83f3ffab4be56a50eef2f84679f9f51232c77b79 --- /dev/null +++ b/3360_General Medicine.txt @@ -0,0 +1,93 @@ +CHIEF COMPLAINT: + + "I can’t walk as far as I used to." + +HISTORY OF PRESENT ILLNESS: + + The patient is a 66-year-old African American gentleman with a past medical history of atrial fibrillation and arthritis who presented c/o progressively worsening shortness of breath. The patient stated that he had been in his usual state of health six years ago at which time he had been able to walk more than five blocks without difficulty. Approximately five years prior to admission, he began to note a decreased tolerance to exercise. This progressed with a gradual worsening in his functional capacity such that he is presently unable to walk for more than 25 feet. Over the two years prior to admission, he has been having a gradually worsening non-productive cough associated with shortness of breath. His shortness of breath is worse when he lies flat, and he periodically wakes at night gasping for air. He sleeps with three pillows. He has also noted swelling of his legs and states that he has had two episodes of syncope at home for which he has not sought medical attention. Approximately one month prior to admission he was seen in an outside clinic where he states that he was started on medications for heart failure. He stated that he had had a brother who died of heart failure at age 72. + +He did report that he had had an episode of hemoptysis approximately 2 years prior to admission for which he did not seek medical attention. He denied any history of chest pain and did not report any history of myocardial infarction. He denied fever, chills, and night sweats. He denied diarrhea, dysuria, hematuria, urgency and frequency. He denied any history of rash. He had been diagnosed with osteoarthritis of the knees and had undergone arthroscopy years prior to admission. + +PAST MEDICAL HISTORY : + + Atrial fibrillation on anticoagulation, osteoarthritis of the knees bilaterally, h/o retinal tear. + +PAST SURGICAL HISTORY : + + Hernia repair, bilateral arthroscopic evaluation, h/o surgical correction of retinal tear. + +FAMILY HISTORY: + + The Father of the patient died at age 69 with a CVA. The Mother of the patient died at age 79 when her "heart stopped". There were 12 siblings. Four siblings have died, two due to diabetes, one cause unknown, and one brother died at age 72 with heart failure. The patient has four children with no known medical problems. + +SOCIAL HISTORY: + + The patient retired one year PTA due to his disability. He was formerly employed as an electronic technician for the US postal service. The patient lives with his wife and daughter in an apartment. He denied any smoking history. He used to drink alcohol rarely but stopped entirely with the onset of his symptoms. He denied any h/o drug abuse. He denied any recent travel history. + +MEDICATIONS: + +1. Spironolactone 25 mg po qd. + +2. Digoxin 0.125 mg po qod. + +3. Coumadin 3 mg Monday and Tuesday and 4.5 mg Saturday and Sunday. + +4. Metolazone 10 mg po qd. + +5. Captopril 25 mg po tid. + +6. Torsemide 40 mg po qam and 20 mg po qpm. + +7. Carvedilol 3.125 mg po bid. + +ALLERGIES: + + No known drug allergies. + +REVIEW OF SYSTEMS: + + No headaches. No visual, hearing, or swallowing difficulties. No changes in bowel or urinary habits. + +PHYSICAL EXAM: + +Temperature: 98.4 degrees Fahrenheit. + +Blood pressure: 134/84. + +Heart rate: 98 beats per minute. + +Respiratory rate: 18 breaths per minute. + +Pulse oximetry: 92% on 2L O 2 via nasal canula. + +GEN: Elderly gentleman lying in bed in mild respiratory distress, thin, tired appearing, wife and daughter present at bedside, articulate. + +HEENT: The right eye was opacified. The left pupil was reactive to light. There was mild bitemporal wasting. The tongue was moist. There was no lymphadenopathy. The sclerae were anicteric. The oropharynx was clear. The conjunctivae were pink. + +NECK: The neck was supple with 15 cm of jugular venous distension. + +HEART: Irregularly irregular. No murmurs, gallops, rubs. No displaced PMI. + +LUNGS: Breath sounds were absent over two thirds of the right lower lung field. There were trace crackles at the left base. + +ABDOMEN: Soft, nontender, nondistended, bowel sounds were present. There was no hepatosplenomegaly. No rebound or guarding. + +EXT: Bilateral pitting edema to the thighs with diminished peripheral pulses bilaterally. + +NEURO: The patient was alert and oriented x three. Cranial nerves were intact. The DTRs were 2+ bilaterally and symmetrically. Motor strength and sensation were within normal limits. + +LYMPH: No cervical, axillary, or inguinal lymph nodes were present. + +SKIN: Warm, no rashes, no lesions; no tattoos. + +MUSCULOSKELETAL: No synovitis. There were no joint deformities. Full range of motion b/l throughout. + +STUDIES: + +CXR: Large right sided pleural effusion. A small pleural effusion with atelectatic changes are seen on the left. The heart size is borderline. + +ECHO: LV size is normal. There is severe concentric LV hypertrophy. Global hypokinesis. LV function is severely depressed. Estimate EF is 20-24%. There is RV hypertrophy. RV size is mildly enlarged. RV function is severely depressed. RV wall motion is severely hypokinetic. LA size is moderately enlarged. RA size is mildly enlarged. Trace aortic regurgitation. Moderate tricuspid regurgitation. Estimated PA systolic pressure is 46-51 mmHg, assuming a mean RAP of 15-20mmHg. Small anterior and posterior pericardial effusion. + +HOSPITAL COURSE: + + The patient was admitted to the hospital for workup and management. A diagnostic procedure was performed. \ No newline at end of file diff --git a/3362_General Medicine.txt b/3362_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..bc4f4b639c647bb93f2210b18c33d1de44336048 --- /dev/null +++ b/3362_General Medicine.txt @@ -0,0 +1,35 @@ +SUBJECTIVE: + + Mom brings the patient in today for possible ear infection. He is complaining of left ear pain today. He was treated on 04/14/2004, with amoxicillin for left otitis and Mom said he did seem to get better but just started complaining of the left ear pain today. He has not had any fever but the congestion has continued to be very thick and purulent. It has never really resolved. He has a loose, productive-sounding cough but not consistently and not keeping him up at night. No wheezing or shortness of breath. + +PAST MEDICAL HISTORY: + + He has had some wheezing in the past but nothing recently. + +FAMILY HISTORY: + + All siblings are on antibiotics for ear infections and URIs. + +OBJECTIVE: + +General: The patient is a 5-year-old male. Alert and cooperative. No acute distress. + +Neck: Supple without adenopathy. + +HEENT: Ear canals clear. TMs, bilaterally, have distorted light reflexes but no erythema. Gray in color. Oropharynx pink and moist with a lot of postnasal discharge. Nares are swollen and red. Thick, purulent drainage. Eyes are a little puffy. + +Chest: Respirations regular, nonlabored. + +Lungs: Clear to auscultation throughout. + +Heart: Regular rhythm without murmur. + +Skin: Warm, dry, pink. Moist mucus membranes. No rash. + +ASSESSMENT: + + Ongoing purulent rhinitis. Probable sinusitis and serous otitis. + +PLAN: + + Change to Omnicef two teaspoons daily for 10 days. Frequent saline in the nose. Also, there was some redness around the nares with a little bit of yellow crusting. It appeared to be the start of impetigo, so hold off on the Rhinocort for a few days and then restart. Use a little Neosporin for now. \ No newline at end of file diff --git a/3364_General Medicine.txt b/3364_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..14b6459ddf39d10888df906ea1a4800fffb61b2e --- /dev/null +++ b/3364_General Medicine.txt @@ -0,0 +1,39 @@ +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. \ No newline at end of file diff --git a/3366_General Medicine.txt b/3366_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..7cf34ce5b0ed8dc12036b543568ebf7cce67eeb8 --- /dev/null +++ b/3366_General Medicine.txt @@ -0,0 +1,49 @@ +SUBJECTIVE: + + This is an 11-year-old female who comes in for two different things. 1. She was seen by the allergist. No allergies present, so she stopped her Allegra, but she is still real congested and does a lot of snorting. They do not notice a lot of snoring at night though, but she seems to be always like that. 2. On her right great toe, she has got some redness and erythema. Her skin is kind of peeling a little bit, but it has been like that for about a week and a half now. + +PAST MEDICAL HISTORY: + + Otherwise reviewed and noted. + +CURRENT MEDICATIONS: + + None. + +ALLERGIES TO MEDICINES: + + None. + +FAMILY SOCIAL HISTORY: + + Everyone else is healthy at home. + +REVIEW OF SYSTEMS: + + She has been having the redness of her right great toe, but also just a chronic nasal congestion and fullness. Review of systems is otherwise negative. + +PHYSICAL EXAMINATION: + +General: Well-developed female, in no acute distress, afebrile. + +HEENT: Sclerae and conjunctivae clear. Extraocular muscles intact. TMs clear. Nares patent. A little bit of swelling of the turbinates on the left. Oropharynx is essentially clear. Mucous membranes are moist. + +Neck: No lymphadenopathy. + +Chest: Clear. + +Abdomen: Positive bowel sounds and soft. + +Dermatologic: She has got redness along the lateral portion of her right great toe, but no bleeding or oozing. Some dryness of her skin. Her toenails themselves are very short and even on her left foot and her left great toe the toenails are very short. + +ASSESSMENT: + +1. History of congestion, possibly enlarged adenoids, or just her anatomy. + +2. Ingrown toenail, but slowly resolving on its own. + +PLAN: + +1. For the congestion, we will have ENT evaluate. Appointment has been made with Dr. XYZ for in a couple of days. + +2. I told her just Neosporin for her toe, letting the toenail grow out longer. Call if there are problems. \ No newline at end of file diff --git a/3368_General Medicine.txt b/3368_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..a5146c7a5be0fe05053d4d01b32d49397af81af2 --- /dev/null +++ b/3368_General Medicine.txt @@ -0,0 +1,59 @@ +HISTORY OF PRESENT ILLNESS: + + A 49-year-old female with history of atopic dermatitis comes to the clinic with complaint of left otalgia and headache. Symptoms started approximately three weeks ago and she was having difficulty hearing, although that has greatly improved. She is having some left-sided sinus pressure and actually went to the dentist because her teeth were hurting; however, the teeth were okay. She continues to have some left-sided jaw pain. Denies any headache, fever, cough, or sore throat. She had used Cutivate cream in the past for the atopic dermatitis with good results and is needing a refill of that. She has also had problems with sinusitis in the past and chronic left-sided headache. + +FAMILY HISTORY: + + Reviewed and unchanged. + +ALLERGIES: + + To cephalexin. + +CURRENT MEDICATIONS: + + Ibuprofen. + +SOCIAL HISTORY: + + She is a nonsmoker. + +REVIEW OF SYSTEMS: + + As above. No nausea, vomiting, or diarrhea. + +PHYSICAL EXAMINATION: + +General: A well-developed and well-nourished female, conscious, alert, and in no acute distress. + +Vital Signs: Weight: 121 pounds. Temperature: 97.9 degrees. + +Skin: Reveals scattered erythematous plaques with some mild lichenification on the nuchal region and behind the knees. + +Eyes: PERRLA. Conjunctivae are clear. + +Ears: Left TM with some effusion. Right TM is clear. Canals are clear. External auricles are nontender to manipulation. + +Nose: Nasal mucosa is pink and moist without discharge. + +Throat: Nonerythematous. No tonsillar hypertrophy or exudate. + +Neck: Supple without adenopathy or thyromegaly. + +Lungs: Clear. Respirations are regular and unlabored. + +Heart: Regular rate and rhythm at rate of 100 beats per minute. + +ASSESSMENT: + +1. Serous otitis. + +2. Atopic dermatitis. + +PLAN: + +1. Nasacort AQ two sprays each nostril daily. + +2. Duraphen II one b.i.d. + +3. Refills Cutivate cream 0.05% to apply to affected areas b.i.d. Recheck p.r.n. \ No newline at end of file diff --git a/3372_General Medicine.txt b/3372_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..17dc539f1699282ff120403604f57feffe68f6ae --- /dev/null +++ b/3372_General Medicine.txt @@ -0,0 +1,31 @@ +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. \ No newline at end of file diff --git a/3374_General Medicine.txt b/3374_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..076e8027be163ae4d8501028d4e0e13427107e68 --- /dev/null +++ b/3374_General Medicine.txt @@ -0,0 +1,57 @@ +CHIEF COMPLAINT: + + Questionable foreign body, right nose. Belly and back pain. + +SUBJECTIVE: + + Mr. ABC is a 2-year-old boy, who is brought in by parents, stating that the child keeps complaining of belly and back pain. This does not seem to be slowing him down. They have not noticed any change in his urine or bowels. They have not noted him to have any fevers or chills or any other illness. They state he is otherwise acting normally. He is eating and drinking well. He has not had any other acute complaints, although they have noted a foul odor coming from his nose. Apparently, he was seen here a few weeks ago for a foreign body in the right nose, which was apparently a piece of cotton; this was removed and placed on antibiotics. His nose got better and then started to become malodorous again. Mother restarted him on the remainder of the antibiotics and they are also stating that they think there is something still in there. Otherwise, he has not had any runny nose, earache, no sore throat. He has not had any cough, congestion. He has been acting normally. Eating and drinking okay. No other significant complaints. He has not had any pain with bowel movement or urination, nor have they noted him to be more frequently urinating, then again he is still on a diaper. + +PAST MEDICAL HISTORY: + + Otherwise negative. + +ALLERGIES: + + No allergies. + +MEDICATIONS: + + No medications other than recent amoxicillin. + +SOCIAL HISTORY: + + Parents do smoke around the house. + +PHYSICAL EXAMINATION: + + VITAL SIGNS: Stable. He is afebrile. + +GENERAL: This is a well-nourished, well-developed 2-year-old little boy, who is appearing very healthy, normal for his stated age, pleasant, cooperative, in no acute distress, looks very healthy, afebrile and nontoxic in appearance. + +HEENT: TMs, canals are normal. Left naris normal. Right naris, there is some foul odor as well as questionable purulent drainage. Examination of the nose, there was a foreign body noted, which was the appearance of a cotton ball in the right nose, that was obviously infected and malodorous. This was removed and reexamination of the nose was done and there was absolutely no foreign body left behind or residual. There was some erythema. No other purulent drainage noted. There was some bloody drainage. This was suctioned and all mucous membranes were visualized and are negative. + +NECK: Without lymphadenopathy. No other findings. + +HEART: Regular rate and rhythm. + +LUNGS: Clear to auscultation. + +ABDOMEN: His abdomen is entirely benign, soft, nontender, nondistended. Bowel sounds active. No organomegaly or mass noted. + +BACK: Without any findings. Diaper area normal. + +GU: No rash or infections. Skin is intact. + +ED COURSE: + + He also had a P-Bag placed, but did not have any urine. Therefore, a straight catheter was done, which was done with ease without complication and there was no leukocytes noted within the urine. There was a little bit of blood from catheterization but otherwise normal urine. X-ray noted some stool within the vault. Child is acting normally. He is jumping up and down on the bed without any significant findings. + +ASSESSMENT: + +1. Infected foreign body, right naris. + +2. Mild constipation. + +PLAN: + + As far as the abdominal pain is concerned, they are to observe for any changes. Return if worse, follow up with the primary care physician. The right nose, I will place the child on amoxicillin 125 per 5 mL, 1 teaspoon t.i.d. Return as needed and observe for more foreign bodies. I suspect, the child had placed this cotton ball in his nose again after the first episode. \ No newline at end of file diff --git a/3378_General Medicine.txt b/3378_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..b6d9f3eaec85085ac6c2ab7af5e3dae720d6bfef --- /dev/null +++ b/3378_General Medicine.txt @@ -0,0 +1,49 @@ +CHIEF COMPLAINT: + + Left flank pain and unable to urinate. + +HISTORY: + + The patient is a 46-year-old female who presented to the emergency room with left flank pain and difficulty urinating. Details are in the history and physical. She does have a vague history of a bruised left kidney in a motor vehicle accident. She feels much better today. I was consulted by Dr. X. + +MEDICATIONS: + + Ritalin 50 a day. + +ALLERGIES: + + To penicillin. + +PAST MEDICAL HISTORY: + + ADHD. + +SOCIAL HISTORY: + + No smoking, alcohol, or drug abuse. + +PHYSICAL EXAMINATION: + + She is awake, alert, and quite comfortable. Abdomen is benign. She points to her left flank, where she was feeling the pain. + +DIAGNOSTIC DATA: + + Her CAT scan showed a focal ileus in left upper quadrant, but no thickening, no obstruction, no free air, normal appendix, and no kidney stones. + +LABORATORY WORK: + + Showed white count 6200, hematocrit 44.7. Liver function tests and amylase were normal. Urinalysis 3+ bacteria. + +IMPRESSION: + +1. Left flank pain, question etiology. + +2. No evidence of surgical pathology. + +3. Rule out urinary tract infection. + +PLAN: + +1. No further intervention from my point of view. + +2. Agree with discharge and followup as an outpatient. Further intervention will depend on how she does clinically. She fully understood and agreed. \ No newline at end of file diff --git a/3379_General Medicine.txt b/3379_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..7ae4e3d62f4b68431146f451d693871e2acd79df --- /dev/null +++ b/3379_General Medicine.txt @@ -0,0 +1,27 @@ +FEMALE 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 dysuria, frequency or incontinence. No difficulties with vaginal discharge. + +Musculoskeletal: No myalgias or arthralgias. + +Breasts: Patient performs self-breast examinations and has noticed no abnormalities or nipple discharge. + +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. \ No newline at end of file diff --git a/3381_General Medicine.txt b/3381_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..193b728bb6bd16416c46dab866b32e11c67b1b62 --- /dev/null +++ b/3381_General Medicine.txt @@ -0,0 +1,95 @@ +SUBJECTIVE: + + The patient is a 76-year-old white female who presents to the clinic today originally for hypertension and a med check. She has a history of hypertension, osteoarthritis, osteoporosis, hypothyroidism, allergic rhinitis and kidney stones. Since her last visit she has been followed by Dr. Kumar. Those issues are stable. She has had no fever or chills, cough, congestion, nausea, vomiting, chest pain, chest pressure. + +PAST MEDICAL HISTORY: + + She has an intolerance to Prevacid. + +CURRENT MEDICATIONS: + + Evista 60 daily, Levothroid 0.05 mg daily, Claritin 10 daily, Celebrex 200 daily, HCTZ 25 daily and amitriptyline p.r.n. + +PAST SURGICAL HISTORY: + + Bilateral mastectomies, tonsillectomy, EGD + + flex sig in 2001 and a heart cath. + +FAMILY HISTORY: + + Father passed away at 81; mother of multiple myeloma at 83. + +SOCIAL HISTORY: + + She is married. A 76-year-old who used to smoke a pack a day and quit in 1985. She is retired. + +REVIEW OF SYSTEMS: + + Essentially negative in HEENT + + chest, cardiovascular, GI + + GU + + musculoskeletal, or neurologic. + +OBJECTIVE: + + Temperature is 97.5 degrees. Blood pressure is 168/70. Pulse is 88. Weight is 129 pounds. + +GENERAL: She is an elderly 76-year-old in no acute distress. + +HEENT: Atraumatic. Extraocular muscles were intact. Pupils equal, round and reactive to light and accommodation. Tympanic membranes are clear, dry and intact. Sinuses and throat are clear. Neck is soft, supple. No meningeal signs are present. No thyromegaly is present. + +CHEST: Clear to auscultation. + +CARDIOVASCULAR: Regular rate and rhythm without murmur. + +ABDOMEN: Soft, nontender. Bowel sounds are positive. No organomegaly or peritoneal signs are present. + +EXTREMITIES: Moving all extremities. Peripheral pulses are normal. No edema is present. + +NEUROLOGIC: Alert and oriented. Cranial nerves II-XII grossly intact. Strength 5+/5 globally. Reflexes 2+/IV globally. Romberg is negative. There is no numbness, tingling, weakness or other neurologic deficit present. + +BREASTS: Surgically absent but there are no lumps, lesions, masses, discharge or adenopathy present. + +BACK: Straight. + +SKIN: Clear. + +GENITALIA: Deferred as she has been followed by Dr. XYZ many times this year. She does have a history of some elevated cholesterol. + +ASSESSMENT: + +1. Hypertension, suboptimal control. + +2. Hypothyroidism. + +3. Arthritis. + +4. Allergic rhinitis. + +5. History of kidney stones. + +6. Osteoporosis. + +PLAN: + +1. CBC + + complete metabolic profile, UA for hypertension. + +2. Chest x-ray for history of breast cancer. + +3. DEXA scan, full body for osteoporosis. + +4. Flex is up to date. + +5. Pneumovax has been given in the last five years. + +6. Lipid profile for elevated cholesterol. + +7. Refill meds. + +8. Follow up every three to six months for blood pressure check or sooner p.r.n. problems. \ No newline at end of file diff --git a/3383_General Medicine.txt b/3383_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..ae2c1df3fc0ac8bbb6693b69669c592771e78876 --- /dev/null +++ b/3383_General Medicine.txt @@ -0,0 +1,83 @@ +REASON FOR CONSULTATION: + + This is a 66-year-old patient who came to the emergency room because she was feeling dizzy and was found to be tachycardic and hypertensive. + +PAST MEDICAL HISTORY: + + Hypertension. The patient noncompliant,HISTORY OF PRESENT COMPLAINT: + + This 66-year-old patient has history of hypertension and has not taken medication for several months. She is a smoker and she drinks alcohol regularly. She drinks about 5 glasses of wine every day. Last drink was yesterday evening. This afternoon, the patient felt palpitations and generalized weakness and came to the emergency room. On arrival in the emergency room, the patient's heart rate was 121 and blood pressure was 195/83. The patient received 5 mg of metoprolol IV + + after which heart rate was reduced to the 70 and blood pressure was well controlled. On direct questioning, the patient said she had been drinking a lot. She had not had any withdrawal before. Today is the first time she has been close to withdrawal. + +REVIEW OF SYSTEMS: + +CONSTITUTIONAL: No fever. + +ENT: Not remarkable. + +RESPIRATORY: No cough or shortness of breath. + +CARDIOVASCULAR: The patient denies chest pain. + +GASTROINTESTINAL: No nausea. No vomiting. No history of GI bleed. + +GENITOURINARY: No dysuria. No hematuria. + +ENDOCRINE: Negative for diabetes or thyroid problems. + +NEUROLOGIC: No history of CVA or TIA. + +Rest of review of systems is not remarkable. + +SOCIAL HISTORY: + +The patient is a smoker and drinks alcohol daily in considerable amounts. + +FAMILY HISTORY: + + Noncontributory. + +PHYSICAL EXAMINATION: + +GENERAL: This is a 66-year-old lady with telangiectasia of the face. She is not anxious at this moment and had no tremors. + +CHEST: Clear to auscultation. No wheezing. No crepitations. Chest is tympanitic to percussion. + +CARDIOVASCULAR: First and second heart sounds were heard. No murmur was appreciated. + +ABDOMEN: Soft and nontender. Bowel sounds are positive. + +EXTREMITIES: There is no swelling. No clubbing. No cyanosis. + +NEUROLOGIC: The patient is alert and oriented x3. Examination is nonfocal. + +DIAGNOSTIC DATA: + + EKG shows sinus tachycardia, no acute ST changes. + +LABORATORY DATA: + + White count is 6.3, hemoglobin is 12.4, hematocrit 38, and platelets 488,000. Glucose is 124, BUN is 18, creatinine is 1.07, sodium is 146, and potassium is 3.4. Liver enzymes are within normal limits. TSH is normal. + +ASSESSMENT AND PLAN: + +1. Uncontrolled hypertension. We will start the patient on beta-blockers. The patient is to see her primary physician within 1 week's time. + +2. Tachycardia, probable mild withdrawal to alcohol. The patient is stable now. We will discharge home with diazepam p.r.n. The patient had been advised that she should not take alcohol if she takes the diazepam. + +3. Tobacco smoking disorder. The patient has been counseled. She is not contemplating quitting at this time. + +DISPOSITION: + + The patient is discharged home. + +DISCHARGE MEDICATIONS: + +1. Atenolol 50 mg p.o. b.i.d. + +2. Diazepam 5 mg tablet 1 p.o. q.8h. p.r.n. + + total of 5 tablets. + +3. Thiamine 100 mg p.o. daily. \ No newline at end of file diff --git a/3388_General Medicine.txt b/3388_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..1d0a2c708ae7c6b115dcdc1b7caa28058e030e4a --- /dev/null +++ b/3388_General Medicine.txt @@ -0,0 +1,51 @@ +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. \ No newline at end of file diff --git a/3389_General Medicine.txt b/3389_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..24e3f238e4aa82e331c3e000c98bd76bf7a5f962 --- /dev/null +++ b/3389_General Medicine.txt @@ -0,0 +1,45 @@ +CC: + + Fall and laceration. + +HPI: + + Mr. B is a 42-year-old man who was running to catch a taxi when he stumbled, fell and struck his face on the sidewalk. He denies loss of consciousness but says he was dazed for a while after it happened. He complains of pain over the chin and right forehead where he has abrasions. He denies neck pain, back pain, extremity pain or pain in the abdomen. + +PMH: + + Hypertension. + +MEDS: + + None. + +ROS: + + As above. Otherwise negative. + +PHYSICAL EXAM: + + This is a gentleman in full C-spine precautions on a backboard brought by EMS. He is in no apparent distress. + +Vital Signs: BP 165/95 HR 80 RR 12 Temp 98.4 SpO2 95% + +HEENT: No palpable step offs, there is blood over the right fronto-parietal area where there is a small 1cm laceration and surrounding abrasion. Also, 2 cm laceration over the base of the chin without communication to the oro-pharynx. No other trauma noted. No septal hematoma. No other facial bony tenderness. + +Neck: Nontender + +Chest: Breathing comfortably; equal breath sounds. + +Heart: Regular rhythm. + +Abd: Benign. + +Ext: No tenderness or deformity; pulses are equal throughout; good cap refill + +Neuro: Awake and alert; slight slurring of speech and cognitive slowing consistent with alcohol; moves all extremities; cranial nerves normal. + +COURSE IN THE ED: + + Patient arrived and was placed on monitors. An IV had been placed in the field and labs were drawn. X-rays of the C spine show no fracture and I've removed the C-collar. The lacerations were explored and no foreign body found. They were irrigated and closed with simple interrupted sutures. Labs showed normal CBC + + Chem-7, and U/A except there was moderate protein in the urine. The blood alcohol returned at 0.146. A banana bag is ordered and his care will be turned over to Dr. G for further evaluation and care. \ No newline at end of file diff --git a/3390_General Medicine.txt b/3390_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..41ac86e624f3e7e7f35009e3296b1988205cbe01 --- /dev/null +++ b/3390_General Medicine.txt @@ -0,0 +1,63 @@ +CHIEF COMPLAINT: + + Dog bite to his right lower leg. + +HISTORY OF PRESENT ILLNESS: + + This 50-year-old white male earlier this afternoon was attempting to adjust a cable that a dog was tied to. Dog was a German shepherd, it belonged to his brother, and the dog spontaneously attacked him. He sustained a bite to his right lower leg. Apparently, according to the patient, the dog is well known and is up-to-date on his shots and they wanted to confirm that. The dog has given no prior history of any reason to believe he is not a healthy dog. The patient himself developed a puncture wound with a flap injury. The patient has a flap wound also below the puncture wound, a V-shaped flap, which is pointing towards the foot. It appears to be viable. The wound is open about may be roughly a centimeter in the inside of the flap. He was seen by his medical primary care physician and was given a tetanus shot and the wound was cleaned and wrapped, and then he was referred to us for further assessment. + +PAST MEDICAL HISTORY: + +Significant for history of pulmonary fibrosis and atrial fibrillation. He is status post bilateral lung transplant back in 2004 because of the pulmonary fibrosis. + +ALLERGIES: + +There are no known allergies. + +MEDICATIONS: + + Include multiple medications that are significant for his lung transplant including Prograf, CellCept, prednisone, omeprazole, Bactrim which he is on chronically, folic acid, vitamin D, Mag-Ox, Toprol-XL + + calcium 500 mg, vitamin B1, Centrum Silver, verapamil, and digoxin. + +FAMILY HISTORY: + + Consistent with a sister of his has ovarian cancer and his father had liver cancer. Heart disease in the patient's mother and father, and father also has diabetes. + +SOCIAL HISTORY: + + He is a non-cigarette smoker. He has occasional glass of wine. He is married. He has one biological child and three stepchildren. He works for ABCD. + +REVIEW OF SYSTEMS: + + He denies any chest pain. He does admit to exertional shortness of breath. He denies any GI or GU problems. He denies any bleeding disorders. + +PHYSICAL EXAMINATION + +GENERAL: Presents as a well-developed, well-nourished 50-year-old white male who appears to be in mild distress. + +HEENT: Unremarkable. + +NECK: Supple. There is no mass, adenopathy or bruit. + +CHEST: Normal excursion. + +LUNGS: Clear to auscultation and percussion. + +COR: Regular. There is no S3 or S4 gallop. There is no obvious murmur. + +ABDOMEN: Soft. It is nontender. Bowel sounds are present. There is no tenderness. + +SKIN: He does have like a Chevron incisional scar across his lower chest and upper abdomen. It appears to be well healed and unremarkable. + +GENITALIA: Deferred. + +RECTAL: Deferred. + +EXTREMITIES: He has about 1+ pitting edema to both legs and they have been present since the surgery. In the right leg, he has an about midway between the right knee and right ankle on the anterior pretibial area, he has a puncture wound that measures about may be centimeter around that appears to be relatively clean, and just below that about may be 3 cm below, he has a flap traumatic injury that measures about may be 4 cm to the point of the flap. The wound is spread apart about may be a centimeter all along that area and it is relatively clean. There was some bleeding when I removed the dressing and we were able to pretty much control that with pressure and some silver nitrate. There were exposed subcutaneous tissues, but there was no exposed tendons that we could see, etc. The flap appeared to be viable. + +NEUROLOGIC: Without focal deficits. The patient is alert and oriented. + +IMPRESSION: + + A 50-year-old white male with dog bite to his right leg with a history of pulmonary fibrosis, status post bilateral lung transplant several years ago. He is on multiple medications and he is on chronic Bactrim. We are going to also add some fluoroquinolone right now to protect the skin and probably going to obtain an Infectious Disease consult. We will see him back in the office early next week to reassess his wound. He is to keep the wound clean with the moist dressing right now. He may shower several times a day. \ No newline at end of file diff --git a/3392_General Medicine.txt b/3392_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..ce31996f358b59e3dafa67a33cc081adece5c190 --- /dev/null +++ b/3392_General Medicine.txt @@ -0,0 +1,87 @@ +HISTORY OF PRESENT ILLNESS: + + The patient is an 88-year-old white female, household ambulator with a walker, who presents to the emergency department this morning after incidental fall at home. The patient states that she was on the ladder on Saturday and she stepped down after the ladder. Felt some pain in her left hip. Subsequently fell injuring her left shoulder. It's unclear how long she was on the floor. She was taken by EMS to Hospital where she was noted radiographically to have a left proximal humerus fracture and a nondisplaced left hip fracture. Orthopedics was consulted. Given the nature of the injury and the unclear events, an extensive workup was performed including a head CT and CT of the abdomen, which identified no evidence of intracranial injury and renal calculi only. She presently is complaining of pain to the left shoulder. She states she also has pain to the hip with motion of the leg. She denies any numbness or paresthesias. She states prior to this, she was relatively active within her home. She does care for her daughter who has a mess. The patient denies any other injuries. Denies back pain. + +PREVIOUS MEDICAL HISTORY: + + Extensive including coronary artery disease, peripheral vascular disease, status post MI + + history of COPD + + diverticular disease, irritable bowel syndrome, GERD + + PMR + + depressive disorder, and hypertension. + +PREVIOUS SURGICAL HISTORY: + + Includes a repair of a right intertrochanteric femur fracture. + +ALLERGIES + +1. PENICILLIN. + +2. SULFA. + +3. ACE INHIBITOR. + +PRESENT MEDICATIONS + +1. Lipitor 20 mg q.d. + +2. Metoprolol 25 mg b.i.d. + +3. Plavix 75 mg once a day. + +4. Aspirin 325 mg. + +5. Combivent Aerosol two puffs twice a day. + +6. Protonix 40 mg q.d. + +7. Fosamax 70 mg weekly. + +8. Multivitamins including calcium and vitamin D. + +9. Hydrocortisone. + +10. Nitroglycerin. + +11. Citalopram 20 mg q.d. + +SOCIAL HISTORY: + + She denies alcohol or tobacco use. She is the caretaker for her daughter, who is widowed and lives at home. + +FAMILY HISTORY: + + Not obtainable. + +REVIEW OF SYSTEMS: + + Patient is hard of hearing. She also has vision problems. Denies headache syndrome. Presently, denies chest pain or shortness of breath. She denies abdominal pain. Presently, she has left hip pain and left shoulder pain. No urinary frequency or dysuria. No skin lesions. She does have swelling to both lower extremities for the last several weeks. She denies endocrinopathies. Psychiatric issues include chronic depression. + +PHYSICAL EXAMINATION + +GENERAL: The patient is alert and responsive. + +EXTREMITIES: The left upper extremity, there is moderate swelling and ecchymosis to the brachial compartment. She is diffusely tender over the proximal humerus. She is unable to actively elevate her arm due to pain. The neurovascular exam to the left upper extremity is otherwise intact with a 1+ radial pulse. She does have chronic degenerative change to the MP and IP joints of both hands. The left lower extremity, the thigh compartment is supple. She has pain with log rolling tenderness over the greater trochanter. The patient has pain with any attempt at hip flexion passively or actively. The knee range of motion between 5 and 60 degrees with no point specific tenderness, no joint effusion, and an intact extensive mechanism. She has 2 to 3+ bilateral pitting edema pretibially and pedally. The patient has a weak motor response to the left lower extremity. She has a 1+ dorsalis pedis pulse. Her sensory examination is intact plantarly and dorsally on the foot. + +RADIOGRAPHS: + + Left shoulder series was performed which identifies a three-part valgus-impacted left proximal humerus fracture with displacement of the greater tuberosity fragment approximately 1 cm. There is no evidence of dislocation. There was an AP pelvis as well as left hip series, which identify a nondisplaced valgus-impacted type 1 femoral neck fracture. There is also evidence of severe degenerative disk disease with degenerative scoliosis of the LS spine. There is evidence of previous surgical repair of the right proximal femur with an intact intramedullary nail. + +LABORATORY STUDIES: + + Patient's H&H is 13 and 38.7, white blood cell count is 6.9, and there are 198,000 platelets. Electrolytes, sodium 137, potassium 4.1, chloride 102, CO2 is 27, BUN is 20, and creatinine 0.62. Urinalysis, the urine is clear yellow, 0 to 2 white cells, and no bacteria. + +ASSESSMENT + +1. This is an 88-year-old household ambulator with a walker, status post fall with injuries to left shoulder and left hip. The left shoulder fracture is a valgus-impacted proximal humerus fracture and the left hip is a nondisplaced type 1 femoral neck fracture. + +2. Extensive medical history including coronary artery disease, peripheral vascular disease, and chronic obstructive pulmonary disease on Plavix. + +PLAN: + + I have discussed this case with the emergency room physician as well as the patient. Patient should be admitted to medical service for medical clearance for surgery of her left hip, which will include a percutaneous screw fixation. Since the patient is on Plavix, I recommend that the Plavix be discontinued and should be placed on Lovenox 30 mg subcu q.d. which may be stopped 24 hours before the procedure. She will need cardiology clearance, which would include an echo in advance of the procedure. I have explained the nature of the injuries to the patient, the recommended surgical procedures, and the postop course and rehabilitation required thereafter. She presently understands and agrees with the plan. \ No newline at end of file diff --git a/3393_General Medicine.txt b/3393_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..deaa82c5c7874936703af66cadf246807a71b8bd --- /dev/null +++ b/3393_General Medicine.txt @@ -0,0 +1,37 @@ +HISTORY OF PRESENT ILLNESS: + + The patient is a two-and-a-half-month-old male who has been sick for the past three to four days. His mother has described congested sounds with cough and decreased appetite. He has had no fever. He has had no rhinorrhea. Nobody else at home is currently ill. He has no cigarette smoke exposure. She brought him to the emergency room this morning after a bad coughing spell. He did not have any apnea during this episode. + +PAST MEDICAL HISTORY: + + Unremarkable. He has had his two-month immunizations. + +PHYSICAL EXAMINATION: + +VITAL SIGNS: Temperature 99.1, oxygen saturations 98% + + respirations by the nurse at 64, however, at my examination was much slower and regular in the 40s. + +GENERAL: Sleeping, easily aroused, smiling, and in no distress. + +HEENT: Soft anterior fontanelle. TMs are normal. Moist mucous membranes. + +LUNGS: Equal and clear. + +CHEST: Without retraction. + +HEART: Regular in rate and rhythm without murmur. + +ABDOMEN: Benign. + +DIAGNOSTIC STUDIES: + + Chest x-ray ordered by ER physician is unremarkable, but to me also. + +ASSESSMENT: + + Upper respiratory infection. + +TREATMENT: + + Use the bulb syringe and saline nose drops if there is any mucus in the anterior nares. Smaller but more frequent feeds. Discuss proper sleeping position. Recheck if there is any fever or if he is no better in the next three days. \ No newline at end of file diff --git a/3399_General Medicine.txt b/3399_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..e6324e2fe82f847746b14e282d71952731e2d7d5 --- /dev/null +++ b/3399_General Medicine.txt @@ -0,0 +1,55 @@ +DIAGNOSES: + +1. Disseminated intravascular coagulation. + +2. Streptococcal pneumonia with sepsis. + +CHIEF COMPLAINT: + + Unobtainable as the patient is intubated for respiratory failure. + +CURRENT HISTORY OF PRESENT ILLNESS: + + This is a 20-year-old female who presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation. At this time, she is being treated aggressively with mechanical ventilation and other supportive measures and has developed disseminated intravascular coagulation with prolonged partial thromboplastin time, prothrombin time, low fibrinogen, and elevated D-dimer. At this time, I am being consulted for further evaluation and recommendations for treatment. The nurses report that she has actually improved clinically over the last 24 hours. Bleeding has been a problem; however, it seems to have been abrogated at this time with factor replacement as well as platelet infusion. There is no prior history of coagulopathy. + +PAST MEDICAL HISTORY: + +Otherwise nondescript as is the past surgical history. + +SOCIAL HISTORY: + +There were possible illicit drugs. Her family is present, and I have discussed her case with her mother and sister. + +FAMILY HISTORY: + +Otherwise noncontributory. + +REVIEW OF SYSTEMS: + + Not otherwise pertinent. + +PHYSICAL EXAMINATION: + +GENERAL: She is a sedated, young black female in no acute distress, lying in bed intubated. + +VITAL SIGNS: She has a rate of 67, blood pressure of 100/60, and the respiratory rate per the ventilator approximately 14 to 16. + +HEENT: Her sclerae showed conjunctival hemorrhage. There are no petechiae. Her nasal vestibules are clear. Oropharynx has ET tube in place. + +NECK: No jugular venous pressure distention. + +CHEST: Coarse breath sounds bilaterally. + +HEART: Regular rate and rhythm. + +ABDOMEN: Soft and nontender with good bowel sounds. There was some oozing around the site of her central line. + +EXTREMITIES: No clubbing, cyanosis, or edema. There is no evidence of compromise arterial blood flow at the digits or of her hands or feet. + +LABORATORY STUDIES: + +The DIC parameters with a platelet count of approximately 50,000, INR of 2.4, normal PTT at this time, fibrinogen of 200, and a D-dimer of 13. + +IMPRESSION/PLAN: + +At this time is disseminated intravascular coagulation from sepsis from pneumococcal disease. My recommendation for the patient is to continue factor replacement as you are. It seems that her clinical course is reversing and simple factor replacement is probably is the best measure at this time. There is no indication at this point for Xigris. However, if her coagulopathy does not resolve within the next 24 hours and continue to improve with an elevated fibrinogen, normalization of her coagulation times, I would consider low-dose continuous infusion heparin for abrogation of consumption of coagulation routines and continued supportive infusions. I will repeat her laboratory studies in the morning and give more recommendations at that time. \ No newline at end of file diff --git a/3402_General Medicine.txt b/3402_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..19b2411149c19a9325d1f62754bd84815b4327d3 --- /dev/null +++ b/3402_General Medicine.txt @@ -0,0 +1,43 @@ +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. \ No newline at end of file diff --git a/3405_General Medicine.txt b/3405_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..4f2b341734b5602b1c794fbf644d15e4a2df764a --- /dev/null +++ b/3405_General Medicine.txt @@ -0,0 +1,69 @@ +ADMITTING DIAGNOSIS: + + Intractable migraine with aura. + +DISCHARGE DIAGNOSIS: + + Migraine with aura. + +SECONDARY DIAGNOSES: + +1. Bipolar disorder. + +2. Iron deficiency anemia. + +3. Anxiety disorder. + +4. History of tubal ligation. + +PROCEDURES DURING THIS HOSPITALIZATION: + +1. CT of the head with and without contrast, which was negative. + +2. An MRA of the head and neck with and without contrast also negative. + +3. The CTA of the neck also read as negative. + +4. The patient also underwent a lumbar puncture in the Emergency Department, which was grossly unremarkable though an opening pressure was not obtained. + +HOME MEDICATIONS: + +1. Vicodin 5/500 p.r.n. + +2. Celexa 40 mg daily. + +3. Phenergan 25 mg p.o. p.r.n. + +4. Abilify 10 mg p.o. daily. + +5. Klonopin 0.5 mg p.o. b.i.d. + +6. Tramadol 30 mg p.r.n. + +7. Ranitidine 150 mg p.o. b.i.d. + +ALLERGIES: + + SULFA drugs. + +HISTORY OF PRESENT ILLNESS: + + The patient is a 25-year-old right-handed Caucasian female who presented to the emergency department with sudden onset of headache occurring at approximately 11 a.m. on the morning of the July 31, 2008. She described the headache as worse in her life and it was also accompanied by blurry vision and scotoma. The patient also perceived some swelling in her face. Once in the Emergency Department, the patient underwent a very thorough evaluation and examination. She was given the migraine cocktail. Also was given morphine a total of 8 mg while in the Emergency Department. For full details on the history of present illness, please see the previous history and physical. + +BRIEF SUMMARY OF HOSPITAL COURSE: + +The patient was admitted to the neurological service after her headache felt to be removed with the headache cocktail. The patient was brought up to 4 or more early in the a.m. on the August 1, 2008 and was given the dihydroergotamine IV + + which did allow some minimal resolution in her headache immediately. At the time of examination this morning, the patient was feeling better and desired going home. She states the headache had for the most part resolved though she continues to have some diffuse trigger point pain. + +PHYSICAL EXAMINATION AT THE TIME OF DISCHARGE: + + General physical exam was unremarkable. HEENT: Pupils were equal and respond to light and accommodation bilaterally. Extraocular movements were intact. Visual fields were intact to confrontation. Funduscopic exam revealed no disc pallor or edema. Retinal vasculature appeared normal. Face is symmetric. Facial sensation and strength are intact. Auditory acuities were grossly normal. Palate and uvula elevated symmetrically. Sternocleidomastoid and trapezius muscles are full strength bilaterally. Tongue protrudes in midline. Mental status exam: revealed the patient alert and oriented x 4. Speech was clear and language is normal. Fund of knowledge, memory, and attention are grossly intact. Neurologic exam: Vasomotor system revealed full power throughout. Normal muscle tone and bulk. No pronator drift was appreciated. Coordination was intact to finger-to-nose, heel-to-shin and rapid alternating movement. No tremor or dysmetria. Excellent sensory. Sensation is intact in all modalities throughout. The patient does have notable trigger points diffusely including the occiput, trapezius bilaterally, lumbar, back, and sacrum. Gait was assessed, the patient's routine and tandem gait were normal. The patient is able to balance on heels and toes. Romberg is negative. Reflexes are 2+ and symmetric throughout. Babinski reflexes are plantar. + +DISPOSITION: + + The patient is discharged home. + +INSTRUCTIONS FOR FOLLOWUP: + +The patient is to followup with her primary care physician as needed. \ No newline at end of file diff --git a/3406_General Medicine.txt b/3406_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..621dd3da54b2e3ab3d53bf291796372125e383aa --- /dev/null +++ b/3406_General Medicine.txt @@ -0,0 +1,97 @@ +PRIMARY DISCHARGE DIAGNOSES: + +1. Urinary tract infection. + +2. Gastroenteritis with nausea and vomiting. + +3. Upper gastrointestinal bleed likely secondary to gastritis. + +4. Right hip osteoarthritic pain. + +SECONDARY DISCHARGE DIAGNOSES: + +1. Hypertension. + +2. Gastroesophageal reflux disease. + +3. Chronic atrial fibrillation. + +4. Osteoporosis. + +5. Valvular heart disease. + +HOSPITAL COURSE SUMMARY: + + The patient is 93-year-old Caucasian female with a past medical history of hypertension, chronic atrial fibrillation, gastroesophageal reflux disease, osteoporosis and chronic right hip pain after total hip arthroplasty was admitted to our hospital for complaints of nausea and vomiting and urinary tract infection. Over the course of her hospitalization, the patient was started on antibiotic regimen and proton pump inhibitors for an episode of coffee-ground emesis. The patient was managed conservatively and was also provided with physical therapy for chronic right hip pain. + +At the time of discharge, the patient continues to complain of right hip pain impairing ability to walk. The patient denies any chest pain, nausea, vomiting, fever, chills, shortness of breath, abdominal pain or any urine or bowel problems. + +PAST MEDICAL HISTORY: + + Can be referred to the H&P dictated in the chart. + +PAST SURGICAL HISTORY: + + Can be referred to the H&P dictated in the chart. + +PHYSICAL EXAMINATION: + +VITAL SIGNS: At the time of discharge temperature 36.6 degree Celsius, pulse rate of 77 per minute, respiratory rate 20 per minute, blood pressure 115/63, and oxygen saturation of 94% on room air. + +GENERAL: The patient is a thin built Caucasian female with no pallor, cyanosis or icterus. She is alert and oriented x3. + +HEENT: No carotid bruits, JVD + + lymphadenopathy or thyromegaly. Pupils are equally reactive to light and accommodation. + +BACK AND EXTREMITY: Bilateral pitting edema and peripheral pulses are palpable. The patient has right hip brace/immobilizer. + +HEART: Irregularly irregular heart rhythm, grade 2-3/6 systolic ejection murmur best heard over the aortic area and normal S1 and S2. + +CHEST: Auscultation revealed bibasilar crackles. + +ABDOMEN: Soft, nontender, no organomegaly and bowel sounds are present. + +CNS: Nonfocal. + +LABORATORY STUDIES: + + WBC 6.5, hemoglobin 12.5, hematocrit 38.9, platelet count 177,000, INR 1.2, sodium 141, potassium 3.6 and serum creatinine of 0.8. Liver function tests were normal. The patient's troponin was elevated at 0.05 at the time or presentation, but it trended down to 0.04 on the third set. Urinalysis revealed trace protein, trace blood, and 10-20 WBCs. Blood culture showed no growth till date. Urine culture grew 50-100,000 colonies of Enterococcus susceptible to ampicillin and nitrofurantoin. + +Chest x-ray showed enlarged heart with large intrathoracic hiatal hernia. Lung parenchyma was otherwise clear. + +Right hip x-ray showed that the prosthesis was in satisfactory position. There was small gap between the cancellous bone and the long stem femoral component of the prosthesis, which is within normal limits. + +DISCHARGE MEDICATIONS: + +1. Aspirin 81 mg orally once daily. + +2. Calcium with vitamin D two tablets orally once daily. + +3. Nexium 40 mg orally once daily. + +4. Multivitamins with minerals one capsule once daily. + +5. Zoloft 25 mg orally once daily. + +6. Norco 325/10 mg every 6-8 hours as needed for pain. + +7. Systane ophthalmic solution two drops in both eyes every two hours as needed. + +8. Herbal __________ by mouth everyday. + +9. Macrodantin 100 mg orally every six hours for seven days. + +ALLERGIES: + + Penicillin. + +PROGNOSIS: + + Improved. + +ASSESSMENT AND DISCHARGE PLAN: + +The patient is a 93-year-old Caucasian female with a past medical history of chronic right hip pain, osteoporosis, hypertension, depression, and chronic atrial fibrillation admitted for evaluation and management of severe nausea and vomiting and urinary tract infection. + +PROBLEM #1: \ No newline at end of file diff --git a/3408_General Medicine.txt b/3408_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..a9847cb28650f4c467a591cda8765d4ef8d1ed8f --- /dev/null +++ b/3408_General Medicine.txt @@ -0,0 +1,69 @@ +ADMITTING DIAGNOSES: + +1. Bradycardia. + +2. Dizziness. + +3. Diabetes. + +4. Hypertension. + +5. Abdominal pain. + +DISCHARGE DIAGNOSIS: + + Sick sinus syndrome. The rest of her past medical history remained the same. + +PROCEDURES DONE: + + Permanent pacemaker placement after temporary internal pacemaker. + +HOSPITAL COURSE: + + The patient was admitted to the intensive care unit. Dr. X was consulted. A temporary intracardiac pacemaker was placed. Consultation was requested to Dr. Y. He considered the need to have a permanent pacemaker after reviewing electrocardiograms and telemetry readings. The patient remained in sinus rhythm with severe bradycardias, but all of them one to one transmission. This was considered to be a sick sinus syndrome. Permanent pacemaker was placed on 09/05/2007 with right atrium appendage and right ventricular apex electrode placement. This is a Medtronic pacemaker. After this, the patient remained with pain in the left side of the chest in the upper area as expected, but well controlled. Right femoral artery catheter was removed. The patient remained with good pulses in the right lower extremity with no hematoma. Other problem was the patient's blood pressure, which on 09/05/2007 was found at 180/90. Medication was adjusted to benazepril 20 mg a day. Norvasc 5 mg was added as well. Her blood pressure has remained better, being today 144/74 and 129/76. + +FINAL DIAGNOSES: + +Sick sinus syndrome. The rest of her past medical history remained without change, which are: + +1. Diabetes mellitus. + +2. History of peptic ulcer disease. + +3. Hypertension. + +4. Insomnia. + +5. Osteoarthritis. + +PLAN: + + The patient is discharged home to continue her previous home medications, which are: + +1. Actos 45 mg a day. + +2. Bisacodyl 10 mg p.o. daily p.r.n. constipation. + +3. Cosopt eye drops, 1 drop in each eye 2 times a day. + +4. Famotidine 20 mg 1 tablet p.o. b.i.d. + +5. Lotemax 0.5% eye drops, 1 drop in each eye 4 times a day. + +6. Lotensin (benazepril) increased to 20 mg a day. + +7. Triazolam 0.125 mg p.o. at bedtime. + +8. Milk of Magnesia suspension 30 mL daily for constipation. + +9. Tylenol No. 3, one to two tablets every 6 hours p.r.n. pain. + +10. Promethazine 25 mg IM every 6 hours p.r.n. nausea or vomiting. + +11. Tylenol 325 mg tablets every 4 to 6 hours as needed for pain. + +12. The patient will finish cefazolin 1 g IV every 6 hours, total 5 dosages after pacemaker placement. + +DISCHARGE INSTRUCTIONS: + + Follow up in the office in 10 days for staple removal. Resume home activities as tolerated with no starch, sugar-free diet. \ No newline at end of file diff --git a/3410_General Medicine.txt b/3410_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..afc9be8c490050d9be6c451f923756fc8c810a72 --- /dev/null +++ b/3410_General Medicine.txt @@ -0,0 +1,43 @@ +ADMISSION DIAGNOSIS: + + Upper respiratory illness with apnea, possible pertussis. + +DISCHARGE DIAGNOSIS: + + Upper respiratory illness with apnea, possible pertussis. + +COMPLICATIONS: + + None. + +OPERATIONS: + + None,BRIEF HISTORY AND PHYSICAL: + + This is a one plus-month-old female with respiratory symptoms for approximately a week prior to admission. This involved cough, post-tussive emesis, questionable fever, but only 99.7. Their usual doctor prescribed amoxicillin over the phone. The coughing persisted and worsened. She went to the ER + + where sats were normal at baseline, but dropped into the 80s with coughing spells. They did witness some apnea. They gave some Rocephin, did some labs, and the patient was transferred to hospital. + +PHYSICAL EXAMINATION: + + On admission, GENERAL: Well-developed, well-nourished baby in no apparent distress. HEENT: There was some nasal discharge. Remainder of the HEENT was normal. LUNG: Had few rhonchi. No retractions. No significant coughing or apnea during the admission physical. ABDOMEN: Benign. EXTREMITIES: Were without any cyanosis. + +SIGNIFICANT LABS AND X-RAYS: + +She had a CBC done Garberville, which showed a white count of 12.4, with a differential of 10 segs, 82 lymphs, 8 monos, hemoglobin of 15, hematocrit 42, platelets 296,000, and a normal BMP. An x-ray was done and I do not have an official interpretation, but to the admitting physician, Dr. X it showed no significant infiltrate. Well at hospital, she had a rapid influenza swab done, which was negative. She had a rapid RSV done, which is still not in the chart, but I believe I was told that it was negative. She also had a pertussis PCR swab done and a pertussis culture done, neither of which has result in the chart. I do know that the pertussis culture proved to be negative. + +CONSULTATION: + + Public Health Department was notified of a case of suspected pertussis. + +HOSPITAL COURSE: + + The baby was afebrile. Required no oxygen in the hospital. Actually fed reasonably well. Did have one episode of coughing with slight emesis. Appeared basically quite well between episodes. Had no apnea witnessed and after overnight observation, the parents were anxious to go home. The patient was started on Zithromax in the hospital. + +CONDITION AND TREATMENT: + + The patient was in stable condition and good condition on exam at the time and was discharged home on Zithromax to be followed up in the office within a week. + +INSTRUCTIONS TO PATIENT: + + Include usual diet and to follow up within a week, but certainly sooner if the coughing is worse and there is cyanosis or apnea again. \ No newline at end of file diff --git a/3414_General Medicine.txt b/3414_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..af884019030b27843354f6359f9f5b83ae3ab82f --- /dev/null +++ b/3414_General Medicine.txt @@ -0,0 +1,39 @@ +HISTORY OF PRESENT ILLNESS: + + The patient is a 60-year-old female patient who off and on for the past 10 to 12 months has had almost daily diarrhea, nausea, inability to eat. She had an EGD and colonoscopy with Dr. ABC a few days prior to this admission. Colonoscopy did reveal diverticulosis and EGD showed retained bile and possible gastritis. Biopsies were done. The patient presented to our emergency room for worsening abdominal pain as well as swelling of the right lower leg. + +PAST MEDICAL HISTORY: + + Extensive and well documented in prior charts. + +PHYSICAL EXAMINATION: + + Abdomen was diffusely tender. Lungs clear. Blood pressure 129/69 on admission. At the time of admission, she had just a trace of bilateral lower edema. + +LABORATORY STUDIES: + + White count 6.7, hemoglobin 13, hematocrit 39.3. Potassium of 3.2 on 08/15/2007. + +HOSPITAL COURSE: + + Dr. ABC apparently could not advance the scope into the cecum and therefore warranted a barium enema. This was done and did not really show what the cecum on the barium enema. There was some retained stool in that area and the patient had a somewhat prolonged hospital course on the remaining barium from the colon. She did have some enemas. She had persistent nausea, headache, neck pain throughout this hospitalization. Finally, she did improve enough to the point where she could be discharged home. + +DISCHARGE DIAGNOSIS: + + Nausea and abdominal pain of uncertain etiology. + +SECONDARY DIAGNOSIS: + +Migraine headache. + +COMPLICATIONS: + +None. + +DISCHARGE CONDITION: + + Guarded. + +DISCHARGE PLAN: + +Follow up with me in the office in 5 to 7 days to resume all pre-admission medications. Diet and activity as tolerated. \ No newline at end of file diff --git a/3418_General Medicine.txt b/3418_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..977dfd9b2bf273d69db105f34452d5fd59a50908 --- /dev/null +++ b/3418_General Medicine.txt @@ -0,0 +1,47 @@ +CHIEF COMPLAINT: + + Cut on foot. + +HISTORY OF PRESENT ILLNESS: + + This is a 32-year-old male who had a piece of glass fall on to his right foot today. The patient was concerned because of the amount of bleeding that occurred with it. The bleeding has been stopped and the patient does not have any pain. The patient has normal use of his foot, there is no numbness or weakness, the patient is able to ambulate well without any discomfort. The patient denies any injuries to any other portion of his body. He has not had any recent illness. The patient has no other problems or complaints. + +PAST MEDICAL HISTORY: + + Asthma. + +CURRENT MEDICATION: + + Albuterol. + +ALLERGIES: + + NO KNOWN DRUG ALLERGIES. + +SOCIAL HISTORY: + + The patient is a smoker. + +PHYSICAL EXAMINATION: + + VITAL SIGNS: Temperature 98.8 oral, blood pressure 132/86, pulse is 76, and respirations 16. Oxygen saturation is 100% on room air and interpreted as normal. CONSTITUTIONAL: The patient is well-nourished, well-developed, the patient 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 conjunctiva and cornea bilaterally. NECK: Supple with full range of motion. CARDIOVASCULAR: Peripheral pulse is +2 to the right foot. Capillary refills less than two seconds to all the digits of the right foot. RESPIRATIONS: No shortness of breath. MUSCULOSKELETAL: The patient has a 4-mm partial thickness laceration to the top of the right foot and about the area of the mid foot. There is no palpable foreign body, no foreign body is visualized. There is no active bleeding, there is no exposed deeper tissues and certainly no exposed tendons, bone, muscle, nerves, or vessels. It appears that the laceration may have nicked a small varicose vein, which would have accounted for the heavier than usual bleeding that currently occurred at home. The patient does not have any tenderness to the foot. The patient has full range of motion to all the joints, all the toes, as well as the ankles. The patient ambulates well without any difficulty or discomfort. There are no other injuries noted to the rest of the body. SKIN: The 4-mm partial thickness laceration to the right foot as previously described. No other injuries are noted. NEUROLOGIC: Motor is 5/5 to all the muscle groups of the right lower extremity. Sensory is intact to light touch to all the dermatomes of the right foot. The patient has normal speech and normal ambulation. PSYCHIATRIC: The patient is alert and oriented x4. Normal mood and affect. HEMATOLOGIC/LYMPHATIC: No active bleeding is occurring at this time. No evidence of bruising is noted to the body. + +EMERGENCY DEPARTMENT COURSE: + + The patient had antibiotic ointment and a bandage applied to his foot. + +DIAGNOSES: + +1. A 4-MM LACERATION TO THE RIGHT FOOT. + +2. ACUTE RIGHT FOOT PAIN + + NOW RESOLVED. + +CONDITION UPON DISPOSITION: + + Stable. + +DISPOSITION: + + To home. The patient was given discharge instructions on wound care and asked to return to emergency room should he have any evidence or signs and symptoms of infection. The patient was precautioned that there may still be a small piece of glass retained in the foot and that there is a possibility of infection or that the piece of glass may be extruded later on. \ No newline at end of file diff --git a/3420_General Medicine.txt b/3420_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..b10be066d680138489de83ddce237d8b6bd05a0d --- /dev/null +++ b/3420_General Medicine.txt @@ -0,0 +1,31 @@ +HISTORY OF PRESENT ILLNESS: + + The patient is a 74-year-old white woman who has a past medical history of hypertension for 15 years, history of CVA with no residual hemiparesis and uterine cancer with pulmonary metastases, who presented for evaluation of recent worsening of the hypertension. According to the patient, she had stable blood pressure for the past 12-15 years on 10 mg of lisinopril. In August of 2007, she was treated with doxorubicin and, as well as Procrit and her blood pressure started to go up to over 200s. Her lisinopril was increased to 40 mg daily. She was also given metoprolol and HCTZ two weeks ago, after she visited the emergency room with increased systolic blood pressure. Denies any physical complaints at the present time. Denies having any renal problems in the past. + +PAST MEDICAL HISTORY: + + As above plus history of anemia treated with Procrit. No smoking or alcohol use and lives alone. + +FAMILY HISTORY: + + Unremarkable. + +PRESENT MEDICATIONS: + + As above. + +REVIEW OF SYSTEMS: + + Cardiovascular: No chest pain. No palpitations. Pulmonary: No shortness of breath, cough, or wheezing. Gastrointestinal: No nausea, vomiting, or diarrhea. GU: No nocturia. Denies having gross hematuria. Salt intake is minimal. Neurological: Unremarkable, except for history of old CVA. + +PHYSICAL EXAMINATION: + + Blood pressure today is 182/78. Examination of the head is unremarkable. Neck is supple with no JVD. Lungs are clear. There is no abdominal bruit. Extremities 1+ edema bilaterally. + +LABORATORY DATA: + + Urinalysis done in the office shows 1+ proteinuria; same is shown by urinalysis done at Hospital. The creatinine is 0.8. Renal ultrasound showed possible renal artery stenosis and a 2 cm cyst in the left kidney. MRA of the renal arteries was essentially unremarkable with no suspicion for renal artery stenosis. + +IMPRESSION AND PLAN: + + Accelerated hypertension. No clear-cut etiology for recent worsening since renal artery stenosis was ruled out by negative MRA. I could only blame Procrit initiation, as well as possible fluid retention as a cause of the patient's accelerated hypertension. She was started on hydrochlorothiazide less than two weeks ago with some improvement in her hypertension. At this point, I would not pursue a diagnosis of renal artery stenosis. Since she is maxed out on lisinopril and her pulse is 60, I would not increase beta-blocker or ACE inhibitor. I will continue HCTZ at 24 mg daily. The patient was also given a sample of Tekturna, which would hopefully improve her systolic blood pressure. The patient was told to be stick with her salt intake. She will report to me in 10 days with the result of her blood pressure. She will also repeat an SMA7 to rule out possible hyperkalemia due to Tekturna. \ No newline at end of file diff --git a/3421_General Medicine.txt b/3421_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..b2f3c8111f366a56fc78b48bb0fcbf39116dc283 --- /dev/null +++ b/3421_General Medicine.txt @@ -0,0 +1,105 @@ +REASON FOR THE CONSULT: + + Sepsis, possible SBP. + +HISTORY OF PRESENT ILLNESS: + + This is a 53-year-old Hispanic man with diabetes, morbid obesity, hepatitis C, cirrhosis, history of alcohol and cocaine abuse, who presented in the emergency room on 01/07/09 for ground-level fall secondary to weak knees. He complained of bilateral knee pain, but also had other symptoms including hematuria and epigastric pain for at least a month. He ran out of prescription medications 1 month ago. In the ER he was initially afebrile, but then spiked up to 101.3 with heart rate of 130, respiratory rate of 24. White blood cell count was slightly low at 4 and platelet count was only 22,000. Abdominal ultrasound showed mild-to-moderate ascites. He was given 1 dose of Zosyn and then started on levofloxacin and Flagyl last night. Dr. X was called early this morning due to hypotension, SBP in the 70s. He then changed antibiotic regiment to vancomycin and doripenem. + +PAST MEDICAL HISTORY: + + Hepatitis C, cirrhosis, coronary artery disease, hyperlipidemia, chronic venous stasis, gastroesophageal reflux disease, history of exploratory laparotomy for stab wounds, chronic recurrent leg wounds, and hepatic encephalopathy. + +SOCIAL HISTORY: + + The patient is a former smoker, reportedly quit in 2007. He used cocaine in the past, reportedly quit in 2005. He also has a history of alcohol abuse, but apparently quit more than 10 years ago. + +ALLERGIES: + + None known. + +CURRENT MEDICATIONS: + + Vancomycin, doripenem, thiamine, Protonix, potassium chloride p.r.n. + + magnesium p.r.n. + + Zofran. p.r.n. + + norepinephrine drip, and vitamin K. + +REVIEW OF SYSTEMS: + + Not obtainable as the patient is drowsy and confused. + +PHYSICAL EXAMINATION: + +CONSTITUTIONAL/VITAL SIGNS: Heart rate 101, respiratory rate 17, blood pressure 92/48, temperature 97.5, and oxygen saturation 98% on 2 L nasal cannula. + +GENERAL APPEARANCE: The patient is drowsy. Morbidly obese. Height 5 feet 8 inches, body weight 182 kilos. + +EYES: Slightly pale conjunctivae, icteric sclerae. Pupils equal, brisk reaction to light. + +EARS + + NOSE + + MOUTH AND THROAT: Intact gross hearing. Moist oral mucosa. No oral lesions. + +NECK: No palpable neck masses. Thyroid is not enlarged on inspection. + +RESPIRATORY: Regular inspiratory effort. No crackles or wheezes. + +CARDIOVASCULAR: Regular cardiac rhythm. No rales or rubs. Positive bipedal edema, 2+ + + right worse than left. + +GASTROINTESTINAL: Globular abdomen. Soft. No guarding, no rigidity. Tender on palpation of n right upper quadrant and epigastric area. Mildly tender on palpation of right upper quadrant and epigastric area. + +LYMPHATIC: No cervical lymphadenopathy. + +SKIN: Positive diffuse jaundice. No palpable subcutaneous nodules. + +PSYCHIATRIC: Poor judgment and insight. + +LABORATORY DATA: + + White blood cell count from 01/08/09 is 9 with 68% neutrophils, 20% bands, H&H 9.7/28.2, platelet count 24,000. INR 3.84, PTT more than 240. BUN and creatinine 26.8/1.2. AST 76, ALT 27, alkaline phosphatase 48, total bilirubin 17.85. Total CK 1198.6, LDH 873.2. Troponin 0.09, myoglobin 2792. Urinalysis from 01/07/09 shows small leucocyte esterase, positive nitrites, 1 to 3 wbc's, 0 to 1 rbc's, 2+ bacteria. Two sets of blood cultures from 01/07/09 still pending. + +RADIOLOGY: + + Chest x-ray from 01/07/09 did not show any pathologic abnormalities of the heart, mediastinum, lung fields, bony or soft tissue structures. Left knee x-rays on 01/07/09 showed advanced osteoarthritis. Abdominal ultrasound on 01/07/09 showed mild-to-moderate ascites, mild prominence of the gallbladder with thickened ball and pericholecystic fluid. Preliminary report of CAT scan of the abdomen showed changes consistent to liver cirrhosis and portal hypertension with mild ascites, splenomegaly, and dilated portal/splenic and superior mesenteric vein. Appendix was not clearly seen, but there was no evidence of pericecal inflammation. + +IMPRESSION: + +1. Septic shock. + +2. Possible urinary tract infection. + +3. Ascites, rule out spontaneous bacterial peritenonitis. + +4. Hyperbilirubinemia, consider cholangitis. + +5. Alcoholic liver disease. + +6. Thrombocytopenia. + +7. Hepatitis C. + +8. Cryoglobulinemia. + +RECOMMENDATIONS: + +1. Continue with vancomycin and doripenem at this point. + +2. Agree with paracentesis. + +3. Send ascitic fluid for cell count, differential and cultures. + +4. Follow up with result of blood cultures. + +5. We will get urine culture from the specimen on admission. + +6. The patient needs hepatitis A vaccination. + +Additional ID recommendations as appropriate upon followup. \ No newline at end of file diff --git a/3422_General Medicine.txt b/3422_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..eb8edf3a682d2fc869be6e138adedb70543770b6 --- /dev/null +++ b/3422_General Medicine.txt @@ -0,0 +1,15 @@ +CHIEF COMPLAINT: + + I need refills. + +HISTORY OF PRESENT ILLNESS: + + The patient presents today stating that she needs refills on her Xanax, and she would also like to get something to help her quit smoking. She is a new patient today. She states that she has mesothelioma in the lining of her stomach and that it does cause her some problems with eating and it causes some chronic pain. She states that she is under the care of a cancer specialist; however, she just recently moved back to this area and is trying to find a doctor a little closer than his office. She states that she has tried several different things to help her quit smoking and she has failed everything and had heard good results about Chantix and wanted to give it a try. + +OBJECTIVE: + +Well developed and well nourished. She does not appear to be in any acute distress. Cardiovascular: Regular rhythm. No murmurs, gallops, or rubs. Capillary refill less than 3 seconds. Peripheral pulses are 2+ bilaterally. Respiratory: Her lungs are clear to auscultation bilaterally with good effort. No tenderness to palpation over chest wall. Musculoskeletal: She has full range of motion of all four extremities. No tenderness to palpation over long bones. Skin: Warm and dry. No rashes or lesions. Neuro: Alert and oriented x3. Cranial nerves II-XII are grossly intact. No focal deficits. + +PLAN: + + I did refill her medications. I have requested that she have her primary doctor forward her records to me. I have discussed Chantix and its use and success rate. She was given a prescription, as well as a coupon. She is to watch for any worsening signs or symptoms. She verbalized understanding of discharge instructions and prescriptions. I would like to see her back to proceed with her preventive health measures. \ No newline at end of file diff --git a/3424_General Medicine.txt b/3424_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..45d60b589bff5b8f8d153c69a00b7e068a8c6241 --- /dev/null +++ b/3424_General Medicine.txt @@ -0,0 +1,99 @@ +REASON FOR CONSULTATION: + + Coronary artery disease (CAD) + + prior bypass surgery. + +HISTORY OF PRESENT ILLNESS: + + The patient is a 70-year-old gentleman who was admitted for management of fever. The patient has history of elevated PSA and BPH. He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic. From cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness. No symptoms of chest pain or shortness of breath. + +His history from cardiac standpoint as mentioned below. + +CORONARY RISK FACTORS: + + History of hypertension, history of diabetes mellitus, nonsmoker. Cholesterol elevated. History of established coronary artery disease in the family and family history positive. + +FAMILY HISTORY: + + Positive for coronary artery disease. + +SURGICAL HISTORY: + + Coronary artery bypass surgery and a prior angioplasty and prostate biopsies. + +MEDICATIONS: + +1. Metformin. + +2. Prilosec. + +3. Folic acid. + +4. Flomax. + +5. Metoprolol. + +6. Crestor. + +7. Claritin. + +ALLERGIES: + + DEMEROL + + SULFA. + +PERSONAL HISTORY: + + He is married, nonsmoker, does not consume alcohol, and no history of recreational drug use. + +PAST MEDICAL HISTORY: + + Significant for multiple knee surgeries, back surgery, and coronary artery bypass surgery with angioplasty, hypertension, hyperlipidemia, elevated PSA level, BPH with questionable cancer. Symptoms of shortness of breath, fatigue, and tiredness. + +REVIEW OF SYSTEMS: + +CONSTITUTIONAL: No history of fever, rigors, or chills except for recent fever and rigors. + +HEENT: No history of cataract or glaucoma. + +CARDIOVASCULAR: As above. + +RESPIRATORY: Shortness of breath. No pneumonia or valley fever. + +GASTROINTESTINAL: Nausea and vomiting. No hematemesis or melena. + +UROLOGICAL: Frequency, urgency. + +MUSCULOSKELETAL: No muscle weakness. + +SKIN: None significant. + +NEUROLOGICAL: No TIA or CVA. No seizure disorder. + +PSYCHOLOGICAL: No anxiety or depression. + +ENDOCRINE: As above. + +HEMATOLOGICAL: None significant. + +PHYSICAL EXAMINATION: + +VITAL SIGNS: Pulse of 75, blood pressure 130/68, afebrile, and respiratory rate 16 per minute. + +HEENT: Atraumatic, normocephalic. + +NECK: Veins flat. No significant carotid bruits. + +LUNGS: Air entry bilaterally fair. + +HEART: PMI displaced. S1 and S2 regular. + +ABDOMEN: Soft, nontender. Bowel sounds present. + +EXTREMITIES: No edema. Pulses are palpable. No clubbing or cyanosis. + +CNS: Benign. + +EKG: \ No newline at end of file diff --git a/3426_General Medicine.txt b/3426_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..95aa5a8d82ddf455ac0cc78b23f3a10bda81bbca --- /dev/null +++ b/3426_General Medicine.txt @@ -0,0 +1,97 @@ +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. \ No newline at end of file diff --git a/3429_General Medicine.txt b/3429_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..1fd485acce87e628cda3e7ea2f690703a765b4e4 --- /dev/null +++ b/3429_General Medicine.txt @@ -0,0 +1,95 @@ +REASON FOR CONSULTATION: + + Syncope. + +HISTORY OF PRESENT ILLNESS: + +The patient is a 69-year-old gentleman, a good historian, who relates that he was brought in the Emergency Room following an episode of syncope. The patient relates that he may have had a seizure activity prior to that. Prior to the episode, he denies having any symptoms of chest pain or shortness of breath. No palpitation. Presently, he is comfortable, lying in the bed. As per the patient, no prior cardiac history. + +CORONARY RISK FACTORS: + + History of hypertension. No history of diabetes mellitus. Nonsmoker. Cholesterol status is borderline elevated. No history of established coronary artery disease. Family history noncontributory. + +PAST MEDICAL HISTORY: + +Hypertension, hyperlipidemia, recently diagnosed with Parkinson's, as a Parkinson's tremor, admitted for syncopal evaluation. + +PAST SURGICAL HISTORY: + +Back surgery, shoulder surgery, and appendicectomy. + +FAMILY HISTORY: + + Nonsignificant. + +MEDICATIONS: + +1. Pain medications. + +2. Thyroid supplementation. + +3. Lovastatin 20 mg daily. + +4. Propranolol 20 b.i.d. + +5. Protonix. + +6. Flomax. + +ALLERGIES: + + None. + +PERSONAL HISTORY: + + He is married. Nonsmoker. Does not consume alcohol. No history of recreational drug use. + +REVIEW OF SYSTEMS + +CONSTITUTIONAL: No weakness, fatigue, or tiredness. + +HEENT: No history of cataract or glaucoma. + +CARDIOVASCULAR: No congestive heart failure. No arrhythmias. + +RESPIRATORY: No history of pneumonia or valley fever. + +GASTROINTESTINAL: No nausea, vomiting, hematemesis, or melena. + +UROLOGICAL: No frequency or urgency. + +MUSCULOSKELETAL: Arthritis and muscle weakness. + +SKIN: Nonsignificant. + +NEUROLOGIC: No TIA or CVA. No seizure disorder. + +ENDOCRINE/HEMATOLOGIC: Nonsignificant. + +PHYSICAL EXAMINATION + +VITAL SIGNS: Pulse of 93, blood pressure of 158/93, afebrile, and respiratory rate 16 per minute. + +HEENT: Atraumatic and normocephalic. + +NECK: Neck veins are flat. No significant carotid bruits. + +LUNGS: Air entry is bilaterally decreased. + +HEART: PMI is displaced. S1 and S2 are regular. + +ABDOMEN: Soft and nontender. Bowel sounds are present. + +EXTREMITIES: No edema. Pulses are palpable. No clubbing or cyanosis. The patient is moving all extremities; however, the patient has tremors. + +RADIOLOGICAL DATA: + + EKG reveals normal sinus rhythm with underlying nonspecific ST-T changes secondary to tremors. + +LABORATORY DATA: + + H&H stable. White count of 14. BUN and creatinine are within normal limits. Cardiac enzyme profile is negative. Ammonia level is elevated at 69. CT angiogram of the chest, no evidence of pulmonary embolism. Chest x-ray is negative for acute changes. CT of the head, unremarkable, chronic skin changes. Liver enzymes are within normal limits. + +IMPRESSION: + +1. The patient is a 69-year-old gentleman, admitted with syncopal episode and possible seizure disorder. \ No newline at end of file diff --git a/3433_General Medicine.txt b/3433_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..915f4cb28cbe22b8e48213d402ee44f46f74fe8c --- /dev/null +++ b/3433_General Medicine.txt @@ -0,0 +1,93 @@ +CHIEF COMPLAINT: + + Multiple problems, main one is chest pain at night. + +HISTORY OF PRESENT ILLNESS: + + This is a 60-year-old female with multiple problems as numbered below: + +1. She reports that she has chest pain at night. This happened last year exactly the same. She went to see Dr. Murphy, and he did a treadmill and an echocardiogram, no concerns for cardiovascular disease, and her symptoms resolved now over the last month. She wakes in the middle of the night and reports that she has a pressure. It is mild-to-moderate in the middle of her chest and will stay there as long she lies down. If she gets up, it goes away within 15 minutes. It is currently been gone on for the last week. She denies any fast heartbeats or irregular heartbeats at this time. + +2. She has been having stomach pains that started about a month ago. This occurs during the daytime. It has no relationship to foods. It is mild in nature, located in the mid epigastric area. It has been better for one week as well. + +3. She continues to have reflux, has noticed that if she stops taking Aciphex, then she has symptoms. If she takes her Aciphex, she seems that she has the reflux belching, burping, and heartburn under control. + +4. She has right flank pain when she lies down. She has had this off and on for four months. It is a dull achy pain. It is mild in nature. + +5. She has some spots on her shoulder that have been present for a long time, but over the last month have been getting bigger in size and is elevated whereas they had not been elevated in the past. It is not painful. + +6. She has had spots in her armpits initially on the right side and then going to the left side. They are not itchy. + +7. She is having problems with urgency of urine. When she has her bladder full, she suddenly has an urge to use the restroom, and sometimes does not make it before she begins leaking. She is wearing a pad now. + +8. She is requesting a colonoscopy for screening as well. She is wanting routine labs for following her chronic leukopenia, also is desiring a hepatitis titer. + +9. She has had pain in her thumbs when she is trying to do fine motor skills, has noticed this for the last several months. There has been no swelling or redness or trauma to these areas. + +REVIEW OF SYSTEMS: + + She has recently been to the eye doctor. She has noticed some hearing loss gradually. She denies any problems with swallowing. She denies episodes of shortness of breath, although she has had a little bit of chronic cough. She has had normal bowel movements. Denies any black or bloody stools, diarrhea, or constipation. Denies seeing blood in her urine and has had no urinary problems other than what is stated above. She has had no problems with edema or lower extremity numbness or tingling. + +SOCIAL HISTORY: + + She works at nursing home. She is a nonsmoker. She is currently trying to lose weight. She is on the diet and has lost several pounds in the last several months. She quit smoking in 1972. + +FAMILY HISTORY: + + Her father has type I diabetes and heart disease. She has a brother who had heart attack at the age of 52. He is a smoker. + +PAST MEDICAL HISTORY: + + Episodic leukopenia and mild irritable bowel syndrome. + +CURRENT MEDICATIONS: + + Aciphex 20 mg q.d. and aspirin 81 mg q.d. + +ALLERGIES: + + No known medical allergies. + +OBJECTIVE: + +Vital Signs: Weight: 142 pounds. Blood pressure: 132/78. Pulse: 72. + +General: This is a well-developed adult female who is awake, alert, and in no acute distress. + +HEENT: Her pupils are equally round and reactive to light. Conjunctivae are white. TMs look normal bilaterally. Oropharynx appears to be normal. Dentition is excellent. + +Neck: Supple without lymphadenopathy or thyromegaly. + +Lungs: Clear with normal respiratory effort. + +Heart: Regular rhythm and rate without murmur. Radial pulses are normal bilaterally. + +Abdomen: Soft, nontender, and nondistended without organomegaly. + +Extremities: Examination of the hands reveals some tenderness at the base of her thumbs bilaterally as well as at the PIP joint and DIP joint. Her armpits are examined. She has what appears to be a tinea versicolor rash present in the armpits bilaterally. She has a lesion on her left shoulder, which is 6 mm in diameter. It has diffuse borders and is slightly red. It has two brown spots in it. In her lower extremities, there is no cyanosis or edema. Pulses at the radial and posterior tibial pulses are normal bilaterally. Her gait is normal. + +Psychiatric: Her affect is pleasant and positive. + +Neurological: She is grossly intact. Her speech seems to be clear. Her coordination of upper and lower extremities is normal. + +ASSESSMENT/PLAN: + +1. Chest pain. At this point, because of Dr. Murphy’s evaluation last year and the symptoms exactly the same, I think this is noncardiac. My intonation is that this is reflux. I am going have her double her Aciphex or increase it to b.i.d. + + and I am going to have her see Dr. XYZ for possible EGD if he thinks that would be appropriate. She is to let me know if her symptoms are getting worse or if she is having any severe episodes. + +2. Stomach pain, uncertain at this point, but I feel like this is probably related as well to chest pain. + +3. Suspicious lesions on the left shoulder. We will do a punch biopsy and set her up for an appointment for that. + +4. Tinea versicolor in the axillary area. I have prescribed selenium sulfide lotion to apply 10 minutes a day for seven days. + +5. Cystocele. We will have her see Dr. XYZ for further discussion of repair due to her urinary incontinence. + +6. History of leukopenia. We will check a CBC. + +7. Pain in the thumbs, probably arthritic in nature, observe for now. + +8. Screening. We will have her see Dr. XYZ for discussion of colon cancer screening. + +9. Gastroesophageal reflux disease. I have increased Aciphex to b.i.d. for now. \ No newline at end of file diff --git a/3438_General Medicine.txt b/3438_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..f282cd60e92f8954307781bd39a5ffa8a692c599 --- /dev/null +++ b/3438_General Medicine.txt @@ -0,0 +1,75 @@ +REASON FOR CONSULT: + +I was asked to see the patient for C. diff colitis. + +HISTORY OF PRESENTING ILLNESS: + + Briefly, the patient is a very pleasant 72-year-old female with previous history of hypertension and also recent diagnosis of C. diff for which she was admitted here in 5/2009, who presents to the hospital on 6/18/2009 with abdominal pain, cramping, and persistent diarrhea. After admission, she had a CT of the abdomen done, which showed evidence of diffuse colitis and she was started on IV Flagyl and also on IV Levaquin. She was also placed on IV Reglan because of nausea and vomiting. In spite of the above, her white count still continues to be elevated today. On questioning the patient, she states the nausea and vomiting has resolved, but the diarrhea still present, but otherwise denies any other specific complaints except for some weakness. + +PAST MEDICAL HISTORY: + + Hypertension, hyperlipidemia, recent C. diff colitis, which had resolved based on speaking to Dr. X. Two weeks ago, he had seen the patient and she was clinically well. + +PAST SURGICAL HISTORY: + +Noncontributory. + +SOCIAL HISTORY: + +No history of smoking, alcohol, or drug use. She lives at home. + +HOME MEDICATIONS: + +She is on atenolol and Mevacor. + +ALLERGIES: NO KNOWN DRUG ALLERGIES. + +REVIEW OF SYSTEMS: + +Positive for diarrhea and abdominal pain, otherwise main other complaints are weakness. She denies any cough, sputum production, or dysuria at this time. Otherwise, a 10-system review is essentially negative. + +PHYSICAL EXAM: + +GENERAL: She is awake and alert, currently in no apparent distress. + +VITAL SIGNS: She has been afebrile since admission, temperature today 96.5, heart rate 80, respirations 18, blood pressure 125/60, and O2 sat is 98% on 2 L. + +HEENT: Pupils are round and reactive to light and accommodation. + +CHEST: Clear to auscultation bilaterally. + +CARDIOVASCULAR: S1 and S2 are present. No rales appreciated. + +ABDOMEN: She does have tenderness to palpation all over with some mild rebound tenderness also. No guarding noted. Bowel sounds present. + +EXTREMITIES: No clubbing, cyanosis, or edema. + +CT of the abdomen and pelvis is also reviewed on the computer, which showed evidence of diffuse colitis. + +LABORATORY: + + White blood cell count today 21.5, hemoglobin 12.4, platelet count 284,000, and neutrophils 89. UA on 6/18/2009 showed no evidence of UTI. Sodium today 130, potassium 2.7, and creatinine 0.4. AST and ALT on 6/20/2009 were normal. Blood cultures from admission were negative. Urine culture on admission was negative. C. diff was positive. Stool culture was negative. + +ASSESSMENT: + +1. A 72-year-old female with Clostridium difficile colitis. + +2. Diarrhea secondary to above and also could be related Reglan, which was discontinued today. + +3. Leukocytosis secondary to above, mild improvement today though. + +4. Bilateral pleural effusion by CT of the chest, although could represent thickening. + +5. New requirement for oxygen, rule out pneumonia. + +6. Hypertension. + +PLAN: + +1. Treat the C. diff aggressively especially given CT appearance and her continued leukocytosis and because of the Levaquin, which could have added additional antibiotic pressure, so I will restart the IV Flagyl. + +2. Continue p.o. vancomycin. Add Florastor to help replenish the gut flora. + +3. Monitor WBCs closely and follow clinically and if there is any deterioration in her clinical status, I would recommend getting surgical evaluation immediately for surgery if needed. + +4. We will check a chest x-ray especially given her new requirement for oxygen. \ No newline at end of file diff --git a/3441_General Medicine.txt b/3441_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..d04079c2e4ec9f0592acb6e1b617ead4cc5fbbf3 --- /dev/null +++ b/3441_General Medicine.txt @@ -0,0 +1,37 @@ +CHIEF COMPLAINT: + + Burn, right arm. + +HISTORY OF PRESENT ILLNESS: + + This is a Workers' Compensation injury. This patient, a 41 year-old male, was at a coffee shop, where he works as a cook, and hot oil splashed onto his arm, burning from the elbow to the wrist on the medial aspect. He has had it cooled, and presents with his friend to the Emergency Department for care. + +PAST MEDICAL HISTORY: + +Noncontributory. + +MEDICATIONS: + +None. + +ALLERGIES: + +None. + +PHYSICAL EXAMINATION: + + GENERAL: Well-developed, well-nourished 21-year-old male adult who is appropriate and cooperative. His only injury is to the right upper extremity. There are first and second degree burns on the right forearm, ranging from the elbow to the wrist. Second degree areas with blistering are scattered through the medial aspect of the forearm. There is no circumferential burn, and I see no areas of deeper burn. The patient moves his hands well. Pulses are good. Circulation to the hand is fine. + +FINAL DIAGNOSIS: + +1. First-degree and second-degree burns, right arm secondary to hot oil spill. + +2. Workers' Compensation industrial injury. + +TREATMENT: + + The wound is cooled and cleansed with soaking in antiseptic solution. The patient was ordered Demerol 50 mg IM for pain, but he refused and did not want pain medication. A burn dressing is applied with Neosporin ointment. The patient is given Tylenol No. 3, tabs #4, to take home with him and take one or two every four hours p.r.n. for pain. He is to return tomorrow for a dressing change. Tetanus immunization is up to date. Preprinted instructions are given. Workers' Compensation first report and work status report are completed. + +DISPOSITION: + + Home. \ No newline at end of file diff --git a/3442_General Medicine.txt b/3442_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..343b2810a70e573447ab8ff52c9c7260136f3057 --- /dev/null +++ b/3442_General Medicine.txt @@ -0,0 +1,57 @@ +CHIEF COMPLAINT: + + Buttock abscess. + +HISTORY OF PRESENT ILLNESS: + + This patient is a 24-year-old African-American female who presented to the hospital with buttock pain. She started off with a little pimple on the buttock. She was soaking it at home without any improvement. She came to the hospital on the first. The patient underwent incision and drainage in the emergency department. She was admitted to the hospitalist service with elevated blood sugars. She has had positive blood cultures. Surgery is consulted today for evaluation. + +PAST MEDICAL HISTORY: + +Diabetes type II + + poorly controlled, high cholesterol. + +PAST SURGICAL HISTORY: + + C-section and D&C. + +ALLERGIES: + + NO KNOWN DRUG ALLERGIES. + +MEDICATIONS: + + Insulin, metformin, Glucotrol, and Lipitor. + +FAMILY HISTORY: + + Diabetes, hypertension, stroke, Parkinson disease, and heart disease. + +REVIEW OF SYSTEMS: + + Significant for pain in the buttock. Otherwise negative. + +PHYSICAL EXAMINATION: + +GENERAL: This is an overweight African-American female not in any distress. + +VITAL SIGNS: She has been afebrile since admission. Vital signs have been stable. Blood sugars have been in the 200 range. + +HEENT: Normal to inspection. + +NECK: No bruits or adenopathy. + +LUNGS: Clear to auscultation. + +CV: Regular rate and rhythm. + +ABDOMEN: Protuberant, soft, and nontender. + +EXTREMITIES: No clubbing, cyanosis or edema. + +RECTAL EXAM: The patient has a drained abscess on the buttock cheek. There is some serosanguineous drainage. There is no longer any purulent drainage. The wound appears relatively clean. I do not see a lot of erythema. + +ASSESSMENT AND PLAN: + + Left buttock abscess, status post incision and drainage. I do not believe surgical intervention is warranted. I have recommended some local wound care. Please see orders for details. \ No newline at end of file diff --git a/3450_General Medicine.txt b/3450_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..90103868bc3cf1c00f3e21258fffdd6c390a0108 --- /dev/null +++ b/3450_General Medicine.txt @@ -0,0 +1,71 @@ +DIAGNOSIS: + + Refractory anemia that is transfusion dependent. + +CHIEF COMPLAINT: + + I needed a blood transfusion. + +HISTORY: + + The patient is a 78-year-old gentleman with no substantial past medical history except for diabetes. He denies any comorbid complications of the diabetes including kidney disease, heart disease, stroke, vision loss, or neuropathy. At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion. He reports that he has no signs or symptom of bleeding and had a blood transfusion approximately two months ago and actually several weeks before that blood transfusion, he had a transfusion for anemia. He has been placed on B12, oral iron, and Procrit. At this time, we are asked to evaluate him for further causes and treatment for his anemia. He denies any constitutional complaints except for fatigue, malaise, and some dyspnea. He has no adenopathy that he reports. No fevers, night sweats, bone pain, rash, arthralgias, or myalgias. + +PAST MEDICAL HISTORY: + +Diabetes. + +PAST SURGICAL HISTORY: + + Hernia repair. + +ALLERGIES: + + He has no allergies. + +MEDICATIONS: + + Listed in the chart and include Coumadin, Lasix, metformin, folic acid, diltiazem, B12, Prevacid, and Feosol. + +SOCIAL HISTORY: + + He is a tobacco user. He does not drink. He lives alone, but has family and social support to look on him. + +FAMILY HISTORY: + + Negative for blood or cancer disorders according to the patient. + +PHYSICAL EXAMINATION: + +GENERAL: He is an elderly gentleman in no acute distress. He is sitting up in bed eating his breakfast. He is alert and oriented and answering questions appropriately. + +VITAL SIGNS: Blood pressure of 110/60, pulse of 99, respiratory rate of 14, and temperature of 97.4. He is 69 inches tall and weighs 174 pounds. + +HEENT: Sclerae show mild arcus senilis in the right. Left is clear. Pupils are equally round and reactive to light. Extraocular movements are intact. Oropharynx is clear. + +NECK: Supple. Trachea is midline. No jugular venous pressure distention is noted. No adenopathy in the cervical, supraclavicular, or axillary areas. + +CHEST: Clear. + +HEART: Regular rate and rhythm. + +ABDOMEN: Soft and nontender. There may be some fullness in the left upper quadrant, although I do not appreciate a true spleen with inspiration. + +EXTREMITIES: No clubbing, but there is some edema, but no cyanosis. + +NEUROLOGIC: Noncontributory. + +DERMATOLOGIC: Noncontributory. + +CARDIOVASCULAR: Noncontributory. + +IMPRESSION: + + At this time is refractory anemia, which is transfusion dependent. He is on B12, iron, folic acid, and Procrit. There are no sign or symptom of blood loss and a recent esophagogastroduodenoscopy, which was negative. His creatinine was 1. My impression at this time is that he probably has an underlying myelodysplastic syndrome or bone marrow failure. His creatinine on this hospitalization was up slightly to 1.6 and this may contribute to his anemia. + +RECOMMENDATIONS: + +At this time, my recommendation for the patient is that he undergoes further serologic evaluation with reticulocyte count, serum protein, and electrophoresis, LDH + + B12, folate, erythropoietin level, and he should undergo a bone marrow aspiration and biopsy. I have discussed the procedure in detail which the patient. I have discussed the risks, benefits, and successes of that treatment and usefulness of the bone marrow and predicting his cause of refractory anemia and further therapeutic interventions, which might be beneficial to him. He is willing to proceed with the studies I have described to him. We will order an ultrasound of his abdomen because of the possible fullness of the spleen, and I will probably see him in follow up after this hospitalization. + +As always, we greatly appreciate being able to participate in the care of your patient. We appreciate the consultation of the patient. \ No newline at end of file diff --git a/3453_General Medicine.txt b/3453_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..2707d1e2f6ce9db27b1988caef0a16e1ca375821 --- /dev/null +++ b/3453_General Medicine.txt @@ -0,0 +1,41 @@ +HISTORY OF PRESENT ILLNESS: + +This 59-year-old white male is seen for comprehensive annual health maintenance examination on 02/19/08, although this patient is in excellent overall health. Medical problems include chronic tinnitus in the left ear with moderate hearing loss for many years without any recent change, dyslipidemia well controlled with niacin, history of hemorrhoids with occasional external bleeding, although no problems in the last 6 months, and also history of concha bullosa of the left nostril, followed by ENT associated with slight septal deviation. There are no other medical problems. He has no symptoms at this time and remains in excellent health. + +PAST MEDICAL HISTORY: + + Otherwise noncontributory. There is no operation, serious illness or injury other than as noted above. + +ALLERGIES: + + There are no known allergies. + +FAMILY HISTORY: + + Father died of an MI at age 67 with COPD and was a heavy smoker. His mother is 88, living and well, status post lung cancer resection. Two brothers, living and well. One sister died at age 20 months of pneumonia. + +SOCIAL HISTORY: + + The patient is married. Wife is living and well. He jogs or does Cross Country track 5 times a week, and weight training twice weekly. No smoking or significant alcohol intake. He is a physician in allergy/immunology. + +REVIEW OF SYSTEMS: + + Otherwise noncontributory. He has no gastrointestinal, cardiopulmonary, genitourinary or musculoskeletal symptomatology. No symptoms other than as described above. + +PHYSICAL EXAMINATION: + +GENERAL: He appears alert, oriented, and in no acute distress with excellent cognitive function. VITAL SIGNS: His height is 6 feet 2 inches, weight is 181.2, blood pressure is 126/80 in the right arm, 122/78 in the left arm, pulse rate is 68 and regular, and respirations are 16. SKIN: Warm and dry. There is no pallor, cyanosis or icterus. HEENT: Tympanic membranes benign. The pharynx is benign. Nasal mucosa is intact. Pupils are round, regular, and equal, reacting equally to light and accommodation. EOM intact. Fundi reveal flat discs with clear margins. Normal vasculature. No hemorrhages, exudates or microaneurysms. No thyroid enlargement. There is no lymphadenopathy. LUNGS: Clear to percussion and auscultation. Normal sinus rhythm. No premature beat, murmur, S3 or S4. Heart sounds are of good quality and intensity. The carotids, femorals, dorsalis pedis, and posterior tibial pulsations are brisk, equal, and active bilaterally. ABDOMEN: Benign without guarding, rigidity, tenderness, mass or organomegaly. NEUROLOGIC: Grossly intact. EXTREMITIES: Normal. GU: Genitalia normal. There are no inguinal hernias. There are mild hemorrhoids in the anal canal. The prostate is small, if any normal to mildly enlarged with discrete margins, symmetrical without significant palpable abnormality. There is no rectal mass. The stool is Hemoccult negative. + +IMPRESSION: + +1. Comprehensive annual health maintenance examination. + +2. Dyslipidemia. + +3. Tinnitus, left ear. + +4. Hemorrhoids. + +PLAN: + + At this time, continue niacin 1000 mg in the morning, 500 mg at noon, and 1000 mg in the evening; aspirin 81 mg daily; multivitamins; vitamin E 400 units daily; and vitamin C 500 mg daily. Consider adding lycopene, selenium, and flaxseed to his regimen. All appropriate labs will be obtained today. Followup fasting lipid profile and ALT in 6 months. \ No newline at end of file diff --git a/3455_Gastroenterology.txt b/3455_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..e831aa7767c1b7217c1bd1e7918167a1558d9f07 --- /dev/null +++ b/3455_Gastroenterology.txt @@ -0,0 +1,11 @@ +HISTORY OF PRESENT ILLNESS: + + Ms. Connor is a 50-year-old female who returns to clinic for a wound check. The patient underwent an APR secondary to refractory ulcerative colitis. Subsequently, she developed a wound infection, which has since healed. On our most recent visit to our clinic, she has her perineal stitches removed and presents today for followup of her perineal wound. She describes no drainage or erythema from her bottom. She is having good ostomy output. She does not describe any fevers, chills, nausea, or vomiting. The patient does describe some intermittent pain beneath the upper portion of the incision as well as in the right lower quadrant below her ostomy. She has been taking Percocet for this pain and it does work. She has since run out has been trying extra strength Tylenol, which will occasionally help this intermittent pain. She is requesting additional pain medications for this occasional abdominal pain, which she still experiences. + +PHYSICAL EXAMINATION: + + Temperature 95.8, pulse 68, blood pressure 132/73, and weight 159 pounds. This is a pleasant female in no acute distress. The patient's abdomen is soft, nontender, nondistended with a well-healed midline scar. There is an ileostomy in the right hemiabdomen, which is pink, patent, productive, and protuberant. There are no signs of masses or hernias over the patient's abdomen. + +ASSESSMENT AND PLAN: + + This is a pleasant 50-year-old female who has undergone an APR secondary to refractory ulcerative colitis. Overall, her quality of life has significantly improved since she had her APR. She is functioning well with her ileostomy. She did have concerns or questions about her diet and we discussed the BRAT diet, which consisted of foods that would slow down the digestive tract such as bananas, rice, toast, cheese, and peanut butter. I discussed the need to monitor her ileostomy output and preferential amount of daily output is 2 liters or less. I have counseled her on refraining from soft drinks and fruit drinks. I have also discussed with her that this diet is moreover a trial and error and that she may try certain foods that did not agree with her ileostomy, however others may and that this is something she will just have to perform trials with over the next several months until she finds what foods that she can and cannot eat with her ileostomy. She also had questions about her occasional abdominal pain. I told her that this was probably continue to improve as months went by and I gave her a refill of her Percocet for the continued occasional pain. I told her that this would the last time I would refill the Percocet and if she has continued pain after she finishes this bottle then she would need to start ibuprofen or Tylenol if she had continued pain. The patient then brought up some right hand and arm numbness, which has been there postsurgically and was thought to be from positioning during surgery. This is all primarily gone away except for a little bit of numbness at the tip of the third digit as well as some occasional forearm muscle cramping. I told her that I felt that this would continue to improve as it has done over the past two months since her surgery. I told her to continue doing hand exercises as she has been doing and this seems to be working for her. Overall, I think she has healed from her surgery and is doing very well. Again, her quality of life is significantly improved. She is happy with her performance. We will see her back in six months just for a general routine checkup and see how she is doing at that time. \ No newline at end of file diff --git a/3457_General Medicine.txt b/3457_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..93cd4f388bcdc6c88ecfecd4c844e48d75dbc489 --- /dev/null +++ b/3457_General Medicine.txt @@ -0,0 +1,61 @@ +REASON FOR CONSULTATION: + + Possible free air under the diaphragm. + +HISTORY OF PRESENT ILLNESS: + + The patient is a 77-year-old female who is unable to give any information. She has been sedated with Ativan and came into the emergency room obtunded and unable to give any history. On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm. + +PAST MEDICAL HISTORY: + + Significant for alcohol abuse. Unable to really gather any other information because she is so obtunded. + +PAST SURGICAL HISTORY: + +Looking at the medical chart, she had an appendectomy, right hip fracture from a fall in 2005, and TAH/BSO. + +MEDICATIONS: + + Unable to evaluate. + +ALLERGIES: + + UNABLE TO EVALUATE. + +SOCIAL HISTORY: + +Significant history of alcohol abuse, according to the emergency room physician, who sees her on a regular basis. + +REVIEW OF SYSTEMS: + + Unable to obtain. + +PHYSICAL EXAM + +VITAL SIGNS: Temp 98.3, heart rate 82, respiratory rate 24, and blood pressure 141/70. + +GENERAL: She is a very obtunded female who upon arousal is not able to provide any information of any use. + +HEENT: Atraumatic. + +NECK: Soft and supple. + +LUNGS: Bilaterally diminished. + +HEART: Regular. + +ABDOMEN: Soft, and with deep palpation I am unable to arouse the patient, unable to elicit any tenderness. + +LABORATORY STUDIES: + + Show a normal white blood cell count with no shift. Elevated AST at 138, with a normal ALT at 38. Alkaline phosphatase of 96, bilirubin 0.8. Sodium is 107, with 68 chloride and potassium of 2.8. + +X-ray of the chest shows the possibility of free air; therefore, a CT scan was obtained because of the patient's physical examination, which shows no evidence of intra-abdominal pathology. The etiology of the air under the diaphragm is actually a colonic air that is anterior superior to the dome of the diaphragm, near the dome of the liver. + +ASSESSMENT: + + No intra-abdominal pathology. + +PLAN: + + Have her admitted to the medical service for treatment of her hyponatremia. \ No newline at end of file diff --git a/3458_Gastroenterology.txt b/3458_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..416ce258200c3c549e7386a7ad4ab36e99d3cdac --- /dev/null +++ b/3458_Gastroenterology.txt @@ -0,0 +1,13 @@ +PROCEDURE PERFORMED: + + Umbilical hernia repair. + +PROCEDURE: + + After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table. The patient was sedated, and an adequate local anesthetic was administered using 1% lidocaine without epinephrine. The patient was prepped and draped in the usual sterile manner. + +A standard curvilinear umbilical incision was made, and dissection was carried down to the hernia sac using a combination of Metzenbaum scissors and Bovie electrocautery. The sac was cleared of overlying adherent tissue, and the fascial defect was delineated. The fascia was cleared of any adherent tissue for a distance of 1.5 cm from the defect. The sac was then placed into the abdominal cavity and the defect was closed primarily using simple interrupted 0 Vicryl sutures. The umbilicus was then re-formed using 4-0 Vicryl to tack the umbilical skin to the fascia. + +The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery. The skin was approximated with 4-0 Vicryl in a subcuticular fashion. The skin was prepped with benzoin, and Steri-Strips were applied. A dressing was then applied. All surgical counts were reported as correct. + +Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition. \ No newline at end of file diff --git a/3460_General Medicine.txt b/3460_General Medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..e8c7d9d51c74be43ba3c8243b80e26abe20d7602 --- /dev/null +++ b/3460_General Medicine.txt @@ -0,0 +1,51 @@ +HISTORY OF PRESENT ILLNESS: + + Patient is a three years old male who about 45 minutes prior admission to the emergency room ingested about two to three tablets of Celesta 40 mg per tablets. Mom called to the poison control center and the recommendation was to take the patient to the emergency room and be evaluated. The patient was alert and did not vomit during the transport to the emergency room. Mom left the patient and his little one-year-old brother in the room by themselves and she went outside of the house for a couple of minutes, and when came back, she saw the patient having the Celesta foils in his hands and half of tablet was moist and on the floor. The patient said that the pills "didn't taste good," so it is presumed that the patient actually ingested at least two-and-a-half tablets of Celesta, 40 mg per tablet. + +PAST MEDICAL HISTORY: + + Baby was born premature and he required hospitalization, but was not on mechanical ventilation. He doesn't have any hospitalizations after the new born. No surgeries. + +IMMUNIZATIONS: + + Up-to-date. + +ALLERGIES: + + NOT KNOWN DRUG ALLERGIES. + +PHYSICAL EXAMINATION + +VITAL SIGNS: Temperature 36.2 Celsius, pulse 112, respirations 24, blood pressure 104/67, weight 15 kilograms. + +GENERAL: Alert, in no acute distress. + +SKIN: No rashes. + +HEENT: Head: Normocephalic, atraumatic. Eyes: EOMI + + PERRL. Nasal mucosa clear. Throat and tonsils, normal. No erythema, no exudates. + +NECK: Supple, no lymphadenopathy, no masses. + +LUNGS: Clear to auscultation bilateral. + +HEART: Regular rhythm and rate without murmur. Normal S1, S2. + +ABDOMEN: Soft, nondistended, nontender, present bowel sounds, no hepatosplenomegaly, no masses. + +EXTREMITIES: Warm. Capillary refill brisk. Deep tendon reflexes present bilaterally. + +NEUROLOGICAL: Alert. Cranial nerves II through XII intact. No focal exam. Normal gait. + +RADIOGRAPHIC DATA: + + Patient has had an EKG done at the admission and it was within normal limits for the age. + +EMERGENCY ROOM COURSE: + + Patient was under observation for 6 hours in the emergency room. He had two more EKGs during observation in the emergency room and they were all normal. His vital signs were monitored every hour and were within normal limits. There was no vomiting, no diarrhea during observation. Patient did not receive any medication or has had any other lab work besides the EKG. + +ASSESSMENT AND PLAN: + + Three years old male with accidental ingestion of Celesta. Discharged home with parents, with a followup in the morning with his primary care physician. \ No newline at end of file diff --git a/3463_Gastroenterology.txt b/3463_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..0f0bd16a8cc179cc73cda7f4e3034ecaa261565f --- /dev/null +++ b/3463_Gastroenterology.txt @@ -0,0 +1,21 @@ +PROCEDURE: + + Upper endoscopy with removal of food impaction. + +HISTORY OF PRESENT ILLNESS: + + A 92-year-old lady with history of dysphagia on and off for two years. She comes in this morning with complaints of inability to swallow anything including her saliva. This started almost a day earlier. She was eating lunch and had beef stew and suddenly noticed inability to finish her meal and since then has not been able to eat anything. She is on Coumadin and her INR is 2.5. + +OPERATIVE NOTE: + + Informed consent was obtained from patient. The risks of aspiration, bleeding, perforation, infection, and serious risk including need for surgery and ICU stay particularly in view of food impaction for almost a day was discussed. Daughter was also informed about the procedure and risks. Conscious sedation initially was administered with Versed 2 mg and fentanyl 50 mcg. The scope was advanced into the esophagus and showed liquid and solid particles from mid esophagus all the way to the distal esophagus. There was a meat bolus in the distal esophagus. This was visualized after clearing the liquid material and small particles of what appeared to be carrots. The patient, however, was not tolerating the conscious sedation. Hence, Dr. X was consulted and we continued the procedure with propofol sedation. + +The scope was reintroduced into the esophagus after propofol sedation. Initially a Roth net was used and some small amounts of soft food in the distal esophagus was removed with the Roth net. Then, a snare was used to cut the meat bolus into pieces, as it was very soft. Small pieces were grabbed with the snare and pulled out. Thereafter, the residual soft meat bolus was passed into the stomach along with the scope, which was passed between the bolus and the esophageal wall carefully. The patient had severe bruising and submucosal hemorrhage in the esophagus possibly due to longstanding bolus impaction and Coumadin therapy. No active bleeding was seen. There was a distal esophageal stricture, which caused slight resistance to the passage of the scope into the stomach. As this area was extremely inflamed, a dilatation was not attempted. + +IMPRESSION: + + Distal esophageal stricture with food impaction. Treated as described above. + +RECOMMENDATIONS: + + IV Protonix 40 mg q.12h. Clear liquid diet for 24 hours. If the patient is stable, thereafter she may take soft pureed diet only until next endoscopy, which will be scheduled in three to four weeks. She should take Prevacid SoluTab 30 mg b.i.d. on discharge. \ No newline at end of file diff --git a/3464_Gastroenterology.txt b/3464_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..3ba7060539b495f16622c80d131d90b1f598d3c7 --- /dev/null +++ b/3464_Gastroenterology.txt @@ -0,0 +1,23 @@ +PREOPERATIVE DIAGNOSES + +1. Bowel obstruction. + +2. Central line fell off. + +POSTOPERATIVE DIAGNOSES + +1. Bowel obstruction. + +2. Central line fell off. + +PROCEDURE: + + Insertion of a triple-lumen central line through the right subclavian vein by the percutaneous technique. + +PROCEDURE DETAIL: + + This lady has a bowel obstruction. She was being fed through a central line, which as per the patient was just put yesterday and this slipped out. At the patient's bedside after obtaining an informed consent, the patient's right deltopectoral area was prepped and draped in the usual fashion. Xylocaine 1% was infiltrated and with the patient in Trendelenburg position, she had her right subclavian vein percutaneously cannulated without any difficulty. A Seldinger technique was used and a triple-lumen catheter was inserted. There was a good flow through all three ports, which were irrigated with saline prior to connection to the IV solutions. + +The catheter was affixed to the skin with sutures and then a dressing was applied. + +The postprocedure chest x-ray revealed that there were no complications to the procedure and that the catheter was in good place. \ No newline at end of file diff --git a/3465_Gastroenterology.txt b/3465_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..a168a6f02006f25313ea6bc8e08ef827992802af --- /dev/null +++ b/3465_Gastroenterology.txt @@ -0,0 +1,23 @@ +EXAM: + + Ultrasound Abdomen. + + + +REASON FOR EXAM: + + Elevated liver function tests. + + + +INTERPRETATION: + + The liver demonstrates heterogeneously increased echotexture with significant fatty infiltration. The gallbladder is surgically absent. There is no fluid collection in the cholecystectomy bed. There is dilatation of the common bile duct up to 1 cm. There is also dilatation of the pancreatic duct that measures up to 3 mm. There is caliectasis in the right kidney. The bladder is significantly distended measuring 937 cc in volume. The caliectasis in the right kidney may be secondary to back pressure from the distended bladder. The aorta is normal in caliber. + + + +IMPRESSION: + +1. Dilated common duct as well as pancreatic duct as described. Given the dilatation of these two ducts, ERCP versus MRCP is recommended to exclude obstructing mass. The findings could reflect changes of cholecystectomy. + +2. Significantly distended bladder with probably resultant caliectasis in the right kidney. Clinical correlation recommended. \ No newline at end of file diff --git a/3470_Gastroenterology.txt b/3470_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..a1bd9a3c76c8cc7b754760623c4e4718aafc0ec5 --- /dev/null +++ b/3470_Gastroenterology.txt @@ -0,0 +1,57 @@ +PREOPERATIVE DIAGNOSES: + +1. Squamous cell carcinoma of the head and neck. + +2. Ethanol and alcohol abuse. + +POSTOPERATIVE DIAGNOSES: + +1. Squamous cell carcinoma of the head and neck. + +2. Ethanol and alcohol abuse. + +PROCEDURE: + +1. Failed percutaneous endoscopic gastrostomy tube placement. + +2. Open Stamm gastrotomy tube. + +3. Lysis of adhesions. + +4. Closure of incidental colotomy. + +ANESTHESIA: + + General endotracheal anesthesia. + +IV FLUIDS: + + Crystalloid 1400 ml. + +ESTIMATED BLOOD LOSS: + + Thirty ml. + +DRAINS: + + Gastrostomy tube was placed to Foley. + +SPECIMENS: + + None. + +FINDINGS: + + Stomach located high in the peritoneal cavity. Multiple adhesions around the stomach to the diaphragm and liver. + +HISTORY: + +The patient is a 59-year-old black male who is indigent, an ethanol and tobacco abuse. He presented initially to the emergency room with throat and bleeding. Following evaluation by ENT and biopsy, it was determined to be squamous cell carcinoma of the right tonsil and soft palate, The patient is to undergo radiation therapy and possibly chemotherapy and will need prolonged enteral feeding with a bypass route from the mouth. The malignancy was not obstructing. Following obtaining informed consent for percutaneous endoscopic gastrostomy tube with possible conversion to open procedure, we elected to proceed following diagnosis of squamous cell carcinoma and election for radiation therapy. + +DESCRIPTION OF PROCEDURE: + + The patient was placed in the supine position and general endotracheal anesthesia was induced. Preoperatively, 1 gram of Ancef was given. The abdomen was prepped and draped in the usual sterile fashion. After anesthesia was achieved, an endoscope was placed down into the stomach, and no abnormalities were noted. The stomach was insufflated with air and the endoscope was positioned in the midportion and directed towards the anterior abdominal wall. With the room darkened and intensity turned up on the endoscope, a light reflex was noted on the skin of the abdominal wall in the left upper quadrant at approximately 2 fingerbreadths inferior from the most inferior rib. Finger pressure was applied to the light reflex with adequate indentation on the stomach wall on endoscopy. A 21-gauge 1-1/2 inch needle was initially placed at the margin of the light reflex, and this was done twice. Both times it was not visualized on the endoscopy. At this point, repositioning was made and, again, what was felt to be adequate light reflex was obtained, and the 14-gauge angio catheter was placed. Again, after two attempts, we were unable to visualize the needle in the stomach endoscopically. At this point, decision was made to convert the procedure to an open Stamm gastrostomy. + +OPEN STAMM GASTROSTOMY: + +A short upper midline incision was made and deepened through the subcutaneous tissues. Hemostasis was achieved with electrocautery. The linea alba was identified and incised, and the peritoneal cavity was entered. The abdomen was explored. Adhesions were lysed with electrocautery under direct vision. The stomach was identified, and a location on the anterior wall near the greater curvature was selected. After lysis of adhesions was confirmed, we sufficiently moved the original chosen site without tension. A pursestring suture of #3-0 silk was placed on the interior surface of the stomach, and a second #3-0 pursestring silk stitch was placed exterior to that pursestring suture. An incision was then made at the location of the anterior wall which was near the greater curvature and was dissected down to the anterior abdominal wall. A Vanderbilt was used to pass through the abdominal wall in through the skin and then returned to the level of the skin and pulled the Bard feeding tube through the anterior wall into the field. An incision in the center of the pursestring suture on the anterior surface of the stomach was then made with electrocautery. The interior pursestring suture was sutured into place in such a manner as to inkwell the stomach around the catheter. The second outer concentric pursestring suture was then secured as well and tied to further inkwell the stomach. The stomach was then tacked to the anterior abdominal wall at the catheter entrance site with four #2-0 silk sutures in such a manner as to prevent leakage or torsion. The catheter was then secured to the skin with two #2-0 silk sutures. Hemostasis was checked and the peritoneal cavity was washed out and brought to the surgical field. Prior to the initiation of the gastrotomy, the bowel was run and at that time there was noted to be one incidental colotomy. This was oversewn with three #4-0 silk Lembert sutures. At the completion of the operation, the fascia was closed with #1 interrupted Vicryl suture, and the skin was closed with staples. The patient tolerated the procedure well and was taken to the postanesthesia care unit in stable condition. \ No newline at end of file diff --git a/3471_Gastroenterology.txt b/3471_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..05a2e8680c73c3b4eda6e8c52013bbac75afce8b --- /dev/null +++ b/3471_Gastroenterology.txt @@ -0,0 +1,23 @@ +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. \ No newline at end of file diff --git a/3472_Gastroenterology.txt b/3472_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..40cd5d3c1db22cccfaa99e10e732833dfb251101 --- /dev/null +++ b/3472_Gastroenterology.txt @@ -0,0 +1,85 @@ +HISTORY OF PRESENT ILLNESS: + + This is a 1-year-old male patient who was admitted on 12/23/2007 with a history of rectal bleeding. He was doing well until about 2 days prior to admission and when he passes hard stools, there was bright red blood in the stool. He had one more episode that day of stool; the stool was hard with blood in it. Then, he had one episode of rectal bleeding yesterday and again one stool today, which was soft and consistent with dark red blood in it. No history of fever, no diarrhea, no history of easy bruising. Excessive bleeding from minor cut. He has been slightly fussy. + +PAST MEDICAL HISTORY: + +Nothing significant. + +PREGNANCY DELIVERY AND NURSERY COURSE: + + He was born full term without complications. + +PAST SURGICAL HISTORY: + + None. + +SIGNIFICANT ILLNESS AND REVIEW OF SYSTEMS: + + Negative for heart disease, lung disease, history of cancer, blood pressure problems, or bleeding problems. + +DIET: + + Regular table food, 24 ounces of regular milk. He is n.p.o. now. + +TRAVEL HISTORY: + + Negative. + +IMMUNIZATION: + + Up-to-date. + +ALLERGIES: + + None. + +MEDICATIONS: + + None, but he is on IV Zantac now. + +SOCIAL HISTORY: + + He lives with parents and siblings. + +FAMILY HISTORY: + + Nothing significant. + +LABORATORY EVALUATION: + + On 12/24/2007, WBC 8.4, hemoglobin 7.6, hematocrit 23.2 and platelets 314,000. Sodium 135, potassium 4.7, chloride 110, CO2 20, BUN 6 and creatinine 0.3. Albumin 3.3. AST 56 and ALT 26. CRP less than 0.3. Stool rate is still negative. + +DIAGNOSTIC DATA: + + CT scan of the abdomen was read as normal. + +PHYSICAL EXAMINATION: + +VITAL SIGNS: Temperature 99.5 degrees Fahrenheit, pulse 142 per minute and respirations 28 per minute. Weight 9.6 kilogram. + +GENERAL: He is alert and active child in no apparent distress. + +HEENT: Atraumatic and normocephalic. Pupils are equal, round and reactive to light. Extraocular movements, conjunctivae and sclerae fair. Nasal mucosa pink and moist. Pharynx is clear. + +NECK: Supple without thyromegaly or masses. + +LUNGS: Good air entry bilaterally. No rales or wheezing. + +ABDOMEN: Soft and nondistended. Bowel sounds positive. No mass palpable. + +GENITALIA: Normal male. + +RECTAL: Deferred, but there was no perianal lesion. + +MUSCULOSKELETAL: Full range of movement. No edema. No cyanosis. + +CNS: Alert, active and playful. + +IMPRESSION: + + A 1-year-old male patient with history of rectal bleeding. Possibilities include Meckel's diverticulum, polyp, infection and vascular malformation. + +PLAN: + + To proceed with Meckel scan today. If Meckel scan is negative, we will consider upper endoscopy and colonoscopy. We will start colon clean out if Meckel scan is negative. We will send his stool for C. diff toxin, culture, blood for RAST test for cow milk, soy, wheat and egg. Monitor hemoglobin. \ No newline at end of file diff --git a/3473_Gastroenterology.txt b/3473_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..38bfa4be91750e4b7f0a043c82ecc090bb4123b7 --- /dev/null +++ b/3473_Gastroenterology.txt @@ -0,0 +1,95 @@ +HISTORY OF PRESENT ILLNESS: + + This is a 10-year-old who was found with biliary atresia and underwent a Kasai procedure and did not really well because she ended up having a liver transplant. The patient did well after the liver transplant and the only problems started: + +1. History of food allergies. + +2. History of dental cavities. + +At this time, the patient came for a followup and is complaining of a left upper molar pain. There are no other complaints. + +DIET: + + Lactose-limited diet. + +MEDICATIONS: + + Please see the MRC form. + +ALLERGIES: + + There are no allergies. + +SOCIAL HISTORY: + + The patient lives with the parents in Lindsay, California and has a good environment. + +FAMILY HISTORY: + + Negative for gastrointestinal illness except that a sibling has ulcerative colitis. + +REVIEW OF SYSTEMS: + + The system review was only positive for molar pain, but rest of the 13 review of systems were negative to date. + +PHYSICAL EXAMINATION: + +MEASUREMENTS: Height 135 cm and weight 28.1 kg. + +VITAL SIGNS: Temperature 98.9 and blood pressure 105/57. + +GENERAL: A well-developed, well-nourished child in no acute distress. + +HEENT: Atraumatic and normocephalic. The pupils are equal, round, and reactive to light. Full EOMs. The conjunctivae and sclerae are clear. The TMs show normal landmarks. The nasal mucosa is pink and moist. The teeth and gums are in good condition. The pharynx is clear. + +NECK: Supple, without thyromegaly and without masses. + +LYMPHATIC: No adenopathy. + +LUNGS: Clear to auscultation, with no retractions. + +CORONARY: Regular rhythm without murmur. S1 and S2 are normal. The pulses are full and symmetrical bilaterally. + +ABDOMEN: Normal bowel sounds. No hepatosplenomegaly, no masses, and no tenderness. + +GENITALIA: Normal female by inspection. + +SKIN: No unusual lesions. + +BACK: No scoliosis, hairy patch, lipoma, or sacral dimple. + +EXTREMITIES: No cyanosis, clubbing, or edema. + +CENTRAL NERVOUS SYSTEM: Developmentally appropriate for age. DTRs are 2+ and symmetrical. The toes are downgoing bilaterally. Motor and sensory without asymmetry. Cranial nerves II through XII are grossly intact. + +LABORATORY DATA: + + Laboratory data from 12/30/2007 tacrolimus 3.1 and negative Epstein-Barr, CMV was not detected. + +FINAL IMPRESSION: + + This is a 10-year-old with history of: + +1. Biliary atresia. + +2. Status post orthotopic liver transplantation. + +3. Dental cavities. + +4. Food allergies. + +5. History of urinary tract infections. + +PLAN: + + Our plan would be to continue with the medications as follows: + +1. Prograf 0.5 mg p.o. b.i.d. + +2. Valganciclovir 420 mg p.o. b.i.d. + +3. Labs every 2 to 3 months. + +4. To return to clinic in 4 months. + +5. To refer this patient to a pediatric dentist for assessment of the dental cavities. \ No newline at end of file diff --git a/3475_Gastroenterology.txt b/3475_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..a961dd54834a23ec18c42ecd4e3e94cdea84c19e --- /dev/null +++ b/3475_Gastroenterology.txt @@ -0,0 +1,81 @@ +REASON FOR ADMISSION: + + Rectal bleeding. + +HISTORY OF PRESENT ILLNESS: + +The patient is a very pleasant 68-year-old male with history of bilateral hernia repair, who presents with 3 weeks of diarrhea and 1 week of rectal bleeding. He states that he had some stomach discomfort in the last 4 weeks. He has had some physical therapy for his lower back secondary to pain after hernia repair. He states that the pain worsened after this. He has had previous history of rectal bleeding and a colonoscopy approximately 8 years ago that was normal. He denies any dysuria. He denies any hematemesis. He denies any pleuritic chest pain. He denies any hemoptysis. + +PAST MEDICAL HISTORY: + +1. History of bilateral hernia repair by Dr. X in 8/2008. + +2. History of rectal bleeding. + +ALLERGIES: + + NONE. + +MEDICATIONS: + +1. Cipro. + +2. Lomotil. + +FAMILY HISTORY: + + Noncontributory. + +SOCIAL HISTORY: + + No tobacco, alcohol or IV drug use. + +REVIEW OF SYSTEMS: + + As per the history of present illness otherwise unremarkable. + +PHYSICAL EXAMINATION: + +VITAL SIGNS: The patient is afebrile. Pulse 117, respirations 18, and blood pressure 117/55. Saturating 98% on room air. + +GENERAL: The patient is alert and oriented x3. + +HEENT: Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Oropharynx is clear without exudates. + +NECK: Supple. No thyromegaly. No jugular venous distention. + +HEART: Tachycardic. Regular rhythm without murmurs, rubs or gallops. + +LUNGS: Clear to auscultation bilaterally both anteriorly and posteriorly. + +ABDOMEN: Positive bowel sounds. Soft and nontender with no guarding. + +EXTREMITIES: No clubbing, cyanosis or edema in the upper or lower extremities. + +NEUROLOGIC: Nonfocal. + +LABORATORY STUDIES: + + Sodium 131, potassium 3.9, chloride 94, CO2 25, BUN 15, creatinine 0.9, glucose 124, INR 1.2, troponin less than 0.04, white count 17.5, hemoglobin 12.3, and platelet count 278 with 91% neutrophils. EKG shows sinus tachycardia. + +PROBLEM LIST: + +1. Colitis. + +2. Sepsis. + +3. Rectal bleeding. + +RECOMMENDATIONS: + +1. GI consult with Dr. Y's group. + +2. Continue Levaquin and Flagyl. + +3. IV fluids. + +4. Send for fecal WBCs, O&P, and C. diff. + +5. CT of the abdomen and pelvis to rule out abdominal pathology. + +6. PPI for PUD prophylaxis. \ No newline at end of file diff --git a/3477_Gastroenterology.txt b/3477_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..9b721db600e4ff0d36f17721cb84ca2bdc2f5628 --- /dev/null +++ b/3477_Gastroenterology.txt @@ -0,0 +1,13 @@ +EXAM: + + Ultrasound-guided paracentesis,HISTORY: + + Ascites. + +TECHNIQUE AND FINDINGS: + +Informed consent was obtained from the patient after the risks and benefits of the procedure were thoroughly explained. Ultrasound demonstrates free fluid in the abdomen. The area of interest was localized with ultrasonography. The region was sterilely prepped and draped in the usual manner. Local anesthetic was administered. A 5-French Yueh catheter needle combination was taken. Upon crossing into the peritoneal space and aspiration of fluid, the catheter was advanced out over the needle. A total of approximately 5500 mL of serous fluid was obtained. The catheter was then removed. The patient tolerated the procedure well with no immediate postprocedure complications. + +IMPRESSION: + + Ultrasound-guided paracentesis as above. \ No newline at end of file diff --git a/3478_Gastroenterology.txt b/3478_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..47a5fac8a64dd552bc176f72093964b913537a50 --- /dev/null +++ b/3478_Gastroenterology.txt @@ -0,0 +1,27 @@ +PREOPERATIVE DIAGNOSIS: + + Bleeding after transanal excision five days ago. + +POSTOPERATIVE DIAGNOSIS: + + Bleeding after transanal excision five days ago. + +PROCEDURE: + + Exam under anesthesia with control of bleeding via cautery. + +ANESTHESIA: + + General endotracheal. + +INDICATION: + + The patient is a 42-year-old gentleman who is five days out from transanal excision of a benign anterior base lesion. He presents today with diarrhea and bleeding. Digital exam reveals bright red blood on the finger. He is for exam under anesthesia and control of hemorrhage at this time. + +FINDINGS: + + There was an ulcer where most of the polypoid lesion had been excised before. In a near total fashion the wound had opened and again there was a raw ulcer surface in between the edges of the mucosa. There were a few discrete sites of mild oozing, which were treated with cautery and #1 suture. No other obvious bleeding was seen. + +TECHNIQUE: + + The patient was taken to the operating room and placed on the operative table in supine position. After adequate general anesthesia was induced, the patient was then placed in modified prone position. His buttocks were taped, prepped and draped in a sterile fashion. The anterior rectal wall was exposed using a Parks anal retractor. The entire wound was visualized with a few rotations of the retractor and a few sites along the edges were seen to be oozing and were touched up with cautery. There was one spot in the corner that was oozing and this may have been from simply opening the retractor enough to see well. This was controlled with a 3-0 Monocryl figure-of-eight suture. At the completion, there was no bleeding, no oozing, it was completely dry, and we removed our retractor, and the patient was then turned and extubated and taken to the recovery room in stable condition. \ No newline at end of file diff --git a/3479_Gastroenterology.txt b/3479_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..d202ea4cebce15ae98936af608c0062a378583e9 --- /dev/null +++ b/3479_Gastroenterology.txt @@ -0,0 +1,33 @@ +PREOPERATIVE DIAGNOSIS: + + Protein-calorie malnutrition. + +POSTOPERATIVE DIAGNOSIS: + + Protein-calorie malnutrition. + +PROCEDURE PERFORMED: + + Percutaneous endoscopic gastrostomy (PEG) tube. + +ANESTHESIA: + + Conscious sedation per Anesthesia. + +SPECIMEN: + + None. + +COMPLICATIONS: + + None. + +HISTORY: + +The patient is a 73-year-old male who was admitted to the hospital with some mentation changes. He was unable to sustain enough caloric intake and had markedly decreased albumin stores. After discussion with the patient and the son, they agreed to place a PEG tube for nutritional supplementation. + +PROCEDURE: + + After informed consent was obtained, the patient was brought to the endoscopy suite. He was placed in the supine position and was given IV sedation by the Anesthesia Department. An EGD was performed from above by Dr. X. The stomach was transilluminated and an optimal position for the PEG tube was identified using the single poke method. The skin was infiltrated with local and the needle and sheath were inserted through the abdomen into the stomach under direct visualization. The needle was removed and a guidewire was inserted through the sheath. The guidewire was grasped from above with a snare by the endoscopist. It was removed completely and the Ponsky PEG tube was secured to the guidewire. + +The guidewire and PEG tube were then pulled through the mouth and esophagus and snug to the abdominal wall. There was no evidence of bleeding. Photos were taken. The Bolster was placed on the PEG site. A complete dictation for the EGD will be done separately by Dr. X. The patient tolerated the procedure well and was transferred to recovery room in stable condition. He will be started on tube feedings in 6 hours with aspiration precautions and dietary to determine his nutritional goal. \ No newline at end of file diff --git a/3480_Gastroenterology.txt b/3480_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..13b681071741ab5f82bc2fe0675cca985af1871c --- /dev/null +++ b/3480_Gastroenterology.txt @@ -0,0 +1,17 @@ +PREOPERATIVE DIAGNOSIS: + + Abdominal mass. + +POSTOPERATIVE DIAGNOSIS: + + Abdominal mass. + +PROCEDURE: + + Paracentesis. + +DESCRIPTION OF PROCEDURE: + +This 64-year-old female has stage II endometrial carcinoma, which had been resected before and treated with chemotherapy and radiation. At the present time, the patient is under radiation treatment. Two weeks ago or so, she developed a large abdominal mass, which was cystic in nature and the radiologist inserted a pigtail catheter in the emergency room. We proceeded to admit the patient and drained a significant amount of clear fluid in the subsequent days. The cytology of the fluid was negative and the culture was also negative. Eventually, the patient was sent home with the pigtail shut off and the patient a week later underwent a repeat CAT scan of the abdomen and pelvis. + +The CAT scan showed accumulation of the fluid and the mass almost achieving 80% of the previous size. Therefore, I called the patient home and she came to the emergency department where the service was provided. At that time, I proceeded to work on the pigtail catheter after obtaining an informed consent and preparing and draping the area in the usual fashion. Unfortunately, the catheter was open. I did not have a drainage system at that time. So, I withdrew directly with a syringe 700 mL of clear fluid. The system was connected to the draining bag, and the patient was instructed to keep a log and how to use equipment. She was given an appointment to see me in the office next Monday, which is three days from now. \ No newline at end of file diff --git a/3482_Gastroenterology.txt b/3482_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..a21aa9096d18157d7e2be02189c454c2e6a0507a --- /dev/null +++ b/3482_Gastroenterology.txt @@ -0,0 +1,25 @@ +PROCEDURE PERFORMED: + + Nissen fundoplication. + +DESCRIPTION OF PROCEDURE: + + After informed consent was obtained detailing the risks of infection, bleeding, esophageal perforation and death, the patient was brought to the operative suite and placed supine on the operating room table. General endotracheal anesthesia was induced without incident. The patient was then placed in a modified lithotomy position taking great care to pad all extremities. TEDs and Venodynes were placed as prophylaxis against deep venous thrombosis. Antibiotics were given for prophylaxis against surgical infection. + +A 52-French bougie was placed in the proximal esophagus by Anesthesia, above the cardioesophageal junction. A 2 cm midline incision was made at the junction of the upper two-thirds and lower one-third between the umbilicus and the xiphoid process. The fascia was then cleared of subcutaneous tissue using a tonsil clamp. A 1-2 cm incision was then made in the fascia gaining entry into the abdominal cavity without incident. Two sutures of 0 Vicryl were then placed superiorly and inferiorly in the fascia, and then tied to the special 12 mm Hasson trocar fitted with a funnel-shaped adaptor in order to occlude the fascial opening. Pneumoperitoneum was then established using carbon dioxide insufflation to a steady state of pressure of 16 mmHg. A 30-degree laparoscope was inserted through this port and used to guide the remaining trocars. + +The remaining trocars were then placed into the abdomen taking care to make the incisions along Langer's line, spreading the subcutaneous tissue with a tonsil clamp, and confirming the entry site by depressing the abdominal wall prior to insertion of the trocar. A total of 4 other 10/11 mm trocars were placed. Under direct vision 1 was inserted in the right upper quadrant at the midclavicular line, at a right supraumbilical position; another at the left upper quadrant at the midclavicular line, at a left supraumbilical position; 1 under the right costal margin in the anterior axillary line; and another laterally under the left costal margin on the anterior axillary line. All of the trocars were placed without difficulty. The patient was then placed in reverse Trendelenburg position. + +The triangular ligament was taken down sharply, and the left lobe of the liver was retracted superolaterally using a fan retractor placed through the right lateral cannula. The gastrohepatic ligament was then identified and incised in an avascular plane. The dissection was carried anteromedially onto the phrenoesophageal membrane. The phrenoesophageal membrane was divided on the anterior aspect of the hiatal orifice. This incision was extended to the right to allow identification of the right crus. Then along the inner side of the crus, the right esophageal wall was freed by dissecting the cleavage plane. + +The liberation of the posterior aspect of the esophagus was started by extending the dissection the length of the right diaphragmatic crus. The pars flaccida of the lesser omentum was opened, preserving the hepatic branches of the vagus nerve. This allowed free access to the crura, left and right, and the right posterior aspect of the esophagus, and the posterior vagus nerve. + +Attention was next turned to the left anterolateral aspect of the esophagus. At its left border, the left crus was identified. The dissection plane between it and the left aspect of the esophagus was freed. The gastrophrenic ligament was incised, beginning the mobilization of the gastric pouch. By dissecting the intramediastinal portion of the esophagus, we elongated the intra-abdominal segment of the esophagus and reduced the hiatal hernia. + +The next step consisted of mobilization of the gastric pouch. This required ligation and division of the gastrosplenic ligament and several short gastric vessels using the harmonic scalpel. This dissection started on the stomach at the point where the vessels of the greater curvature turned towards the spleen, away from the gastroepiploic arcade. The esophagus was lifted by a Babcock inserted through the left upper quadrant port. Careful dissection of the mesoesophagus and the left crus revealed a cleavage plane between the crus and the posterior gastric wall. Confirmation of having opened the correct plane was obtained by visualizing the spleen behind the esophagus. A one-half inch Penrose drain was inserted around the esophagus and sewn to itself in order to facilitate retraction of the distal esophagus. The retroesophageal channel was enlarged to allow easy passage of the antireflux valve. + +The 52-French bougie was then carefully lowered into the proximal stomach, and the hiatal orifice was repaired. Two interrupted 0 silk sutures were placed in the diaphragmatic crura to close the orifice. + +The last part of the operation consisted of the passage and fixation of the antireflux valve. With anterior retraction on the esophagus using the Penrose drain, a Babcock was passed behind the esophagus, from right to left. It was used to grab the gastric pouch to the left of the esophagus and to pull it behind, forming the wrap. The,52-French bougie was used to calibrate the external ring. Marcaine 0.5% was injected 1 fingerbreadth anterior to the anterior superior iliac spine and around the wound for postanesthetic pain control. The skin incision was approximated with skin staples. A dressing was then applied. All surgical counts were reported as correct. + +Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition. \ No newline at end of file diff --git a/3486_Gastroenterology.txt b/3486_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..ec14a6516280cdfa773ad633ac6c9ade3ded83ca --- /dev/null +++ b/3486_Gastroenterology.txt @@ -0,0 +1,91 @@ +ADMISSION DIAGNOSES: + +1. Seizure. + +2. Hypoglycemia. + +3. Anemia. + +4. Hypotension. + +5. Dyspnea. + +6. Edema. + +DISCHARGE DIAGNOSES: + +1. Colon cancer, status post right hemicolectomy. + +2. Anemia. + +3. Hospital-acquired pneumonia. + +4. Hypertension. + +5. Congestive heart failure. + +6. Seizure disorder. + +PROCEDURES PERFORMED: + +1. Colonoscopy. + +2. Right hemicolectomy. + +HOSPITAL COURSE: + + The patient is a 59-year-old female with multiple medical problems including diabetes mellitus requiring insulin for 26 years, previous MI and coronary artery disease, history of seizure disorder, GERD + + bipolar disorder, and anemia. She was admitted due to a seizure and myoclonic jerks as well as hypoglycemia and anemia. Regarding the seizure disorder, Neurology was consulted. Noncontrast CT of the head was negative. Neurology felt that the only necessary intervention at that time would be to increase her Lamictal to 150 mg in the morning and 100 mg in the evening with gradual increase of the dosage until she was on 200 mg b.i.d. Regarding the hypoglycemia, the patient has diabetic gastroparesis and was being fed on J-tube intermittent feedings throughout the night at the rate of 120 an hour. Her insulin pump had a basal rate of roughly three at night during the feedings. While in the hospital, the insulin pump rate was turned down to 1.5 and then subsequently decreased a few other times. She seemed to tolerate the insulin pump rate well throughout her hospital course. There were a few episodes of hypoglycemia as well as hyperglycemia, but the episode seem to be related to the patient's n.p.o. status and the changing rates of tube feedings throughout her hospital course. + +At discharge, her endocrinologist was contacted. It was decided to change her insulin pump rate to 3 units per hour from midnight till 6 a.m. + + from 0.8 units per hour from 6 a.m. until 8 a.m. + + and then at 0.2 units per hour from 8 a.m. until 6 p.m. The insulin was to be NovoLog. Regarding the anemia, the gastroenterologists were consulted regarding her positive Hemoccult stools. A colonoscopy was performed, which found a mass at the right hepatic flexure. General Surgery was then consulted and a right hemicolectomy was performed on the patient. The patient tolerated the procedure well and tube feeds were slowly restarted following the procedure, and prior to discharge were back at her predischarge rates of 120 per hour. Regarding the cancer itself, it was found that 1 out of 53 nodes were positive for cancer. CT of the abdomen and pelvis revealed no metastasis, a CT of the chest revealed possible lung metastasis. Later in hospital course, the patient developed a septic-like picture likely secondary to hospital-acquired pneumonia. She was treated with Zosyn, Levaquin, and vancomycin, and tolerated the medications well. Her symptoms decreased and serial chest x-rays were followed, which showed some resolution of the illness. The patient was seen by the Infectious Disease specialist. The Infectious Disease specialist recommended vancomycin to cover MRSA bacteria, which was found at the J-tube site. At discharge, the patient was given three additional days of p.o. Levaquin 750 mg as well as three additional days of Bactrim DS every 12 hours. The Bactrim was used to cover the MRSA at the J-tube site. It was found that MRSA was sensitive to Bactrim. Throughout her hospital course, the patient continued to receive Coreg 12.5 mg daily and Lasix 40 mg twice a day for her congestive heart failure, which remains stable. She also received Lipitor for her high cholesterol. Her seizure disorder remained stable and she was discharged on a dose of 100 mg in the morning and 150 mg at night. The dosage increases can begin on an outpatient basis. + +DISCHARGE INSTRUCTIONS/MEDICATIONS: + + The patient was discharged to home. She was told to shy away from strenuous activity. Her discharge diet was to be her usual diet of isotonic fiber feeding through the J-tube at a rate of 120 per hour throughout the night. The discharge medications were as follows: + +1. Coreg 12.5 mg p.o. b.i.d. + +2. Lipitor 10 mg p.o. at bedtime. + +3. Nitro-Dur patch 0.3 mg per hour one patch daily. + +4. Phenergan syrup 6.25 mg p.o. q.4h. p.r.n. + +5. Synthroid 0.175 mg p.o. daily. + +6. Zyrtec 10 mg p.o. daily. + +7. Lamictal 100 mg p.o. daily. + +8. Lamictal 150 mg p.o. at bedtime. + +9. Ferrous sulfate drops 325 mg, PEG tube b.i.d. + +10. Nexium 40 mg p.o. at breakfast. + +11. Neurontin 400 mg p.o. t.i.d. + +12. Lasix 40 mg p.o. b.i.d. + +13. Fentanyl 50 mcg patch transdermal q.72h. + +14. Calcium and vitamin D combination, calcium carbonate 500 mg/vitamin D 200 units one tab p.o. t.i.d. + +15. Bactrim DS 800mg/160 mg tablet one tablet q.12h. x3 days. + +16. Levaquin 750 mg one tablet p.o. x3 days. + +The medications listed above, one listed as p.o. are to be administered via the J-tube. + +FOLLOWUP: + +The patient was instructed to see Dr. X in approximately five to seven days. She was given a lab sheet to have a CBC with diff as well as a CMP to be drawn prior to her appointment with Dr. X. She is instructed to follow up with Dr. Y if her condition changes regarding her colon cancer. She was instructed to follow up with Dr. Z, her oncologist, regarding the positive lymph nodes. We were unable to contact Dr. Z, but his telephone number was given to the patient and she was instructed to make a followup appointment. She was also instructed to follow up with her endocrinologist, Dr. A, regarding any insulin pump adjustments, which were necessary and she was also instructed to follow up with Dr. B, her gastroenterologist, regarding any issues with her J-tube. + +CONDITION ON DISCHARGE: + + Stable. \ No newline at end of file diff --git a/3488_Gastroenterology.txt b/3488_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..bb87b266b3ec827fa2ffa9b26d65be18ed675241 --- /dev/null +++ b/3488_Gastroenterology.txt @@ -0,0 +1,77 @@ +REASON: + + Right lower quadrant pain. + +HISTORY OF PRESENT ILLNESS: + +The patient is a pleasant 48-year-old female with an approximately 24-hour history of right lower quadrant pain, which she describes as being stabbed with a knife, radiating around her side to her right flank. She states that is particularly bad when up and walking around, goes away when she is lying down. She has no nausea or vomiting, no dysuria, no fever or chills, though she said she did feel warm. She states that she feels a bit like she did when she had her gallbladder removed nine years ago. Additionally, I should note that the patient is currently premenopausal with irregular menses, going anywhere from one to two months between cycles. She has no abnormal vaginal discharge, and she is sexually active. + +ALLERGIES: + + NO KNOWN DRUG ALLERGIES. + +MEDICATIONS + +1. Hydrochlorothiazide 25 mg p.o. daily. + +2. Lisinopril 10 mg p.o. daily. + +3. Albuterol p.r.n. + +PAST MEDICAL HISTORY: + +Hypertension and seasonal asthma. + +PAST SURGICAL HISTORY: + + Left bilateral breast biopsy for benign disease. Cholecystitis/cholecystectomy following tubal pregnancy 22 years ago. + +FAMILY HISTORY: + + Mother is alive and well. Father with coronary artery disease. She has siblings who have increased cholesterol. + +SOCIAL HISTORY: + +The patient does not smoke. She quit 25 years ago. She drinks one beer a day. She works as a medical transcriptionist. + +REVIEW OF SYSTEMS: + + Positive for an umbilical hernia, but otherwise negative with the exception of what is noted above. + +PHYSICAL EXAMINATION + +GENERAL: Reveals a morbidly obese female who is alert and oriented x3, pleasant and well groomed, and in mild discomfort. + +VITAL SIGNS: Her temperature is 38.7, pulse 113, respirations 18, and blood pressure 144/85. + +HEENT: Normocephalic and atraumatic. Sclerae are without icterus. Conjunctivae are not injected. + +NECK: Neck is supple. Carotids 2+. Trachea is midline. Carotids are without bruits. + +LYMPH NODES: There is no cervical, supraclavicular, or occipital adenopathy. + +LUNGS: Clear to auscultation. + +CARDIAC: Regular rate and rhythm. + +ABDOMEN: Soft. No hepatosplenomegaly. She has a positive Rovsing sign and a positive obturator sign. She is tender in the right lower quadrant with mild rebound and no guarding. + +EXTREMITIES: Reveal 2+ femoral, popliteal, dorsalis pedis, and posterior tibial pulses. She has only trace edema with varicosities around the bilateral ankles. + +CNS: Without gross neurologic deficits. + +INTEGUMENTARY: Skin integrity is excellent. + +DIAGNOSTICS: + + Urine, specific gravity is 1.010, blood is 50, leukocytes 1+ + + white blood cells 10 to 25, rbc's 2 to 5, and 2 to 5 squamous epithelial cells. White blood cell count is 20,000 with 75 polys and 16 lymphs. H&H is 13.7 and 39.7. Total bilirubin 1.3, direct bilirubin 0.2, and alk phos 98. Sodium 138, potassium 3.1, chloride 101, CO2 26, calcium 9.5, glucose 103, BUN 16, and creatinine 0.91. Lipase is 19. CAT scan is negative for acute appendicitis. In fact, it mentions that the appendix is not discretely identified. There are no focal inflammatory masses, abscess, ascites, or pneumoperitoneum. + +IMPRESSION: + + Abdominal pain right lower quadrant, etiology is unclear. + +PLAN: + + Plan is to admit the patient. Recheck the white blood cell count in the morning. Re-examine her and further plan is pending, the results of that evaluation. \ No newline at end of file diff --git a/3489_Gastroenterology.txt b/3489_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..0f55b689f267c09817078541c732c29bd0a4a220 --- /dev/null +++ b/3489_Gastroenterology.txt @@ -0,0 +1,43 @@ +PREOPERATIVE DIAGNOSIS: + + Right lower quadrant abdominal pain, rule out acute appendicitis. + +POSTOPERATIVE DIAGNOSIS: + + Acute suppurative appendicitis. + +PROCEDURE PERFORMED: + +1. Diagnostic laparoscopy. + +2. Laparoscopic appendectomy. + +ANESTHESIA: + + General endotracheal and injectable 1% lidocaine and 0.25% Marcaine. + +ESTIMATED BLOOD LOSS: + + Minimal. + +SPECIMEN: + + Appendix. + +COMPLICATIONS: + + None. + +BRIEF HISTORY: + + This is a 37-year-old Caucasian female presented to ABCD General Hospital with progressively worsening suprapubic and right lower quadrant abdominal pain, which progressed throughout its course starting approximately 12 hours prior to presentation. She admits to some nausea associated with it. There have been no fevers, chills, and/or genitourinary symptoms. The patient had right lower quadrant tenderness with rebound and percussion tenderness in the right lower quadrant. She had a leukocytosis of 12.8. She did undergo a CT of the abdomen and pelvis, which was non diagnostic for an acute appendicitis. Given the severity of her abdominal examination and her persistence of her symptoms, we recommend the patient undergo diagnostic laparoscopy with probable need for laparoscopic appendectomy and possible open appendectomy. The risks, benefits, complications of the procedure, she gave us informed consent to proceed. + +OPERATIVE FINDINGS: + +Exploration of the abdomen via laparoscopy revealed an appendix with suppurative fluid surrounding it, it was slightly enlarged. The left ovary revealed some follicular cysts. There was no evidence of adnexal masses and/or torsion of the fallopian tubes. The uterus revealed no evidence of mass and/or fibroid tumors. The remainder of the abdomen was unremarkable. + +OPERATIVE PROCEDURE: + + The patient was brought to the operative suite, placed in the supine position. The abdomen was prepped and draped in the normal sterile fashion with Betadine solution. The patient underwent general endotracheal anesthesia. The patient also received a preoperative dose of Ancef 1 gram IV. After adequate sedation was achieved, a #10 blade scalpel was used to make an infraumbilical transverse incision utilizing a Veress needle. Veress needle was inserted into the abdomen and the abdomen was insufflated approximately 15 mmHg. Once the abdomen was sufficiently insufflated, a 10 mm bladed trocar was inserted into the abdomen without difficulty. A video laparoscope was inserted into the infraumbilical trocar site and the abdomen was explored. Next, a 5 mm port was inserted in the midclavicular line of the right upper quadrant region. This was inserted under direct visualization. Finally, a suprapubic 12 mm portal was created. This was performed with #10 blade scalpel to create a transverse incision. A bladed trocar was inserted into the suprapubic region. This was done again under direct visualization. Maryland dissector was inserted into the suprapubic region and a window was created between the appendix and mesoappendix at the base of the cecum. This was done while the 5 mm trocar was used to grasp the middle portion of the appendix and retracted anteriorly. Utilizing a endovascular stapling device, the appendix was transected and doubly stapled with this device. Next, the mesoappendix was doubly stapled and transected with the endovascular stapling device. The staple line was visualized and there was no evidence of bleeding. The abdomen was fully irrigated with copious amounts of normal saline. The abdomen was then aspirated. There was no evidence of bleeding. All ports were removed under direct visualization. No evidence of bleeding from the port sites. The infraumbilical and suprapubic ports were then closed. The fascias were then closed with #0-Vicryl suture on a UR6 needle. Once the fascias were closed, all incisions were closed with #4-0 undyed Vicryl. The areas were cleaned, Steri-Strips were placed across the wound. Sterile dressing was applied. + +The patient tolerated the procedure well. She was extubated following the procedure, returned to Postanesthesia Care Unit in stable condition. She will be admitted to General Medical Floor and she will be followed closely in the early postoperative course. \ No newline at end of file diff --git a/3494_Gastroenterology.txt b/3494_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..f8804fb5465dcbe2db9201b1c8579703cbf9316f --- /dev/null +++ b/3494_Gastroenterology.txt @@ -0,0 +1,31 @@ +PREOPERATIVE DIAGNOSIS: + + Acute cholecystitis. + +POSTOPERATIVE DIAGNOSIS: + + Acute gangrenous cholecystitis with cholelithiasis. + +OPERATION PERFORMED: + + Laparoscopic cholecystectomy with cholangiogram. + +FINDINGS: + +The patient had essentially a dead gallbladder with stones and positive wide bile/pus coming from the gallbladder. + +COMPLICATIONS: + +None. + +EBL: + + Scant. + +SPECIMEN REMOVED: + + Gallbladder with stones. + +DESCRIPTION OF PROCEDURE: + +The patient was prepped and draped in the usual sterile fashion under general anesthesia. A curvilinear incision was made below the umbilicus. Through this incision, the camera port was able to be placed into the peritoneal cavity under direct visualization. Once this complete, insufflation was begun. Once insufflation was adequate, additional ports were placed in the epigastrium as well as right upper quadrant. Once all four ports were placed, the right upper quadrant was then explored. The patient had significant adhesions of omentum and colon to the liver, the gallbladder constituting definitely an acute cholecystitis. This was taken down using Bovie cautery to free up visualization of the gallbladder. The gallbladder was very thick and edematous and had frank necrosis of most of the anterior gallbladder wall. Adhesions were further taken down between the omentum, the colon, and the gallbladder slowly starting superiorly and working inferiorly towards the cystic duct area. Once the adhesions were fully removed, the cholangiogram was done which did not show any evidence of any common bile duct dilatation or obstruction. At this point, due to the patient's gallbladder being very necrotic, it was deemed that the patient should have a drain placed. The cystic duct and cystic artery were serially clipped and transected. The gallbladder was removed from the gallbladder fossa removing the entire gallbladder. Adequate hemostasis with Bovie cautery was achieved. The gallbladder was then placed into a bag and removed from the peritoneal cavity through the camera port. A JP drain was then run through the anterior port and out of one of the trochar sites and secured to the skin using 3-0 nylon suture. Next, the right upper quadrant was copiously irrigated out using the suction irrigator. Once this was complete, the additional ports were able to be removed. The fascial opening at the umbilicus was reinforced by closing it using a 0 Vicryl suture in a figure-of-8 fashion. All skin incisions were injected using Marcaine 1/4 percent plain. The skin was reapproximated further using 4-0 Monocryl sutures in a subcuticular technique. The patient tolerated the procedure well and was able to be transferred to the recovery room in stable condition. \ No newline at end of file diff --git a/3496_Gastroenterology.txt b/3496_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..aa3b78a8cf7972feace6e2695240043f6be8f008 --- /dev/null +++ b/3496_Gastroenterology.txt @@ -0,0 +1,23 @@ +PREOPERATIVE DIAGNOSIS: + + Morbid obesity. + +POSTOPERATIVE DIAGNOSIS: + +Morbid obesity. + +PROCEDURE: + + Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis. + +ANESTHESIA: + + General with endotracheal intubation. + +INDICATION FOR PROCEDURE: + + This is a 30-year-old female, who has been overweight for many years. She has tried many different diets, but is unsuccessful. She has been to our Bariatric Surgery Seminar, received some handouts, and signed the consent. The risks and benefits of the procedure have been explained to the patient. + +PROCEDURE IN DETAIL: + +The patient was taken to the operating room and placed supine on the operating room table. All pressure points were carefully padded. She was given general anesthesia with endotracheal intubation. SCD stockings were placed on both legs. Foley catheter was placed for bladder decompression. The abdomen was then prepped and draped in standard sterile surgical fashion. Marcaine was then injected through umbilicus. A small incision was made. A Veress needle was introduced into the abdomen. CO2 insufflation was done to a maximum pressure of 15 mmHg. A 12-mm VersaStep port was placed through the umbilicus. I then placed a 5-mm port just anterior to the midaxillary line and just subcostal on the right side. I placed another 5-mm port in the midclavicular line just subcostal on the right side, a few centimeters below and medial to that, I placed a 12-mm VersaStep port. On the left side, just anterior to the midaxillary line and just subcostal, I placed a 5-mm port. A few centimeters below and medial to that, I placed a 15-mm port. I began by lifting up the omentum and identifying the transverse colon and lifting that up and thereby identifying my ligament of Treitz. I ran the small bowel down approximately 40 cm and divided the small bowel with a white load GIA stapler. I then divided the mesentery all the way down to the base of the mesentery with a LigaSure device. I then ran the distal bowel down, approximately 100 cm, and at 100 cm, I made a hole at the antimesenteric portion of the Roux limb and a hole in the antimesenteric portion of the duodenogastric limb, and I passed a 45 white load stapler and fired a stapler creating a side-to-side anastomosis. I reapproximated the edges of the defect. I lifted it up and stapled across it with another white load stapler. I then closed the mesenteric defect with interrupted Surgidac sutures. I divided the omentum all the way down to the colon in order to create a passageway for my small bowel to go antecolic. I then put the patient in reverse Trendelenburg. I placed a liver retractor, identified, and dissected the angle of His. I then dissected on the lesser curve, approximately 2.5 cm below the gastroesophageal junction, and got into a lesser space. I fired transversely across the stomach with a 45 blue load stapler. I then used two fires of the 60 blue load with SeamGuard to go up into my angle of His, thereby creating my gastric pouch. I then made a hole at the base of the gastric pouch and had Anesthesia remove the bougie and place the OG tube connected to the anvil. I pulled the anvil into place, and I then opened up my 15-mm port site and passed my EEA stapler. I passed that in the end of my Roux limb and had the spike come out antimesenteric. I joined the spike with the anvil and fired a stapler creating an end-to-side anastomosis, then divided across the redundant portion of my Roux limb with a white load GI stapler, and removed it with an Endocatch bag. I put some additional 2-0 Vicryl sutures in the anastomosis for further security. I then placed a bowel clamp across the bowel. I went above and passed an EGD scope into the mouth down to the esophagus and into the gastric pouch. I distended gastric pouch with air. There was no air leak seen. I could pass the scope easily through the anastomosis. There was no bleeding seen through the scope. We closed the 15-mm port site with interrupted 0 Vicryl suture utilizing Carter-Thomason. I copiously irrigated out that incision with about 2 L of saline. I then closed the skin of all incisions with running Monocryl. Sponge, instrument, and needle counts were correct at the end of the case. The patient tolerated the procedure well without any complications. \ No newline at end of file diff --git a/3497_Gastroenterology.txt b/3497_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..1d6757f64987f65e7bbee8bec7daad09d800e1f7 --- /dev/null +++ b/3497_Gastroenterology.txt @@ -0,0 +1,21 @@ +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. \ No newline at end of file diff --git a/3507_Gastroenterology.txt b/3507_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..ebfab6118a23e1d61ffa8eacc646ee999ffb2d56 --- /dev/null +++ b/3507_Gastroenterology.txt @@ -0,0 +1,19 @@ +PREOPERATIVE DIAGNOSIS: + + Appendicitis. + +POSTOPERATIVE DIAGNOSIS: + + Appendicitis. + +PROCEDURE: + + Laparoscopic appendectomy. + +ANESTHESIA: + + General with endotracheal intubation. + +PROCEDURE IN DETAIL: + +The patient was taken to the operating room and placed supine on the operating room table. General anesthesia was administered with endotracheal intubation. His abdomen was prepped and draped in a standard, sterile surgical fashion. A Foley catheter was placed for bladder decompression. Marcaine was injected into his umbilicus. A small incision was made. A Veress needle was introduced in his abdomen. CO2 insufflation was done to a maximum pressure of 15 mmHg and a 12-mm VersaStep port was placed through his umbilicus. A 5-mm port was then placed just to the right side of the umbilicus. Another 5-mm port was placed just suprapubic in the midline. Upon inspection of the cecum, I was able find an inflamed and indurated appendix. I was able to clear the mesentery at the base of the appendix between the appendix and the cecum. I fired a white load stapler across the appendix at its base and fired a grey load stapler across the mesentery, and thereby divided the mesentery and freed the appendix. I put the appendix in an Endocatch bag and removed it through the umbilicus. I irrigated out the abdomen. I then closed the fascia of the umbilicus with interrupted 0 Vicryl suture utilizing Carter-Thomason and closed the skin of all incisions with a running Monocryl. Sponge, instrument, and needle counts were correct at the end of the case. The patient tolerated the procedure well without any complications. \ No newline at end of file diff --git a/3508_Gastroenterology.txt b/3508_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..efd0af763dcdfea215edb6f29767a94b64e8048b --- /dev/null +++ b/3508_Gastroenterology.txt @@ -0,0 +1,29 @@ +PREOPERATIVE DIAGNOSIS: + +1. Cholelithiasis. + +2. Chronic cholecystitis. + +POSTOPERATIVE DIAGNOSIS: + +1. Cholelithiasis. + +2. Chronic cholecystitis. + +NAME OF OPERATION: + + Laparoscopic cholecystectomy. + +ANESTHESIA: + + General. + +FINDINGS: + + The gallbladder was thickened and showed evidence of chronic cholecystitis. There was a great deal of inflammatory reaction around the cystic duct. The cystic duct was slightly larger. There was a stone impacted in the cystic duct with the gallbladder. The gallbladder contained numerous stones which were small. With the stone impacted in the cystic duct, it was felt that probably none were within the common duct. Other than rather marked obesity, no other significant findings were noted on limited exploration of the abdomen. + +PROCEDURE: + + Under general anesthesia after routine prepping and draping, the abdomen was insufflated with the Veress needle, and the standard four trocars were inserted uneventfully. Inspection was made for any entry problems, and none were encountered. + +After limited exploration, the gallbladder was then retracted superiorly and laterally, and the cystic duct was dissected out. This was done with some difficulty due to the fibrosis around the cystic duct, but care was taken to avoid injury to the duct and to the common duct. In this manner, the cystic duct and cystic artery were dissected out. Care was taken to be sure that the duct that was identified went into the gallbladder and was the cystic duct. The cystic duct and cystic artery were then doubly clipped and divided, taking care to avoid injury to the common duct. The gallbladder was then dissected free from the gallbladder bed. Again, the gallbladder was somewhat adherent to the gallbladder bed due to previous inflammatory reaction. The gallbladder was dissected free from the gallbladder bed utilizing the endo shears and the cautery to control bleeding. The gallbladder was extracted through the operating trocar site, and the trocar was reinserted. Inspection was made of the gallbladder bed. One or two bleeding areas were fulgurated, and bleeding was well controlled. \ No newline at end of file diff --git a/3510_Gastroenterology.txt b/3510_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..136b3100df00e25ab40eb06677e579b3be534327 --- /dev/null +++ b/3510_Gastroenterology.txt @@ -0,0 +1,31 @@ +PREOPERATIVE DIAGNOSIS: + + Acute appendicitis with perforation. + +POSTOPERATIVE DIAGNOSIS: + +Acute appendicitis with perforation. + +ANESTHESIA: + + General. + +PROCEDURE: + + Laparoscopic appendectomy. + +INDICATIONS FOR PROCEDURE: + + The patient is a 4-year-old little boy, who has been sick for several days and was seen in our Emergency Department yesterday where a diagnosis of possible constipation was made, but he was sent home with a prescription for polyethylene glycol but became more acutely ill and returned today with tachycardia, high fever and signs of peritonitis. A CT scan of his abdomen showed evidence of appendicitis with perforation. He was evaluated in the Emergency Department and placed on the appendicitis critical pathway for this acute appendicitis process. He required several boluses of fluid for tachycardia and evidence of dehydration. + +I met with Carlos' parents and talked to them about the diagnosis of appendicis and surgical risks, benefits, and alternative treatment options. All their questions have been answered and they agree with the surgical plan. + +OPERATIVE FINDINGS: + + The patient had acute perforated appendicitis with diffuse suppurative peritonitis including multiple intraloop abscesses and purulent debris in all quadrants of the abdomen including the perihepatic and subphrenic recesses as well. + +DESCRIPTION OF PROCEDURE: + + The patient came to the operating room and had an uneventful induction of general anesthesia. A Foley catheter was placed for decompression, and his abdomen was prepared and draped in a standard fashion. A 0.25% Marcaine was infiltrated in the soft tissues around his umbilicus and in the suprapubic and left lower quadrant locations chosen for trocar insertion. We conducted our surgical timeout and reiterated all of Carlos' unique and important identifying information and confirmed the diagnosis of appendicitis and planned laparoscopic appendectomy as the procedure. A 1-cm vertical infraumbilical incision was made and an open technique was used to place a 12-mm Step trocar through the umbilical fascia. CO2 was insufflated to a pressure of 15 mmHg and then two additional 5-mm working ports were placed in areas that had been previously anesthetized. + +There was a lot of diffuse purulent debris and adhesions between the omentum and adjacent surfaces of the bowel and the parietal peritoneum. After these were gently separated, we began to identify the appendix. In the __________ due to the large amount of small bowel dilatation and distension, I used the hook cautery with the lowest intraperitoneal __________ profile to coagulate the mesoappendix. The base of the appendix was then ligated with 2-0 PDS Endoloops, and the appendix was amputated and withdrawn through the umbilical port. I spent the next 10 minutes irrigating purulent fluid and debris from the peritoneal cavity using 2 L of sterile crystalloid solution and a suction power irrigation system. When this was complete, the CO2 was released one final time and as much of the fluid was drained from the peritoneal cavity as possible. The umbilical fascia was closed with figure-of-eight suture of 0 Monocryl and the skin incisions were closed with subcuticular 5-0 Monocryl and Steri-Strips. The patient tolerated the operation well. He was awakened and taken to the recovery room in satisfactory condition. His blood loss was less than 10 mL, and he received only crystalloid fluid during the procedure. \ No newline at end of file diff --git a/3511_Gastroenterology.txt b/3511_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..344c3ba0686529dc78874000f907e9302c38a88e --- /dev/null +++ b/3511_Gastroenterology.txt @@ -0,0 +1,15 @@ +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. \ No newline at end of file diff --git a/3512_Gastroenterology.txt b/3512_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..734c866ead2259dbf72b44a708ae88d6a0d84802 --- /dev/null +++ b/3512_Gastroenterology.txt @@ -0,0 +1,23 @@ +PREOPERATIVE DIAGNOSIS: + + Appendicitis. + +POSTOPERATIVE DIAGNOSIS: + + Appendicitis. + +PROCEDURE PERFORMED: + + Laparoscopic appendectomy. + +ANESTHESIA: + + General endotracheal. + +INDICATION FOR OPERATION: + + The patient is a 42-year-old female who presented with right lower quadrant pain. She was evaluated and found to have a CT evidence of appendicitis. She was subsequently consented for a laparoscopic appendectomy. + +DESCRIPTION OF PROCEDURE: + + After informed consent was obtained, the patient was brought to the operating room, placed supine on the table. The abdomen was prepared and draped in usual sterile fashion. After the induction of satisfactory general endotracheal anesthesia, supraumbilical incision was made. A Veress needle was inserted. Abdomen was insufflated to 15 mmHg. A 5-mm port and camera placed. The abdomen was visually explored. There were no obvious abnormalities. A 15-mm port was placed in the suprapubic position in addition of 5 mm was placed in between the 1st two. Blunt dissection was used to isolate the appendix. Appendix was separated from surrounding structures. A window was created between the appendix and the mesoappendix. GIA stapler was tossed across it and fired. Mesoappendix was then taken with 2 fires of the vascular load on the GIA stapler. Appendix was placed in an Endobag and removed from the patient. Right lower quadrant was copiously irrigated. All irrigation fluids were removed. Hemostasis was verified. The 15-mm port was removed and the port site closed with 0-Vicryl in the Endoclose device. All other ports were irrigated, infiltrated with 0.25% Marcaine and closed with 4-0 Vicryl subcuticular sutures. Steri-Strips and sterile dressings were applied. Overall, the patient tolerated this well, was awakened and returned to recovery in good condition. \ No newline at end of file diff --git a/3513_Gastroenterology.txt b/3513_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..9872d002782512723ae8975e9be5698f8a45c69d --- /dev/null +++ b/3513_Gastroenterology.txt @@ -0,0 +1,25 @@ +PROCEDURE: + + Laparoscopic cholecystectomy. + +DISCHARGE DIAGNOSES: + +1. Acute cholecystitis. + +2. Status post laparoscopic cholecystectomy. + +3. End-stage renal disease on hemodialysis. + +4. Hyperlipidemia. + +5. Hypertension. + +6. Congestive heart failure. + +7. Skin lymphoma 5 years ago. + +8. Hypothyroidism. + +HOSPITAL COURSE: + + This is a 78-year-old female with past medical condition includes hypertension, end-stage renal disease, hyperlipidemia, hypothyroidism, and skin lymphoma who had a left AV fistula done about 3 days ago by Dr. X and the patient went later on home, but started having epigastric pain and right upper quadrant pain and mid abdominal pain, some nauseated feeling, and then she could not handle the pain, so came to the emergency room, brought by the family. The patient's initial assessment, the patient's vital signs were stable, showed temperature 97.9, pulse was 106, and blood pressure was 156/85. EKG was not available and ultrasound of the abdomen showed there is a renal cyst about 2 cm. There is sludge in the gallbladder wall versus a stone in the gallbladder wall. Thickening of the gallbladder wall with positive Murphy sign. She has a history of cholecystitis. Urine shows positive glucose, but negative for nitrite and creatinine was 7.1, sodium 131, potassium was 5.2, and lipase and amylase were normal. So, the patient admitted to the Med/Surg floor initially and the patient was started on IV fluid as well as low-dose IV antibiotic and 2-D echocardiogram and EKG also was ordered. The patient also had history of CHF in the past and recently had some workup done. The patient does not remember initially. Surgical consult also requested and blood culture and urine culture also ordered. The same day, the patient was seen by Dr. Y and the patient should need cholecystectomy, but the patient also needs dialysis and also needs to be cleared by the cardiologist, so the patient later on seen by Dr. Z and cleared the patient for the surgery with moderate risk and the patient underwent laparoscopic cholecystectomy. The patient also seen by nephrologist and underwent dialysis. The patient's white count went down 6.1, afebrile. On postop day #1, the patient started eating and also walking. The patient also had chronic bronchitis. The patient was later on feeling fine, discussed with surgery. The patient was then able to discharge to home and follow with the surgeon in about 3-5 days. Discharged home with Synthroid 0.5 mg 1 tablet p.o. daily, Plavix 75 mg p.o. daily, folic acid 1 mg p.o. daily, Diovan 80 mg p.o. daily, Renagel 2 tablets 800 mg p.o. twice a day, Lasix 40 mg p.o. 2 tablets twice a day, lovastatin 20 mg p.o. daily, Coreg 3.125 mg p.o. twice a day, nebulizer therapy every 3 hours as needed, also Phenergan 25 mg p.o. q.8 hours for nausea and vomiting, Pepcid 20 mg p.o. daily, Vicodin 1 tablet p.o. q.6 hours p.r.n. as needed, and Levaquin 250 mg p.o. every other day for the next 5 days. The patient also had Premarin that she was taking, advised to discontinue because of increased risk of heart disease and stroke explained to the patient. Discharged home. \ No newline at end of file diff --git a/3515_Gastroenterology.txt b/3515_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..bb029dcd26809e23a46af37af3ad25e5c45eae26 --- /dev/null +++ b/3515_Gastroenterology.txt @@ -0,0 +1,21 @@ +PREOPERATIVE DIAGNOSIS: Large juxtarenal abdominal aortic aneurysm. + +POSTOPERATIVE DIAGNOSIS: Large juxtarenal abdominal aortic aneurysm. + +ANESTHESIA: General endotracheal anesthesia. + +OPERATIVE TIME: Three hours. + +ANESTHESIA TIME: Four hours. + +DESCRIPTION OF PROCEDURE: After thorough preoperative evaluation, the patient was brought to the operating room and placed on the operating table in supine position and after placement of upper extremity IV access and radial A-line, general endotracheal anesthesia was induced. A Foley catheter was placed and a right internal jugular central line was placed. The chest, abdomen, both groin, and perineum were prepped widely with Betadine and draped as a sterile field with an Ioban drape. A long midline incision from xiphoid to pubis was created with a scalpel and the abdomen was carefully entered. A sterile Omni-Tract was introduced into the field to retract the abdominal wall and gentle exploration of the abdomen was performed. With the exception of the vascular findings to be described, there were no apparent intra-abdominal abnormalities. + +The transverse colon retracted superiorly. The small bowel was wrapped in moist green towel and retracted in the right upper quadrant. The posterior peritoneum overlying the aneurysm was scribed mobilizing the ligament of Treitz thoroughly ligating and dividing the inferior mesenteric vein. Dissection continued superiorly to identify the left renal vein and the right and left inferior renal arteries. The mid left renal artery was likewise identified. The perirenal aorta was prepared for clamp superior to the inferior left renal artery. During this portion of the dissection, the patient was given multiple small doses of intravenous mannitol to establish an osmotic diuresis. The distal dissection was then completed exposing each common iliac artery. The arteries were suitable for control. + +The patient was then given 8000 units of intravenous sodium heparin and systemic anticoagulation verified by activated clotting time. The aneurysm was repaired. + +First, the common carotid arteries were controlled with atraumatic clamps. The inferior left renal artery was controlled with a microvascular clamp and a straight aortic clamp was used to control the aorta superior to this renal artery. The aneurysm was opened on the right anterior lateral aspect and an endarterectomy of the aneurysm sac was performed. There was a high-grade stenosis at the origin of the inferior mesenteric artery and an eversion endarterectomy was performed at this site. The vessel was controlled with a microvascular clamp. Two pairs of lumbar arteries were oversewn with 2-0 silk. A 14 mm Hemashield tube graft was selected and sewn end-to-end fashion to the proximal aorta using a semi continuous 3-0 Prolene suture. At the completion of anastomosis three patch stitches of 3-0 Prolene were required for hemostasis. The graft was cut to appropriate length and sewn end-to-end at the iliac bifurcation using semi-continuous 3-0 Prolene suture. Prior to completion of this anastomosis, the graft was flushed of air and debris and blood flow was reestablished slowly to the distal native circulation first to the pelvis with external compression on the femoral vessels and finally to the distal native circulation. The distal anastomosis was competent without leak. + +The patient was then given 70 mg of intravenous protamine and final hemostasis obtained using electrocoagulation. The back bleeding from the inferior mesenteric artery was assessed and was pulsatile and vigorous. The colon was normal in appearance and this vessel was oversewn using 2-0 silk. The aneurysm sac was then closed about the grafts snuggly using 3-0 PDS in a vest-over-pants fashion. The posterior peritoneum was reapproximated using running 3-0 PDS. The entire large and small bowel were inspected and these structures were well perfused with a strong pulse within the SMA normal appearance of the entire viscera. The NG tube was positioned in the fundus of the stomach and the viscera returned to their anatomic location. The midline fascia was then reapproximated using running #1 PDS suture. The subcutaneous tissues were irrigated with bacitracin and kanamycin solution. The skin edges coapted using surgical staples. + +At the conclusion of the case, sponge and needle counts were correct and a sterile occlusive compressive dressing was applied. \ No newline at end of file diff --git a/3517_Gastroenterology.txt b/3517_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..833a91ac70ada381a023958e8d4c745233db37bf --- /dev/null +++ b/3517_Gastroenterology.txt @@ -0,0 +1,19 @@ +PREOPERATIVE DIAGNOSIS: + + Acute appendicitis. + +POSTOPERATIVE DIAGNOSIS: + + Acute appendicitis. + +OPERATIVE PROCEDURE: + + Laparoscopic appendectomy. + +INTRAOPERATIVE FINDINGS: + + Include inflamed, non-perforated appendix. + +OPERATIVE NOTE: + +The patient was seen by me in the preoperative holding area. The risks of the procedure were explained. She was taken to the operating room and given perioperative antibiotics prior to coming to the surgery. General anesthesia was carried out without difficulty and a Foley catheter was inserted. The left arm was tucked and the abdomen was prepped with Betadine and draped in sterile fashion. A 5-mm blunt port was inserted infra-umbilically at the level of the umbilicus under direct vision of a 5-mm 0-degree laparoscope. Once we were inside the abdominal cavity, CO2 was instilled to attain an adequate pneumoperitoneum. A left lower quadrant 5-mm port was placed under direct vision and a 12-mm port in the suprapubic region. The 5-mm scope was introduced at the umbilical port and the appendix was easily visualized. The base of the cecum was acutely inflamed but not perforated. I then was easily able to grasp the mesoappendix and create a window between the base of the mesoappendix and the base of the appendix. The window is big enough to get an Endo GIA blue cartridge through it and fired across the base of the mesoappendix without difficulty. I reloaded with a red vascular cartridge, came across the mesoappendix without difficulty. I then placed the appendix in an Endobag and brought out through the suprapubic port without difficulty. I reinserted the suprapubic port and irrigated out the right lower quadrant until dry. One final inspection revealed no bleeding from the staple line. We then removed all ports under direct vision, and there was no bleeding from the abdominal trocar sites. The pneumoperitoneum was then deflated and the suprapubic fascial defect was closed with 0-Vicryl suture. The skin incision was injected with 0.25% Marcaine and closed with 4-0 Monocryl suture. Steri-strips and sterile dressings were applied. No complications. Minimal blood loss. Specimen is the appendix. Brought to the recovery room in stable condition. \ No newline at end of file diff --git a/3518_Gastroenterology.txt b/3518_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..5e00f8e307a4b65159d9e1daccb8bad99755302e --- /dev/null +++ b/3518_Gastroenterology.txt @@ -0,0 +1,49 @@ +REASON FOR CONSULTATION: + + Pneumatosis coli in the cecum. + +HISTORY OF PRESENT ILLNESS: + +The patient is an 87-year-old gentleman who was admitted on 10/27/07 with weakness and tiredness with aspiration pneumonia. The patient is very difficult to obtain information from; however, he appears to be having frequent nausea and vomiting with an aspiration pneumonia and abdominal discomfort. In addition, this hospitalization, he has undergone an upper endoscopy, which found a small ulcer after dropping his hematocrit and becoming anemic. He had a CT scan on Friday, 11/02/07, which apparently showed pneumatosis and his cecum worrisome for ischemic colitis as well as bilateral hydronephrosis and multiple liver lesions, which could be metastatic disease versus cysts. In discussions with the patient, he had multiple bowel movements yesterday and is currently passing flatus and has epigastric pain. + +PAST MEDICAL HISTORY: + +Obtained from the medical chart. Chronic obstructive pulmonary disease, history of pneumonia, and aspiration pneumonia, osteoporosis, alcoholism, microcytic anemia. + +MEDICATIONS: + + Per his current medical chart. + +ALLERGIES: + + NO KNOWN DRUG ALLERGIES. + +SOCIAL HISTORY: + + The patient had a long history of smoking but quit many years ago. He does have chronic alcohol use. + +PHYSICAL EXAMINATION: + +GENERAL: A very thin white male who is dyspneic and having difficulty breathing at the moment. + +VITAL SIGNS: Afebrile. Heart rate in the 100s to 120s at times with atrial fibrillation. Respiratory rate is 17-20. Blood pressure 130s-150s/60s-70s. + +NECK: Soft and supple, full range of motion. + +HEART: Regular. + +ABDOMEN: Distended with tenderness mainly in the upper abdomen but very difficult to localize due to his difficulty providing information. He does appear to have tenderness but does not have rebound and does not have peritoneal signs. + +DIAGNOSTICS: + + A CT scan done on 11/02/07 shows pneumatosis in the cecum with an enlarged cecum filled with stool and air fluid levels with chronically dilated small bowel. + +ASSESSMENT: + + Possible ischemic cecum with possible metastatic disease, bilateral hydronephrosis on atrial fibrillation, aspiration pneumonia, chronic alcohol abuse, acute renal failure, COPD + + anemia with gastric ulcer. + +PLAN: + + The patient appears to have pneumatosis from a CT scan 2 days ago. Nothing was done about it at that time as the patient appeared to not be symptomatic, but he continues to have nausea and vomiting with abdominal pain, but the fact that pneumatosis was found 2 days ago and the patient has survived this long indicates this may be a benign process at the moment, and I would recommend getting a repeat CT scan to assess it further to see if there is worsening of pneumatosis versus resolution to further evaluate the liver lesions and make decisions regarding planning at that time. The patient has frequent desaturations secondary to his aspiration pneumonia, and any surgical procedure or any surgical intervention would certainly require intubation, which would then necessitate long-term ventilator care as he is not someone who would be able to come off of a ventilator very well in his current state. So we will look at the CT scan and make decisions based on the findings as far as that is concerned. \ No newline at end of file diff --git a/3520_Gastroenterology.txt b/3520_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..482d511ba57ce550e6f910196a9a4cd1aba725a2 --- /dev/null +++ b/3520_Gastroenterology.txt @@ -0,0 +1,52 @@ +PREOPERATIVE DIAGNOSIS: + + Right colon tumor. + +POSTOPERATIVE DIAGNOSES: + +1. Right colon cancer. + +2. Ascites. + +3. Adhesions. + +PROCEDURE PERFORMED: + +1. Exploratory laparotomy. + +2. Lysis of adhesions. + +3. Right hemicolectomy. + +ANESTHESIA: + + General. + +COMPLICATIONS: + + None. + +ESTIMATED BLOOD LOSS: + + Less than 200 cc. + +URINE OUTPUT: + + 200 cc. + +CRYSTALLOIDS GIVEN: + + 2700 cc. + +INDICATIONS FOR THIS PROCEDURE: + +The patient is a 53-year-old African-American female who presented with near obstructing lesion at the hepatic flexure. The patient underwent a colonoscopy which found this lesion and biopsies were taken proving invasive adenocarcinoma. The patient was NG decompressed preoperatively and was prepared for surgery. The need for removal of the colon cancer was explained at length. The patient was agreeable to proceed with the surgery and signed preoperatively informed consent. + +PROCEDURE: + + The patient was taken to the Operative Suite and placed in the supine position under general anesthesia per Anesthesia Department and NG and Foley catheters were placed preoperatively. She was given triple antibiotics IV. Due to her near obstructive symptoms, a formal ________ was not performed. + +The abdomen was prepped and draped in the usual sterile fashion. A midline laparotomy incision was made with a #10 blade scalpel and subcutaneous tissues were separated with electrocautery down to the anterior abdominal fascia. Once divided, the intraabdominal cavity was accessed and bowel was protected as the rest of the abdominal wall was opened in the midline. Extensive fluid was seen upon entering the abdomen, ascites fluid, which was clear straw-colored and this was sampled for cytology. Next, the small bowel was retracted with digital exploration and there was a evidence of hepatic flexure, colonic mass, which was adherent to the surrounding tissues. With mobilization of the colon along the line of Toldt down to the right gutter, the entire ileocecal region up to the transverse colon was mobilized into the field. Next, a window was made 5 inches from the ileocecal valve and a GIA-75 was fired across the ileum. Next, a second GIA device was fired across the proximal transverse colon, just sparring the middle colic artery. The dissection was then carried down along the mesentry, down to the root of the mesentry. Several lymph nodes were sampled carefully, and small radiopaque clips were applied along the base of the mesentry. The mesentry vessels are hemostated and tied with #0-Vicryl suture sequentially, ligated in between. Once this specimen was submitted to pathology, the wound was inspected. There was no evidence of bleeding from any of the suture sites. Next, a side-by-side anastomosis was performed between the transverse colon and the terminal ileum. A third GIA-75 was fired side-by-side and GIA-55 was used to close the anastomosis. A patent anastomosis was palpated. The anastomosis was then protected with a #2-0 Vicryl #0-muscular suture. Next, the mesenteric root was closed with a running #0-Vicryl suture to prevent any chance of internal hernia. The suture sites were inspected and there was no evidence of leakage. Next, the intraabdominal cavity was thoroughly irrigated with sterile saline and the anastomosis was carried into the right lower gutter. Omentum was used to cover the intestines which appeared dilated and indurated from the near obstruction. Next, the abdominal wall was reapproximated and the fascial layer using a two running loop PDS sutures meeting in the middle with good approximation of both the abdominal fascia. Additional sterile saline was used to irrigate the subcutaneous fat and then the skin was closed with sequential sterile staples. + +Sterile dressing was applied and the skin was cleansed and the patient was awakened from anesthesia without difficulty and extubated in the Operating Room and she was transferred to Recovery Room in stable condition and will be continued to be monitored on the Telemetry Floor with triple antibiotics and NG decompression. + diff --git a/3523_Gastroenterology.txt b/3523_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..bbe869a5d9ff648b5c051cb3de7286527740b667 --- /dev/null +++ b/3523_Gastroenterology.txt @@ -0,0 +1,23 @@ +NUCLEAR MEDICINE HEPATOBILIARY SCAN + +REASON FOR EXAM: + + Right upper quadrant pain. + +COMPARISONS: + +CT of the abdomen dated 02/13/09 and ultrasound of the abdomen dated 02/13/09. + +Radiopharmaceutical 6.9 mCi of Technetium-99m Choletec. + +FINDINGS: + + Imaging obtained up to 30 minutes after the injection of radiopharmaceutical shows a normal hepatobiliary transfer time. There is normal accumulation within the gallbladder. + +After the injection of 2.1 mcg of intravenous cholecystic _______, the gallbladder ejection fraction at 30 minutes was calculated to be 32% (normal is greater than 35%). The patient experienced 2/10 pain at 5 minutes after the injection of the radiopharmaceutical and the patient also complained of nausea. + +IMPRESSION: + +1. Negative for acute cholecystitis or cystic duct obstruction. + +2. Gallbladder ejection fraction just under the lower limits of normal at 32% that can be seen with very mild chronic cholecystitis. \ No newline at end of file diff --git a/3524_Gastroenterology.txt b/3524_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..0e7c1049c6accb24cfff27a047b584a614be20b8 --- /dev/null +++ b/3524_Gastroenterology.txt @@ -0,0 +1,32 @@ +PREOPERATIVE DIAGNOSES: + +1. Feeding disorder. + +2. Down syndrome. + +3. Congenital heart disease. + +POSTOPERATIVE DIAGNOSES: + +1. Feeding disorder. + +2. Down syndrome. + +3. Congenital heart disease. + +OPERATION PERFORMED: + + Gastrostomy. + +ANESTHESIA: + + General. + +INDICATIONS: + +This 6-week-old female infant had been transferred to Children's Hospital because of Down syndrome and congenital heart disease. She has not been able to feed well and in fact has to now be NG tube fed. Her swallowing mechanism does not appear to be very functional, and therefore, it was felt that in order to aid in her home care that she would be better served with a gastrostomy. + +OPERATIVE PROCEDURE: + +After the induction of general anesthetic, the abdomen was prepped and draped in usual manner. Transverse left upper quadrant incision was made and carried down through skin and subcutaneous tissue with sharp dissection. The muscle was divided and the peritoneal cavity entered. The greater curvature of the stomach was grasped with a Babcock clamp and brought into the operative field. The site for gastrostomy was selected and a pursestring suture of #4-0 Nurolon placed in the gastric wall. A 14-French 0.8 cm Mic-Key tubeless gastrostomy button was then placed into the stomach and the pursestring secured about the tube. Following this, the stomach was returned to the abdominal cavity and the posterior fascia was closed using a #4-0 Nurolon affixing the stomach to the posterior fascia. The anterior fascia was then closed with #3-0 Vicryl, subcutaneous tissue with the same, and the skin closed with #5-0 subcuticular Monocryl. The balloon was inflated to the full 5 mL. A sterile dressing was then applied and the child awakened and taken to the recovery room in satisfactory condition. + diff --git a/3528_Gastroenterology.txt b/3528_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..0da2c8e9cda8588c680c0b38758fe93af30b5abb --- /dev/null +++ b/3528_Gastroenterology.txt @@ -0,0 +1,81 @@ +CHIEF COMPLAINT: + + GI bleed. + +HISTORY OF PRESENT ILLNESS: + + The patient is an 80-year-old white female with history of atrial fibrillation, on Coumadin, who presented as outpatient, complaining of increasing fatigue. CBC revealed microcytic anemia with hemoglobin of 8.9. Stool dark brown, strongly OB positive. The patient denied any shortness of breath. No chest pain. No GI complaints. The patient was admitted to ABCD for further evaluation. + +PAST MEDICAL HISTORY: + +Significant for atrial fibrillation, hypertension, osteoarthritis of the knees, hypercholesterolemia, non-insulin-dependent diabetes mellitus, asthma, and hypothyroidism. + +PHYSICAL EXAMINATION: + +GENERAL: The patient is in no acute distress. + +VITAL SIGNS: Stable. + +HEENT: Benign. + +NECK: Supple. No adenopathy. + +LUNGS: Clear with good air movement. + +HEART: Irregularly regular. No gallops. + +ABDOMEN: Positive bowel sounds, soft, and nontender. No masses or organomegaly. + +EXTREMITIES: 1+ lower extremity edema bilaterally. + +HOSPITAL COURSE: + + The patient underwent upper endoscopy performed by Dr. A, which revealed erosive gastritis. Colonoscopy did reveal diverticulosis as well as polyp, which was resected. The patient tolerated the procedure well. She was transfused, and prior to discharge hemoglobin was stable at 10.7. The patient was without further GI complaints. Coumadin was held during hospital stay and recommendations were given by GI to hold Coumadin for an additional three days after discharge then resume. The patient was discharged with outpatient PMD + + GI + + and Cardiology followup. + +DISCHARGE DIAGNOSES: + +1. Upper gastrointestinal bleed. + +2. Anemia. + +3. Atrial fibrillation. + +4. Non-insulin-dependent diabetes mellitus. + +5. Hypertension. + +6. Hypothyroidism. + +7. Asthma. + +CONDITION UPON DISCHARGE: + + Stable. + +MEDICATIONS: + + Feosol 325 mg daily, multivitamins one daily, Protonix 40 mg b.i.d. + + KCl 20 mEq daily, Lasix 40 mg b.i.d. + + atenolol 50 mg daily, Synthroid 80 mcg daily, Actos 30 mg daily, Mevacor 40 mg daily, and lisinopril 20 mg daily. + +ALLERGIES: + + None. + +DIET: + + 1800-calorie ADA. + +ACTIVITY: + + As tolerated. + +FOLLOWUP: + + The patient to hold Coumadin through weekend. Followup CBC and INR were ordered. Outpatient followup as arranged. \ No newline at end of file diff --git a/3530_Gastroenterology.txt b/3530_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..a84e01ea09c25c4955362738c2b0c8a8aa57e576 --- /dev/null +++ b/3530_Gastroenterology.txt @@ -0,0 +1,33 @@ +PROCEDURE: + + Gastroscopy. + +PREOPERATIVE DIAGNOSES: + + Dysphagia, possible stricture. + +POSTOPERATIVE DIAGNOSIS: + + Gastroparesis. + +MEDICATION: + + MAC. + +DESCRIPTION OF PROCEDURE: + + The Olympus gastroscope was introduced into the hypopharynx and passed carefully through the esophagus, stomach, and duodenum. The hypopharynx was normal. The esophagus had a normal upper esophageal sphincter, normal contour throughout, and a normal gastroesophageal junction viewed at 39 cm from the incisors. There was no evidence of stricturing or extrinsic narrowing from her previous hiatal hernia repair. There was no sign of reflux esophagitis. On entering the gastric lumen, a large bezoar of undigested food was seen occupying much of the gastric fundus and body. It had 2 to 3 mm diameter. This was broken up using a scope into smaller pieces. There was no retained gastric liquid. The antrum appeared normal and the pylorus was patent. The scope passed easily into the duodenum, which was normal through the second portion. On withdrawal of the scope, additional views of the cardia were obtained, and there was no evidence of any tumor or narrowing. The scope was withdrawn. The patient tolerated the procedure well and was sent to the recovery room. + +FINAL DIAGNOSES: + +1. Normal postoperative hernia repair. + +2. Retained gastric contents forming a partial bezoar, suggestive of gastroparesis. + +3. Otherwise normal upper endoscopy to the descending duodenum. + +RECOMMENDATIONS: + +1. Continue proton pump inhibitors. + +2. Use Reglan 10 mg three to four times a day. \ No newline at end of file diff --git a/3531_Gastroenterology.txt b/3531_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..aab1d83e9ec781882bd81a17eac96b6de52d1f42 --- /dev/null +++ b/3531_Gastroenterology.txt @@ -0,0 +1,39 @@ +PROCEDURE: + + Gastroscopy. + +PREOPERATIVE DIAGNOSIS: + + Gastroesophageal reflux disease. + +POSTOPERATIVE DIAGNOSIS: + + Barrett esophagus. + +MEDICATIONS: + + MAC. + +PROCEDURE: + + The Olympus gastroscope was introduced into the oropharynx and passed carefully through the esophagus, stomach, and duodenum to the transverse duodenum. The preparation was excellent and all surfaces were well seen. The hypopharynx appeared normal. The esophagus had a normal contour and normal mucosa throughout its distance, but at the distal end, there was a moderate-sized hiatal hernia noted. The GE junction was seen at 40 cm and the hiatus was noted at 44 cm from the incisors. Above the GE junction, there were three fingers of columnar epithelium extending cephalad, to a distance of about 2 cm. This appears to be consistent with Barrett esophagus. Multiple biopsies were taken from numerous areas in this region. There was no active ulceration or inflammation and no stricture. The hiatal hernia sac had normal mucosa except for one small erosion at the hiatus. The gastric body had normal mucosa throughout. Numerous small fundic gland polyps were noted, measuring 3 to 5 mm in size with an entirely benign appearance. Biopsies were taken from the antrum to rule out Helicobacter pylori. A retroflex view of the cardia and fundus confirmed the small hiatal hernia and demonstrated no additional lesions. The scope was passed through the pylorus, which was patent and normal. The mucosa throughout the duodenum in the first, second, and third portions was entirely normal. The scope was withdrawn and the patient was sent to the recovery room. He tolerated the procedure well. + +FINAL DIAGNOSES: + +1. A short-segment Barrett esophagus. + +2. Hiatal hernia. + +3. Incidental fundic gland polyps in the gastric body. + +4. Otherwise, normal upper endoscopy to the transverse duodenum. + +RECOMMENDATIONS: + +1. Follow up biopsy report. + +2. Continue PPI therapy. + +3. Follow up with Dr. X as needed. + +4. Surveillance endoscopy for Barrett in 3 years (if pathology confirms this diagnosis). \ No newline at end of file diff --git a/3533_Gastroenterology.txt b/3533_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..88ddc22c659201e1e789d5dba2242d5402b9e16e --- /dev/null +++ b/3533_Gastroenterology.txt @@ -0,0 +1,19 @@ +REASON FOR VISIT: + + Followup of laparoscopic fundoplication and gastrostomy. + +HISTORY OF PRESENT ILLNESS: + + The patient is a delightful baby girl, who is now nearly 8 months of age and had a tracheostomy for subglottic stenosis. Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access and to protect her airway at a time when it is either going to heal enough to improve and allow decannulation or eventually prove that she will need laryngotracheoplasty. Dr. X is following The patient for this and currently plans are to perform a repeat endoscopic exam every couple of months to assist the status of her airway caliber. + +The patient had a laparoscopic fundoplication and gastrostomy on 10/05/2007. She has done well since that time. She has had some episodes of retching intermittently and these seemed to be unpredictable. She also had some diarrhea and poor feeding tolerance about a week ago but that has also resolved. The patient currently takes about 1 ounce to 1.5 ounce of her feedings by mouth and the rest is given by G-tube. She seems otherwise happy and is not having an excessive amount of stools. Her parents have not noted any significant problems with the gastrostomy site. + +The patient's exam today is excellent. Her belly is soft and nontender. All of her laparoscopic trocar sites are healing with a normal amount of induration, but there is no evidence of hernia or infection. We removed The patient's gastrostomy button today and showed her parents how to reinsert one without difficulty. The site of the gastrostomy is excellent. There is not even a hint of granulation tissue or erythema, and I am very happy with the overall appearance. + +IMPRESSION: + + The patient is doing exceptionally well status post laparoscope fundoplication and gastrostomy. Hopefully, the exquisite control of acid reflux by fundoplication will help her airway heal, and if she does well, allow decannulation in the future. If she does require laryngotracheoplasty, the protection from acid reflux will be important to healing of that procedure as well. + +PLAN: + +The patient will follow up as needed for problems related to gastrostomy. We will see her when she comes in the hospital for endoscopic exams and possibly laryngotracheoplasty in the future. \ No newline at end of file diff --git a/3540_Gastroenterology.txt b/3540_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..fd3ef3639c66015cb40106a397114d5dc2d6031a --- /dev/null +++ b/3540_Gastroenterology.txt @@ -0,0 +1,33 @@ +PREOPERATIVE DIAGNOSES: + + Dysphagia and esophageal spasm. + +POSTOPERATIVE DIAGNOSES: + + Esophagitis and esophageal stricture. + +PROCEDURE: + + Gastroscopy. + +MEDICATIONS: + + MAC. + +DESCRIPTION OF PROCEDURE: + + The Olympus gastroscope was introduced into the oropharynx and passed carefully through the esophagus, stomach, and duodenum, to the third portion of the duodenum. The hypopharynx was normal and the upper esophageal sphincter was unremarkable. The esophageal contour was normal, with the gastroesophageal junction located at 38 cm from the incisors. At this point, there were several linear erosions and a sense of stricturing at 38 cm. Below this, there was a small hiatal hernia with the hiatus noted at 42 cm from the incisors. The mucosa within the hernia was normal. The gastric lumen was normal with normal mucosa throughout. The pylorus was patent permitting passage of the scope into the duodenum, which was normal through the third portion. During withdrawal of the scope, additional views were obtained of the cardia, confirming the presence of a small hiatal hernia. It was decided to attempt dilation of the strictured area, so an 18-mm TTS balloon was placed across the stricture and inflated to the recommended diameter. When the balloon was fully inflated, the lumen appeared to be larger than 18 mm diameter, suggesting that the stricture was in fact not a significant one. No stretching of the mucosa took place. The balloon was deflated and the scope was withdrawn. The patient tolerated the procedure well and was sent to the recovery room. + +FINAL DIAGNOSES: + +1. Esophagitis. + +2. Minor stricture at the gastroesophageal junction. + +3. Hiatal hernia. + +4. Otherwise normal upper endoscopy to the transverse duodenum. + +RECOMMENDATIONS: + +Continue proton pump inhibitor therapy. \ No newline at end of file diff --git a/3542_Gastroenterology.txt b/3542_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..bb4792e0d7a0924061dacea85bb5e796fdb87aab --- /dev/null +++ b/3542_Gastroenterology.txt @@ -0,0 +1,33 @@ +PROCEDURE: + + Flexible sigmoidoscopy. + +PREOPERATIVE DIAGNOSIS: + + Rectal bleeding. + +POSTOPERATIVE DIAGNOSIS: + +Diverticulosis. + +MEDICATIONS: + + None. + +DESCRIPTION OF PROCEDURE: + +The Olympus gastroscope was introduced through the rectum and advanced carefully through the colon for a distance of 90 cm, reaching the proximal descending colon. At this point, stool occupied the lumen, preventing further passage. The colon distal to this was well cleaned out and easily visualized. The mucosa was normal throughout the regions examined. Numerous diverticula were seen. There was no blood or old blood or active bleeding. A retroflexed view of the anorectal junction showed no hemorrhoids. He tolerated the procedure well and was sent to the recovery room. + +FINAL DIAGNOSES: + +1. Sigmoid and left colon diverticulosis. + +2. Otherwise normal flexible sigmoidoscopy to the proximal descending colon. + +3. The bleeding was most likely from a diverticulum, given the self limited but moderately severe quantity that he described. + +RECOMMENDATIONS: + +1. Follow up with Dr. X as needed. + +2. If there is further bleeding, a full colonoscopy is recommended. \ No newline at end of file diff --git a/3543_Gastroenterology.txt b/3543_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..015a9af63b372dff869882f61066264a0439872b --- /dev/null +++ b/3543_Gastroenterology.txt @@ -0,0 +1,47 @@ +PREOPERATIVE DIAGNOSIS: + +1. Acute bowel obstruction. + +2. Umbilical hernia. + +POSTOPERATIVE DIAGNOSIS: + +1. Acute small bowel obstruction. + +2. Incarcerated umbilical Hernia. + +PROCEDURE PERFORMED: + +1. Exploratory laparotomy. + +2. Release of small bowel obstruction. + +3. Repair of periumbilical hernia. + +ANESTHESIA: + + General with endotracheal intubation. + +COMPLICATIONS: + + None. + +DISPOSITION: + + The patient tolerated the procedure well and was transferred to recovery in stable condition. + +SPECIMEN: + + Hernia sac. + +HISTORY: + +The patient is a 98-year-old female who presents from nursing home extended care facility with an incarcerated umbilical hernia, intractable nausea and vomiting and a bowel obstruction. Upon seeing the patient and discussing in extent with the family, it was decided the patient needed to go to the operating room for this nonreducible umbilical hernia and bowel obstruction and the family agreed with surgery. + +INTRAOPERATIVE FINDINGS: + + The patient was found to have an incarcerated umbilical hernia. There was a loop of small bowel incarcerated within the hernia sac. It showed signs of ecchymosis, however no signs of any ischemia or necrosis. It was easily reduced once opening the abdomen and the rest of the small bowel was ran without any other defects or abnormalities. + +PROCEDURE: + + After informed written consent, risks and benefits of the procedure were explained to the patient and the patient's family. The patient was brought to the operating suite. After general endotracheal intubation, prepped and draped in normal sterile fashion. A midline incision was made around the umbilical hernia defect with a #10 blade scalpel. Dissection was then carried down to the fascia. Using a sharp dissection, an incision was made above the defect superior to the defect entering the fascia. The abdomen was entered under direct visualization. The small bowel that was entrapped within the hernia sac was easily reduced and observed and appeared to be ecchymotic, however, no signs of ischemia were noted or necrosis. The remaining of the fascia was then extended using Metzenbaum scissors. The hernia sac was removed using Mayo scissors and sent off as specimen. Next, the bowel was run from the ligament of Treitz to the ileocecal valve with no evidence of any other abnormalities. The small bowel was then milked down removing all the fluid. The bowel was decompressed distal to the obstruction. Once returning the abdominal contents to the abdomen, attention was next made in closing the abdomen and using #1 Vicryl suture in the figure-of-eight fashion the fascia was closed. The umbilicus was then reapproximated to its anatomical position with a #1 Vicryl suture. A #3-0 Vicryl suture was then used to reapproximate the deep dermal layers and skin staples were used on the skin. Sterile dressings were applied. The patient tolerated the procedure well and was transferred to recovery in stable condition. \ No newline at end of file diff --git a/3546_Gastroenterology.txt b/3546_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..ecdbff4fb667012f0e575ea0d1ee753b05bc1970 --- /dev/null +++ b/3546_Gastroenterology.txt @@ -0,0 +1,23 @@ +PREOPERATIVE DIAGNOSIS: + + Leaking anastomosis from esophagogastrectomy. + +POSTOPERATIVE DIAGNOSIS: + + Leaking anastomosis from esophagogastrectomy. + +PROCEDURE: + + Exploratory laparotomy and drainage of intra-abdominal abscesses with control of leakage. + +COMPLICATIONS: + + None. + +ANESTHESIA: + + General oroendotracheal intubation. + +PROCEDURE: + + After adequate general anesthesia was administered, the patient's abdomen was prepped and draped aseptically. Sutures and staples were removed. The abdomen was opened. The were some very early stage adhesions that were easy to separate. Dissection was carried up toward the upper abdomen where the patient was found to have a stool filled descended colon. This was retracted caudally to expose the stomach. There were a number of adhesions to the stomach. These were carefully dissected to expose initially the closure over the gastrotomy site. Initially this looked like this was leaking but it was actually found to be intact. The pyloroplasty was identified and also found to be intact with no evidence of leakage. Further dissection up toward the hiatus revealed an abscess collection. This was sent for culture and sensitivity and was aspirated and lavaged. Cavity tracked up toward the hiatus. Stomach itself appeared viable, there was no necrotic sections. Upper apex of the stomach was felt to be viable also. I did not pull the stomach and esophagus down into the abdomen from the mediastinum, but placed a sucker up into the mediastinum where additional turbid fluid was identified. Carefully placed a 10 mm flat Jackson-Pratt drain into the mediastinum through the hiatus to control this area of leakage. Two additional Jackson-Pratt drains were placed essentially through the gastrohepatic omentum. This was the area that most of the drainage had collected in. As I had previously discussed with Dr. Sageman I did not feel that mobilizing the stomach to redo the anastomosis in the chest would be a recoverable situation for the patient. I therefore did not push to visualize any focal areas of the anastomosis with the intent of repair. Once the drains were secured, they were brought out through the anterior abdominal wall and secured with 3-0 silk sutures and secured to bulb suction. The midline fascia was then closed using running #2 Prolene sutures bolstered with retention sutures. Subcutaneous tissue was copiously lavaged and then the skin was closed with loosely approximated staples. Dry gauze dressing was placed. The patient tolerated the procedure well, there were no complications. \ No newline at end of file diff --git a/3548_Gastroenterology.txt b/3548_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..9dfc05ce579ec2d66bac0646d9930ea5e41fd719 --- /dev/null +++ b/3548_Gastroenterology.txt @@ -0,0 +1,19 @@ +PRIMARY DIAGNOSIS: + + Esophageal foreign body, no associated comorbidities are noted. + +PROCEDURE: + + Esophagoscopy with removal of foreign body. + +CPT CODE: + + 43215. + +PRINCIPAL DIAGNOSIS: + + Esophageal foreign body, ICD-9 code 935.1. + +DESCRIPTION OF PROCEDURE: + + Under general anesthesia, flexible EGD was performed. Esophagus was visualized. The quarter was visualized at the aortic knob, was removed with grasper. Estimated blood loss 0. Intravenous fluids during time of procedure 100 mL. No tissues. No complications. The patient tolerated the procedure well. Dr. X Pipkin attending pediatric surgeon was present throughout the entire procedure. The patient was transferred from OR to PACU in stable condition. \ No newline at end of file diff --git a/3549_Gastroenterology.txt b/3549_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..186e85cb62b1668e499f9436e316084cc3549eae --- /dev/null +++ b/3549_Gastroenterology.txt @@ -0,0 +1,37 @@ +PREOPERATIVE DIAGNOSIS: + + History of perforated sigmoid diverticuli with Hartmann's procedure. + +POSTOPERATIVE DIAGNOSES: + +1. History of perforated sigmoid diverticuli with Hartmann's procedure. + +2. Massive adhesions. + +PROCEDURE PERFORMED: + +1. Exploratory laparotomy. + +2. Lysis of adhesions and removal. + +3. Reversal of Hartmann's colostomy. + +4. Flexible sigmoidoscopy. + +5. Cystoscopy with left ureteral stent. + +ANESTHESIA: + + General. + +HISTORY: + + This is a 55-year-old gentleman who had a previous perforated diverticula. Recommendation for reversal of the colostomy was made after more than six months from the previous surgery for a sigmoid colon resection and Hartmann's colostomy. + +PROCEDURE: + +The patient was taken to the operating room placed into lithotomy position after being prepped and draped in the usual sterile fashion. A cystoscope was introduced into the patient's urethra and to the bladder. Immediately, no evidence of cystitis was seen and the scope was introduced superiorly, measuring the bladder and immediately a #5 French ____ was introduced within the left urethra. The cystoscope was removed, a Foley was placed, and wide connection was placed attaching the left ureteral stent and Foley. At this point, immediately the patient was re-prepped and draped and immediately after the ostomy was closed with a #2-0 Vicryl suture, immediately at this point, the abdominal wall was opened with a #10 blade Bard-Parker down with electrocautery for complete hemostasis through the midline. + +The incision scar was cephalad due to the severe adhesions in the midline. Once the abdomen was entered in the epigastric area, then massive lysis of adhesions was performed to separate the small bowel from the anterior abdominal wall. Once the small bowel was completely free from the anterior abdominal wall, at this point, the ostomy was taken down with an elliptical incision with cautery and then meticulous dissection with Metzenbaum scissors and electrocautery down to the anterior abdominal wall, where a meticulous dissection was carried with Metzenbaum scissors to separate the entire ostomy from the abdominal wall. Immediately at this point, the bowel was dropped within the abdominal cavity, and more lysis of adhesions was performed cleaning the left gutter area to mobilize the colon further down to have no tension in the anastomosis. At this point, the rectal stump, where two previous sutures with Prolene were seen, were brought with hemostats. The rectal stump was free in a 360 degree fashion and immediately at this point, a decision to perform the anastomosis was made. First, a self-retaining retractor was introduced in the abdominal cavity and a bladder blade was introduced as well. Blue towel was placed above the small bowel retracting the bowel to cephalad and at this point, immediately the rectal stump was well visualized, no evidence of bleeding was seen, and the towels were placed along the edges of the abdominal wound. Immediately, the pursestring device was fired approximately 1 inch from the skin and on the descending colon, this was fired. The remainder of the excess tissue was closed with Metzenbaum scissors and immediately after dilating #25 and #29 mushroom tip from the T8 Ethicon was placed within the colon and then #9-0 suture was tied. Immediately from the anus, the dilator #25 and #29 was introduced dilating the rectum. The #29 EEA was introduced all the way anteriorly to the staple line and this spike from the EEA was used to perforate the rectum and then the mushroom from the descending colon was attached to it. The EEA was then fired. Once it was fired and was removed, the pelvis was filled with fluid. Immediately both doughnuts were ____ from the anastomosis. A Doyen was placed in both the anastomosis. Colonoscope was introduced. No bubble or air was seen coming from the anastomosis. There was no evidence of bleeding. Pictures of the anastomosis were taken. The scope then was removed from the patient's rectum. Copious amount of irrigation was used within the peritoneal cavity. Immediately at this point, all complete sponge and instrument count was performed. First, the ostomy site was closed with interrupted figure-of-eight #0 Vicryl suture. The peritoneum was closed with running #2-0 Vicryl suture. Then, the midline incision was closed with a loop PDS in cephalad to caudad and caudad to cephalad tight in the middle. Subq tissue was copiously irrigated and the staples on the skin. + +The iodoform packing was placed within the old ostomy site and then the staples on the skin as well. The patient did tolerate the procedure well and will be followed during the hospitalization. The left ureteral stent was removed at the end of the procedure. _____ were performed. Lysis of adhesions were performed. Reversal of colostomy and EEA anastomosis #29 Ethicon. \ No newline at end of file diff --git a/3552_Gastroenterology.txt b/3552_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..09333dc404f9ef901c56afc7edde6f4b00a1e745 --- /dev/null +++ b/3552_Gastroenterology.txt @@ -0,0 +1,35 @@ +PREOPERATIVE DIAGNOSIS: + + Refractory dyspepsia. + +POSTOPERATIVE DIAGNOSIS: + +1. Hiatal hernia. + +2. Reflux esophagitis. + +PROCEDURE PERFORMED: + + Esophagogastroduodenoscopy with pseudo and esophageal biopsy. + +ANESTHESIA: + + Conscious sedation with Demerol and Versed. + +SPECIMEN: + + Esophageal biopsy. + +COMPLICATIONS: + + None. + +HISTORY: + + The patient is a 52-year-old female morbidly obese black female who has a long history of reflux and GERD type symptoms including complications such as hoarseness and chronic cough. She has been on multiple medical regimens and continues with dyspeptic symptoms. + +PROCEDURE: + + After proper informed consent was obtained, the patient was brought to the endoscopy suite. She was placed in the left lateral position and was given IV Demerol and Versed for sedation. When adequate level of sedation achieved, the gastroscope was inserted into the hypopharynx and the esophagus was easily intubated. At the GE junction, a hiatal hernia was present. There were mild inflammatory changes consistent with reflux esophagitis. The scope was then passed into the stomach. It was insufflated and the scope was coursed along the greater curvature to the antrum. The pylorus was patent. There was evidence of bile reflux in the antrum. The duodenal bulb and sweep were examined and were without evidence of mass, ulceration, or inflammation. The scope was then brought back into the antrum. + +A retroflexion was attempted multiple times, however, the patient was having difficulty holding the air and adequate retroflexion view was not visualized. The gastroscope was then slowly withdrawn. There were no other abnormalities noted in the fundus or body. Once again at the GE junction, esophageal biopsy was taken. The scope was then completely withdrawn. The patient tolerated the procedure and was transferred to the recovery room in stable condition. She will return to the General Medical Floor. We will continue b.i.d proton-pump inhibitor therapy as well as dietary restrictions. She should also attempt significant weight loss. \ No newline at end of file diff --git a/3553_Gastroenterology.txt b/3553_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..05b4965d96a593ec176310fd71030fbdec0b23a1 --- /dev/null +++ b/3553_Gastroenterology.txt @@ -0,0 +1,23 @@ +PREOPERATIVE DIAGNOSES: + + Malnutrition and dysphagia. + +POSTOPERATIVE DIAGNOSES: + + Malnutrition and dysphagia with two antral polyps and large hiatal hernia. + +PROCEDURES: + + Esophagogastroduodenoscopy with biopsy of one of the polyps and percutaneous endoscopic gastrostomy tube placement. + +ANESTHESIA: + + IV sedation, 1% Xylocaine locally. + +CONDITION: + + Stable. + +OPERATIVE NOTE IN DETAIL: + + After risk of operation was explained to this patient's family, consent was obtained for surgery. The patient was brought to the GI lab. There, she was placed in partial left lateral decubitus position. She was given IV sedation by Anesthesia. Her abdomen was prepped with alcohol and then Betadine. Flexible gastroscope was passed down the esophagus, through the stomach into the duodenum. No lesions were noted in the duodenum. There appeared to be a few polyps in the antral area, two in the antrum. Actually, one appeared to be almost covering the pylorus. The scope was withdrawn back into the antrum. On retroflexion, we could see a large hiatal hernia. No other lesions were noted. Biopsy was taken of one of the polyps. The scope was left in position. Anterior abdominal wall was prepped with Betadine, 1% Xylocaine was injected in the left epigastric area. A small stab incision was made and a large bore Angiocath was placed directly into the anterior abdominal wall, into the stomach, followed by a thread, was grasped with a snare using the gastroscope, brought out through the patient's mouth. Tied to the gastrostomy tube, which was then pulled down and up through the anterior abdominal wall. It was held in position with a dressing and a stent. A connector was applied to the cut gastrostomy tube, held in place with a 2-0 silk ligature. The patient tolerated the procedure well. She was returned to the floor in stable condition. \ No newline at end of file diff --git a/3555_Gastroenterology.txt b/3555_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..6af25425f2842205df175fa950d36c1003777989 --- /dev/null +++ b/3555_Gastroenterology.txt @@ -0,0 +1,23 @@ +PREOPERATIVE DIAGNOSIS: + + Positive peptic ulcer disease. + +POSTOPERATIVE DIAGNOSIS: + + Gastritis. + +PROCEDURE PERFORMED: + + Esophagogastroduodenoscopy with photography and biopsy. + +GROSS FINDINGS: + + The patient had a history of peptic ulcer disease, epigastric abdominal pain x2 months, being evaluated at this time for ulcer disease. + +Upon endoscopy, gastroesophageal junction was at 40 cm, no esophageal tumor, varices, strictures, masses, or no reflux esophagitis was noted. Examination of the stomach reveals mild inflammation of the antrum of the stomach, no ulcers, erosions, tumors, or masses. The profundus and the cardia of the stomach were unremarkable. The pylorus was concentric. The duodenal bulb and sweep with no inflammation, tumors, or masses. + +OPERATIVE PROCEDURE: + + The patient taken to the Endoscopy Suite, prepped and draped in the left lateral decubitus position. She was given IV sedation using Demerol and Versed. Olympus videoscope was inserted in the hypopharynx, upon deglutition passed into the esophagus. Using air insufflation, the scope was advanced down through the esophagus into the stomach along the greater curvature of the stomach to the pylorus to the duodenal bulb and sweep. The above gross findings noted. The panendoscope was withdrawn back from the stomach, deflected upon itself. The lesser curve fundus and cardiac were well visualized. Upon examination of these areas, panendoscope was returned to midline. Photographs and biopsies were obtained of the antrum of the stomach. Air was aspirated from the stomach and panendoscope was slowly withdrawn carefully examining the lumen of the bowel. + +Photographs and biopsies were obtained as appropriate. The patient is sent to recovery room in stable condition. \ No newline at end of file diff --git a/3556_Gastroenterology.txt b/3556_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..3dc7efa1ccf3bb2299b0c78a57e4172f31b7a9c6 --- /dev/null +++ b/3556_Gastroenterology.txt @@ -0,0 +1,37 @@ +PROCEDURE: + + Esophagogastroduodenoscopy with biopsy and colonoscopy with biopsy. + +INDICATIONS FOR PROCEDURE: + + A 17-year-old with history of 40-pound weight loss, abdominal pain, status post appendectomy with recurrent abscess formation and drainage. Currently, he has a fistula from his anterior abdominal wall out. It does not appear to connect to the gastrointestinal tract, but merely connect from the ventral surface of the rectus muscles out the abdominal wall. CT scans show thickened terminal ileum, which suggest that we are dealing with Crohn's disease. Endoscopy is being done to evaluate for Crohn's disease. + +MEDICATIONS: + +General anesthesia. + +INSTRUMENT: + + Olympus GIF-160 and PCF-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 scope was advanced down the esophagus, which had normal mucosal coloration and vascular pattern. Lower esophageal sphincter was located at 40 cm from the central incisors. It appeared normal and appeared to function normally. The endoscope was advanced into the stomach, which was distended with excess air. Rugal folds were flattened completely. There were multiple superficial erosions scattered throughout the fundus, body, and antral portions consistent with Crohn's involvement of the stomach. The endoscope was advanced through normal-appearing pyloric valve into the first, second, and third portion of the duodenum, which had normal mucosal coloration and fold pattern. Biopsies were obtained x2 in the second portion of the duodenum, antrum, body, and distal esophagus at 37 cm from the central incisors for histology. Two additional biopsies were obtained in the antrum for CLO testing. Excess air was evacuated from the stomach. The scope was removed from the patient who tolerated that part of the procedure well. + +The patient was turned and scope was changed for colonoscopy. Prior to colonoscopy, it was noted that there was a perianal fistula at 7 o'clock. The colonoscope was then inserted into the anal verge. The colonic clean out was excellent. The scope was advanced without difficulty to the cecum. The cecal area had multiple ulcers with exudate. The ileocecal valve was markedly distorted. Biopsies were obtained x2 in the cecal area and then the scope was withdrawn through the ascending, transverse, descending, sigmoid, and rectum. The colonic mucosa in these areas was well seen and there were a few scattered aphthous ulcers in the ascending and descending colon. Biopsies were obtained in the cecum at 65 cm, transverse colon 50 cm, rectosigmoid 20 cm, and rectum at 5 cm. No fistulas were noted in the colon. Excess air was evacuated from the colon. The scope was removed. The patient tolerated the procedure well and was taken to recovery in satisfactory condition. + +IMPRESSION: + + Normal esophagus and duodenum. There were multiple superficial erosions or aphthous ulcers in the stomach along with a very few scattered aphthous ulcers in the colon with marked cecal involvement with large ulcers and a very irregular ileocecal valve. All these findings are consistent with Crohn's disease. + +PLAN: + +Begin prednisone 30 mg p.o. daily. Await PPD results and chest x-ray results, as well as cocci serology results. If these are normal, then we would recommend Remicade 5 mg/kg IV infusion. We would start Modulon 50 mL/h for 20 hours to reverse the malnutrition state of this boy. Check CMP and phosphate every Monday, Wednesday, and Friday for receding syndrome noted by following potassium and phosphate. We will discuss with Dr. X possibly repeating the CT fistulogram if the findings on the previous ones are inconclusive as far as the noting whether we can rule in or out an enterocutaneous fistula. He will need an upper GI to rule out small intestinal strictures and involvement of the small intestine that cannot be seen with upper and lower endoscopy. If he has no stricture formation in the small bowel, we would then recommend a video endoscopy capsule to further evaluate any mucosal lesions consistent with Crohn's in the small intestine that we cannot visualize with endoscopy. \ No newline at end of file diff --git a/3557_Gastroenterology.txt b/3557_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..f01d95bf42bf2e9c857a63b19849364bb0c36be4 --- /dev/null +++ b/3557_Gastroenterology.txt @@ -0,0 +1,5 @@ +PROCEDURE IN DETAIL: + + Following premedication with Vistaril 50 mg and Atropine 0.4 mg IM + + the patient received Versed 5.0 mg intravenously after Cetacaine spray to the posterior palate. The Olympus video gastroscope was then introduced into the upper esophagus and passed by direct vision to the descending duodenum. The upper, mid and lower portions of the esophagus; the lesser and greater curves of the stomach; anterior and posterior walls; body and antrum; pylorus; duodenal bulb; and duodenum were all normal. No evidence of friability, ulceration or tumor mass was encountered. The instrument was withdrawn to the antrum, and biopsies taken for CLO testing, and then the instrument removed. \ No newline at end of file diff --git a/3558_Gastroenterology.txt b/3558_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..1f96d6830cefd0ab1df66a6f2a045f1b5f91c70a --- /dev/null +++ b/3558_Gastroenterology.txt @@ -0,0 +1,35 @@ +PROCEDURES: + + Esophagogastroduodenoscopy and colonoscopy with biopsy and polypectomy. + +REASON FOR PROCEDURE: + + Child with abdominal pain and rectal bleeding. Rule out inflammatory bowel disease, allergic enterocolitis, rectal polyps, and rectal vascular malformations. + +CONSENT: + + History and physical examination was performed. The procedure, indications, alternatives available, and complications, i.e. bleeding, perforation, infection, adverse medication reaction, the possible need for blood transfusion, and surgery should a complication occur were discussed with the parents who understood and indicated this. Opportunity for questions was provided and informed consent was obtained. + +MEDICATION: + +General anesthesia. + +INSTRUMENT: + + Olympus GIF-160. + +COMPLICATIONS: + + None. + +FINDINGS: + + With the patient in the supine position and intubated, the endoscope was inserted without difficulty into the hypopharynx. The esophageal mucosa and vascular pattern appeared normal. The lower esophageal sphincter was located at 25 cm from the central incisors. It appeared normal. A Z-line was identified within the lower esophageal sphincter. The endoscope was advanced into the stomach, which distended with excess air. Rugal folds flattened completely. Gastric mucosa appeared normal throughout. No hiatal hernia was noted. Pyloric valve appeared normal. The endoscope was advanced into the first, second, and third portions of duodenum, which had normal mucosa, coloration, and fold pattern. Biopsies were obtained x2 in the second portion of duodenum, antrum, and distal esophagus at 22 cm from the central incisors for histology. Additional 2 biopsies were obtained for CLO testing in the antrum. Excess air was evacuated from the stomach. The scope was removed from the patient who tolerated that part of procedure well. The patient was turned and the scope was advanced with some difficulty to the terminal ileum. The terminal ileum mucosa and the colonic mucosa throughout was normal except at approximately 10 cm where a 1 x 1 cm pedunculated juvenile-appearing polyp was noted. Biopsies were obtained x2 in the terminal ileum, cecum, ascending colon, transverse colon, descending colon, sigmoid, and rectum. Then, the polyp was snared right at the base of the polyp on the stalk and 20 watts of pure coag was applied in 2-second bursts x3. The polyp was severed. There was no bleeding at the stalk after removal of the polyp head. The polyp head was removed by suction. Excess air was evacuated from the colon. The patient tolerated that part of the procedure well and was taken to recovery in satisfactory condition. Estimated blood loss approximately 5 mL. + +IMPRESSION: + + Normal esophagus, stomach, duodenum, and colon as well as terminal ileum except for a 1 x 1-cm rectal polyp, which was removed successfully by polypectomy snare. + +PLAN: + +Histologic evaluation and CLO testing. I will contact the parents next week with biopsy results and further management plans will be discussed at that time. \ No newline at end of file diff --git a/3562_Gastroenterology.txt b/3562_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..f7a037a60b45b5a30ecec4a418cbf2ddeaa42d49 --- /dev/null +++ b/3562_Gastroenterology.txt @@ -0,0 +1,37 @@ +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. \ No newline at end of file diff --git a/3563_Gastroenterology.txt b/3563_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..c83e2b82df37194aad10ef64a69263aeaaf5bc48 --- /dev/null +++ b/3563_Gastroenterology.txt @@ -0,0 +1,27 @@ +PROCEDURE PERFORMED: + + Esophagogastroduodenoscopy performed in the emergency department. + +INDICATION: + + Melena, acute upper GI bleed, anemia, and history of cirrhosis and varices. + +FINAL IMPRESSION + +1. Scope passage massive liquid in stomach with some fresh blood near the fundus, unable to identify source due to gastric contents. + +2. Endoscopy following erythromycin demonstrated grade I esophageal varices. No stigmata of active bleeding. Small amount of fresh blood within the hiatal hernia. No definite source of bleeding seen. + +PLAN + +1. Repeat EGD tomorrow morning following aggressive resuscitation and transfusion. + +2. Proton-pump inhibitor drip. + +3. Octreotide drip. + +4. ICU bed. + +PROCEDURE DETAILS: + +Prior to the procedure, physical exam was stable. During the procedure, vital signs remained within normal limits. Prior to sedation, informed consent was obtained. Risks, benefits, and alternatives including, but not limited to risk of bleeding, infection, perforation, adverse reaction to medication, failure to identify pathology, pancreatitis, and death explained to the patient and his wife, who accepted all risks. The patient was prepped in the left lateral position. IV sedation was given to a total of fentanyl 100 mcg and midazolam 4 mg for the initial EGD. An additional 50 mcg of fentanyl and 2 mg of midazolam were given following erythromycin. Scope tip of the Olympus gastroscope was passed into the esophagus. Proximal, middle, and distal thirds of the esophagus were well visualized. There was fresh blood in the esophagus, which was washed thoroughly, but no source was seen. No evidence of varices was seen. The stomach was entered. The stomach was filled with very large clot and fresh blood and liquid, which could not be suctioned due to the clot burden. There was a small amount of bright red blood near the fundus, but a source could not be identified due to the clot burden. Because of this, the gastroscope was withdrawn. The patient was given 250 mg of erythromycin in the Emergency Department and 30 minutes later, the scope was repassed. On the second look, the esophagus was cleared. The liquid gastric contents were cleared. There was still a moderate amount of clot burden in the stomach, but no active bleeding was seen. There was a small grade I esophageal varices, but no stigmata of bleed. There was also a small amount of fresh blood within the hiatal hernia, but no source of bleeding was identified. The patient was hemodynamically stable; therefore, a decision was made for a second look in the morning. The scope was withdrawn and air was suctioned. The patient tolerated the procedure well and was sent to recovery without immediate complications. \ No newline at end of file diff --git a/3566_Gastroenterology.txt b/3566_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..719945faf6250c4d6f8012eb3f3fddfa23c15f98 --- /dev/null +++ b/3566_Gastroenterology.txt @@ -0,0 +1,19 @@ +OPERATION + +1. Ivor-Lewis esophagogastrectomy. + +2. Feeding jejunostomy. + +3. Placement of two right-sided #28-French chest tubes. + +4. Right thoracotomy. + +ANESTHESIA: + +General endotracheal anesthesia with a dual-lumen tube. + +OPERATIVE PROCEDURE IN DETAIL: + + After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered. Prior to administration of general anesthesia, the patient had an epidural anesthesia placed. In addition, he had a dual-lumen endotracheal tube placed. The patient was placed in the supine position to begin the procedure. His abdomen and chest were prepped and draped in the standard surgical fashion. After applying sterile dressings, a #10-blade scalpel was used to make an upper midline incision from the level of the xiphoid to just below the umbilicus. Dissection was carried down through the linea using Bovie electrocautery. The abdomen was opened. Next, a Balfour retractor was positioned as well as a mechanical retractor. Next, our attention was turned to freeing up the stomach. In an attempt to do so, we identified the right gastroepiploic artery and arcade. We incised the omentum and retracted it off the stomach and gastroepiploic arcade. The omentum was divided using suture ligature with 2-0 silk. We did this along the greater curvature and then moved to the lesser curvature where the short gastric arteries were taken down with ligation using 2-0 silk. Next, we turned our attention to performing a Kocher maneuver. This was done and the stomach was freed up. We took down the falciform ligament as well as the caudate attachment to the diaphragm. We enlarged the diaphragmatic hiatus so as to be able to place approximately 3 fingers into the chest. We also did a portion of the esophageal dissection from the abdomen into the chest area. The esophagus and the esophageal hiatus were identified in the abdomen. We next turned our attention to the left gastric artery. The left gastric artery was identified at the base of the stomach. We first took the left gastric vein by ligating and dividing it using 0 silk ties. The left gastric artery was next taken using suture ligature with silk ties followed by 2-0 stick tie reinforcement. At this point the stomach was freely mobile. We then turned our attention to performing our jejunostomy feeding tube. A 2-0 Vicryl pursestring was placed in the jejunum approximately 20 cm distal to the ligament of Treitz. We then used Bovie electrocautery to open the jejunum at this site. We placed a 16-French red rubber catheter through this site. We tied down in place. We then used 3-0 silk sutures to perform a Witzel. Next, the loop of jejunum was tacked up to the abdominal wall using 2-0 silk ties. After doing so and pulling the feeding jejunostomy out through the skin and securing it appropriately, we turned our attention to closing the abdomen. This was done with #1 Prolene. We put in a 2nd layer of 2-0 Vicryl. The skin was closed with 4-0 Monocryl. + +Next, we turned our attention to performing the thoracic portion of the procedure. The patient was placed in the left lateral decubitus position. The right chest was prepped and draped appropriately. We then used a #10 blade scalpel to make an incision in a posterolateral, non-muscle-sparing fashion. Dissection was carried down to the level of the ribs with Bovie electrocautery. Next, the ribs were counted and the 5th interspace was entered. The lung was deflated. We placed standard chest retractors. Next, we incised the peritoneum over the esophagus. We dissected the esophagus to just above the azygos vein. The azygos vein, in fact, was taken with 0 silk ligatures and reinforced with 2-0 stick ties. As mentioned, we dissected the esophagus both proximally and distally down to the level of the hiatus. After doing this, we backed our NG tube out to above the level where we planned to perform our pursestring. We used an automatic pursestring and applied. We then transected the proximal portion of the stomach with Metzenbaum scissors. We secured our pursestring and then placed a 28 anvil in the divided proximal portion of the esophagus. The pursestring was then tied down without difficulty. Next, we tabularized our stomach using a #80 GIA stapler. After doing so, we chose a portion of the stomach more distally and opened it using Bovie electrocautery. We placed our EEA stapler through it and then punched out through the gastric wall. We connected our anvil to the EEA stapler. This was then secured appropriately. We checked to make sure that there was appropriate muscle apposition. We then fired the stapler. We obtained 2 complete rings, 1 of the esophagus and 1 of the stomach, which were sent for pathology. We also sent the gastroesophageal specimen for pathology. Of note was the fact that the frozen section showed no evidence of tumor and in the proximal distal margins. We then turned our attention to closing the gastrostomy opening. This was closed with 2-0 Vicryl in a running fashion. We then buttressed this with serosal 3-0 Vicryl interrupted sutures. We returned the newly constructed gastroesophageal anastomosis into the chest and covered it by covering the pleura over it. Next, we placed two #28-French chest tubes, 1 anteriorly and 1 posteriorly, taking care not to place it near the anastomosis. We then closed the chest with #2 Vicryl in an interrupted figure-of-eight fashion. The lung was brought up. We closed the muscle layers with #0 Vicryl followed by #0 Vicryl; then we closed the subcutaneous layer with 2-0 Vicryl and the skin with 4-0 Monocryl. Sterile dressing was applied. The instrument and sponge count was correct at the end of the case. The patient tolerated the procedure well and was extubated in the operating room and transferred to the ICU in good condition. \ No newline at end of file diff --git a/3571_Gastroenterology.txt b/3571_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..317278191aaf62a4284be399fea20e153cc209eb --- /dev/null +++ b/3571_Gastroenterology.txt @@ -0,0 +1,21 @@ +PREOPERATIVE DIAGNOSIS: + + Nausea and vomiting and upper abdominal pain. + +POST PROCEDURE DIAGNOSIS: + +Normal upper endoscopy. + +OPERATION: + + Esophagogastroduodenoscopy with antral biopsies for H. pylori x2 with biopsy forceps. + +ANESTHESIA: + + IV sedation 50 mg Demerol, 8 mg of Versed. + +PROCEDURE: + + The patient was taken to the endoscopy suite. After adequate IV sedation with the above medications, hurricane was sprayed in the mouth as well as in the esophagus. A bite block was placed and the gastroscope placed into the mouth and was passed into the esophagus and negotiated through the esophagus, stomach, and pylorus. The first, second, and third portions of the duodenum were normal. The scope was withdrawn into the antrum which was normal and two bites with the biopsy forceps were taken in separate spots for H. pylori. The scope was retroflexed which showed a normal GE junction from the inside of the stomach and no evidence of pathology or paraesophageal hernia. The scope was withdrawn at the GE junction which was in a normal position with a normal transition zone. The scope was then removed throughout the esophagus which was normal. The patient tolerated the procedure well. + +The plan is to obtain a HIDA scan as the right upper quadrant ultrasound appeared to be normal, although previous ultrasounds several years ago showed a gallstone. \ No newline at end of file diff --git a/3572_Gastroenterology.txt b/3572_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..de7a1414a499873a52e723a7e3ab6c0642ef072f --- /dev/null +++ b/3572_Gastroenterology.txt @@ -0,0 +1,17 @@ +PROCEDURE: + + Upper endoscopy with biopsy. + +PROCEDURE INDICATION: + + This is a 44-year-old man who was admitted for coffee-ground emesis, which has been going on for the past several days. An endoscopy is being done to evaluate for source of upper GI bleeding. + +Informed consent was obtained. Outlining the risks, benefits and alternatives of the procedure included, but not to risks of bleeding, infection, perforation, the patient agreed for the procedure. + +MEDICATIONS: + + Versed 4 mg IV push and fentanyl 75 mcg IV push given throughout the procedure in incremental fashion with careful monitoring of patient's pressures and vital signs. + +PROCEDURE IN DETAIL: + +The patient was placed in the left lateral decubitus position. Medications were given. After adequate sedation was achieved, the Olympus video endoscope was inserted into the mouth and advanced towards the duodenum. \ No newline at end of file diff --git a/3574_Gastroenterology.txt b/3574_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..8c85bbcaefc8fb700af299136cae4cd7a4701d25 --- /dev/null +++ b/3574_Gastroenterology.txt @@ -0,0 +1,31 @@ +PREOPERATIVE DIAGNOSIS: + + Epigastric hernia. + +POSTOPERATIVE DIAGNOSIS: + + Epigastric hernia. + +OPERATIONS: + + Epigastric herniorrhaphy. + +ANESTHESIA: + + General inhalation. + +PROCEDURE: + + Following attainment of satisfactory anesthesia, the patient's abdomen was prepped with Hibiclens and draped sterilely. The hernia mass had been marked preoperatively. This area was anesthetized with a mixture of Marcaine and Xylocaine. A transverse incision was made over the hernia and dissection carried down to the entrapped fat. Sharp dissection was carried around the fat down to the fascial edge. The preperitoneal fat could not be reduced; therefore, it is trimmed away and the small fascial defect then closed with interrupted 0-Ethibond sutures. The fascial edges were injected with the local anesthetic mixture. Subcutaneous tissues were then closed with interrupted 4-0 Vicryl and skin edges closed with running subcuticular 4-0 Vicryl. Steri-Strips and a sterile dressing were applied to complete the closure. The patient was then awakened and taken to the PACU in satisfactory condition. + +ESTIMATED BLOOD LOSS: + + 10 mL. + +SPONGE AND NEEDLE COUNT: + + Reported as correct. + +COMPLICATIONS: + + None. \ No newline at end of file diff --git a/3575_Gastroenterology.txt b/3575_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..9d45bbbf2692dec959112007ce72656cd3c96736 --- /dev/null +++ b/3575_Gastroenterology.txt @@ -0,0 +1,15 @@ +INDICATIONS: + + Dysphagia. + +PREMEDICATION: + + Topical Cetacaine spray and Versed IV. + +PROCEDURE: + +: The scope was passed into the esophagus under direct vision. The esophageal mucosa was all unremarkable. There was no evidence of any narrowing present anywhere throughout the esophagus and no evidence of esophagitis. The scope was passed on down into the stomach. The gastric mucosa was all examined including a retroflexed view of the fundus and there were no abnormalities seen. The scope was then passed into the duodenum and the duodenal bulb and second and third portions of the duodenum were unremarkable. The scope was again slowly withdrawn through the esophagus and no evidence of narrowing was present. The scope was then withdrawn. + +IMPRESSION: + + Normal upper GI endoscopy without any evidence of anatomical narrowing. \ No newline at end of file diff --git a/3576_Gastroenterology.txt b/3576_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..235bfd19d3f1479363c5be8fed28ac8f94a48b54 --- /dev/null +++ b/3576_Gastroenterology.txt @@ -0,0 +1,25 @@ +PROCEDURES PERFORMED: + + Endoscopy. + +INDICATIONS: + + Dysphagia. + +POSTOPERATIVE DIAGNOSIS: + + Esophageal ring and active reflux esophagitis. + +PROCEDURE: + + Informed consent was obtained prior to the procedure from the parents and patient. The oral cavity is sprayed with lidocaine spray. A bite block is placed. Versed IV 5 mg and 100 mcg of IV fentanyl was given in cautious increments. The GIF-160 diagnostic gastroscope used. The patient was alert during the procedure. The esophagus was intubated under direct visualization. The scope was advanced toward the GE junction with active reflux esophagitis involving the distal one-third of the esophagus noted. The stomach was unremarkable. Retroflexed exam unremarkable. Duodenum not intubated in order to minimize the time spent during the procedure. The patient was alert although not combative. A balloon was then inserted across the GE junction, 15 mm to 18 mm, and inflated to 3, 4.7, and 7 ATM + + and left inflated at 18 mm for 45 seconds. The balloon was then deflated. The patient became uncomfortable and a good-size adequate distal esophageal tear was noted. The scope and balloon were then withdrawn. The patient left in good condition. + +IMPRESSION: + + Successful dilation of distal esophageal fracture in the setting of active reflux esophagitis albeit mild. + +PLAN: + + I will recommend that the patient be on lifelong proton pump inhibition and have repeat endoscopy performed as needed. This has been discussed with the parents. He was sent home with a prescription for omeprazole. \ No newline at end of file diff --git a/3577_Gastroenterology.txt b/3577_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..49c39e7d780edcff9ef0dced3af89bb75a5b2e5d --- /dev/null +++ b/3577_Gastroenterology.txt @@ -0,0 +1,21 @@ +1. Odynophagia. + +2. Dysphagia. + +3. Gastroesophageal reflux disease rule out stricture. + +POSTOPERATIVE DIAGNOSES: + +1. Antral gastritis. + +2. Hiatal hernia. + +PROCEDURE PERFORMED: EGD with photos and biopsies. + +GROSS FINDINGS: This is a 75-year-old female who presents with difficulty swallowing, occasional choking, and odynophagia. She has a previous history of hiatal hernia. She was on Prevacid currently. At this time, an EGD was performed to rule out stricture. At the time of EGD + + there was noted some antral gastritis and hiatal hernia. There are no strictures, tumors, masses, or varices present. + +OPERATIVE PROCEDURE: The patient was taken to the Endoscopy Suite in the lateral decubitus position. She was given sedation by the Department Of Anesthesia. Once adequate sedation was reached, the Olympus gastroscope was inserted into oropharynx. With air insufflation entered through the proximal esophagus to the GE junction. The esophagus was without evidence of tumors, masses, ulcerations, esophagitis, strictures, or varices. There was a hiatal hernia present. The scope was passed through the hiatal hernia into the body of the stomach. In the distal antrum, there was some erythema with patchy erythematous changes with small superficial erosions. Multiple biopsies were obtained. The scope was passed through the pylorus into the duodenal bulb and duodenal suite, they appeared within normal limits. The scope was pulled back from the stomach, retroflexed upon itself, _____ fundus and GE junction. As stated, multiple biopsies were obtained. + +The scope was then slowly withdrawn. The patient tolerated the procedure well and sent to recovery room in satisfactory condition. \ No newline at end of file diff --git a/3585_Gastroenterology.txt b/3585_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..b0898981b908cf3f4111e3389cb8a17a24684ba9 --- /dev/null +++ b/3585_Gastroenterology.txt @@ -0,0 +1,41 @@ +PREOPERATIVE DIAGNOSES: + +1. protein-calorie malnutrition. + +2. Intractable nausea, vomiting, and dysphagia. + +POSTOPERATIVE DIAGNOSES: + +1. Protein-calorie malnutrition. + +2. Intractable nausea, vomiting, and dysphagia. + +3. Enterogastritis. + +PROCEDURE PERFORMED: + + EGD with PEG tube placement using Russell technique. + +ANESTHESIA: + + IV sedation with 1% lidocaine for local. + +ESTIMATED BLOOD LOSS: + +None. + +COMPLICATIONS: + +None. + +BRIEF HISTORY: + + This is a 44-year-old African-American female who is well known to this service. She has been hospitalized multiple times for intractable nausea and vomiting and dehydration. She states that her decreased p.o. intake has been progressively worsening. She was admitted to the service of Dr. Lang and was evaluated by Dr. Wickless as well all of whom agreed that the best option for supplemental nutrition for this patient was placement of a PEG tube. + +PROCEDURE: + + After risks, complications, and benefits were explained to the patient and informed consent was obtained, the patient was taken to the operating room. She was placed in the supine position. The area was prepped and draped in the sterile fashion. After adequate IV sedation was obtained by anesthesia, esophagogastroduodenoscopy was performed. The esophagus, stomach, and duodenum were visualized without difficulty. There was no gross evidence of any malignancy. There was some enterogastritis which was noted upon exam. The appropriate location was noted on the anterior wall of the stomach. This area was localized externally with 1% lidocaine. Large gauge needle was used to enter the lumen of the stomach under visualization. A guide wire was then passed again under visualization and the needle was subsequently removed. A scalpel was used to make a small incision, next to the guidewire and ensuring that the underlying fascia was nicked as well. A dilator with break-away sheath was then inserted over the guidewire and under direct visualization was seen to enter the lumen of the stomach without difficulty. The guidewire and dilator were then removed again under visualization and the PEG tube was placed through the break-away sheath and visualized within the lumen of the stomach. The balloon was then insufflated and the break-away sheath was then pulled away. Proper placement of the tube was ensured through visualization with a scope. The tube was then sutured into place using nylon suture. Appropriate sterile dressing was applied. + +DISPOSITION: + +The patient was transferred to the recovery in a stable condition. She was subsequently returned to her room on the General Medical Floor. Previous orders will be resumed. We will instruct the Nursing that the PEG tube can be used at 5 p.m. this evening for medications if necessary and bolus feedings. \ No newline at end of file diff --git a/3587_Gastroenterology.txt b/3587_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..4df0c15ed6f61f384af8678f0da82ee8acb98073 --- /dev/null +++ b/3587_Gastroenterology.txt @@ -0,0 +1,43 @@ +PROCEDURE: + + Upper endoscopy. + +PREOPERATIVE DIAGNOSIS: + + Dysphagia. + +POSTOPERATIVE DIAGNOSIS: + +1. GERD + + biopsied. + +2. Distal esophageal reflux-induced stricture, dilated to 18 mm. + +3. Otherwise normal upper endoscopy. + +MEDICATIONS: + + Fentanyl 125 mcg and Versed 7 mg slow IV push. + +INDICATIONS: + + This is a 50-year-old white male with dysphagia, which has improved recently with Aciphex. + +FINDINGS: + + The patient was placed in the left lateral decubitus position and the above medications were administered. The oropharynx was sprayed with Cetacaine. The endoscope was passed, under direct visualization, into the esophagus. The squamocolumnar junction was irregular and edematous. Biopsies were obtained for histology. There was a mild ring at the LES + + which was dilated with a 15 to 18 mm balloon, with no resultant mucosal trauma. The entire gastric mucosa was normal, including a retroflexed view of the fundus. The entire duodenal mucosa was normal to the second portion. The patient tolerated the procedure well without complication. + +IMPRESSION: + +1. Gastroesophageal reflux disease, biopsied. + +2. Distal esophageal reflux-induced stricture, dilated to 18 mm. + +3. Otherwise normal upper endoscopy. + +PLAN: + +I will await the results of the biopsies. The patient was told to continue maintenance Aciphex and anti-reflux precautions. He will follow up with me on a p.r.n. basis. \ No newline at end of file diff --git a/3590_Gastroenterology.txt b/3590_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..e78b9616430706ac04279a5d0cd2e2ef719a614e --- /dev/null +++ b/3590_Gastroenterology.txt @@ -0,0 +1,31 @@ +PREOPERATIVE DIAGNOSIS: + + Blood loss anemia. + +POSTOPERATIVE DIAGNOSES: + +1. Normal colon with no evidence of bleeding. + +2. Hiatal hernia. + +3. Fundal gastritis with polyps. + +4. Antral mass. + +ANESTHESIA: + + Conscious sedation with Demerol and Versed. + +SPECIMEN: + +Antrum and fundal polyps. + +HISTORY: + + The patient is a 66-year-old African-American female who presented to ABCD Hospital with mental status changes. She has been anemic as well with no gross evidence of blood loss. She has had a decreased appetite with weight loss greater than 20 lb over the past few months. After discussion with the patient and her daughter, she was scheduled for EGD and colonoscopy for evaluation. + +PROCEDURE: + + After informed consent was obtained, the patient was brought to the endoscopy suite. She was placed in the left lateral position and was given IV Demerol and Versed for sedation. When adequate level of sedation was achieved, a digital rectal exam was performed, which demonstrated no masses and no hemorrhoids. The colonoscope was inserted into the rectum and air was insufflated. The scope was coursed through the rectum and sigmoid colon, descending colon, transverse colon, ascending colon to the level of the cecum. There were no polyps, masses, diverticuli, or areas of inflammation. The scope was then slowly withdrawn carefully examining all walls. Air was aspirated. Once in the rectum, the scope was retroflexed. There was no evidence of perianal disease. No source of the anemia was identified. + +Attention was then taken for performing an EGD. The gastroscope was inserted into the hypopharynx and was entered into the hypopharynx. The esophagus was easily intubated and traversed. There were no abnormalities of the esophagus. The stomach was entered and was insufflated. The scope was coursed along the greater curvature towards the antrum. Adjacent to the pylorus, towards the anterior surface, was a mass like lesion with a central _______. It was not clear if this represents a healing ulcer or neoplasm. Several biopsies were taken. The mass was soft. The pylorus was then entered. The duodenal bulb and sweep were examined. There was no evidence of mass, ulceration, or bleeding. The scope was then brought back into the antrum and was retroflexed. In the fundus and body, there was evidence of streaking and inflammation. There were also several small sessile polyps, which were removed with biopsy forceps. Biopsy was also taken for CLO. A hiatal hernia was present as well. Air was aspirated. The scope was slowly withdrawn. The GE junction was unremarkable. The scope was fully withdrawn. The patient tolerated the procedure well and was transferred to recovery room in stable condition. She will undergo a CAT scan of her abdomen and pelvis to further assess any possible adenopathy or gastric obstructional changes. We will await the biopsy reports and further recommendations will follow. \ No newline at end of file diff --git a/3593_Gastroenterology.txt b/3593_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..0ce57d4995596f63b2f90da9063f3002723be6ea --- /dev/null +++ b/3593_Gastroenterology.txt @@ -0,0 +1,71 @@ +PROCEDURES: + +1. Esophagogastroduodenoscopy. + +2. Colonoscopy with polypectomy. + +PREOPERATIVE DIAGNOSES: + +1. History of esophageal cancer. + +2. History of colonic polyps. + +POSTOPERATIVE FINDINGS: + +1. Intact surgical intervention for a history of esophageal cancer. + +2. Melanosis coli. + +3. Transverse colon polyps in the setting of surgical changes related to partial and transverse colectomy. + +MEDICATIONS: + + Fentanyl 250 mcg and 9 mg of Versed. + +INDICATIONS: + + The patient is a 55-year-old dentist presenting for surveillance upper endoscopy in the setting of a history of esophageal cancer with staging at T2N0M0. + +He also has a history of adenomatous polyps and presents for surveillance of this process. + +Informed consent was obtained after explanation of the procedures, as well as risk factors of bleeding, perforation, and adverse medication reaction. + +ESOPHAGOGASTRODUODENOSCOPY: + + The patient was placed in the left lateral decubitus position and medicated with the above medications to achieve and maintain a conscious sedation. Vital signs were monitored throughout the procedure without evidence of hemodynamic compromise or desaturation. The Olympus single-channel endoscope was passed under direct visualization, through the oral cavity, and advanced to the second portion of the duodenum. + +FINDINGS: + +1. ESOPHAGUS: Anatomy consistent with esophagectomy with colonic transposition. + +2. STOMACH: Revealed colonic transposition with normal mucosa. + +3. DUODENUM: Normal. + +IMPRESSION: + + Intact surgical intervention with esophagectomy colonic transposition. + +COLONOSCOPY: + + The patient was then turned and a colonic 140-series colonoscope was passed under direct visualization through the anal verge and advanced to the cecum as identified by the appendiceal orifice. Circumferential visualization the colonic mucosa revealed the following: + +1. Cecum revealed melanosis coli. + +2. Ascending, melanosis coli. + +3. Transverse revealed two diminutive sessile polyps, excised by cold forceps technique and submitted to histology as specimen #1 with surgical changes consistent with partial colectomy related to the colonic transposition. + +4. Descending, melanosis coli. + +5. Sigmoid, melanosis coli. + +6. Rectum, melanosis coli. + +IMPRESSION: + + Diffuse melanosis coli with incidental finding of transverse colon polyps. + +RECOMMENDATION: + + Follow-up histology. Continue fiber with avoidance of stimulant laxatives. \ No newline at end of file diff --git a/3595_Gastroenterology.txt b/3595_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..91a78306d3942cae045497c0083297eeaa14fa90 --- /dev/null +++ b/3595_Gastroenterology.txt @@ -0,0 +1,89 @@ +CHIEF COMPLAINT: + + Dysphagia and hematemesis while vomiting. + +HISTORY OF PRESENT ILLNESS: + + This is a 53-year-old African American female with 15 years known history of HIV and hepatitis B, and known history of compensated heart failure, COPD + + who presented today with complaint of stuck food in her esophagus, bloody cough, and bloody vomiting since 4 o'clock this vomiting, when she ate eggplant parmigiana meal. The back and chest pain is 8/10, no radiation and is constant. She denied fever, abdominal pain, or dysphagia before current event eating bones or fish. This is the first episode of hematemesis and feeling of globus pallidus. In the emergency room, the patient was treated with nitropaste, morphine, and Lopressor with positive results for chest pain. CAT scan of the chest showed diffuse esophageal dilatation with residual food in it, no mediastinal air was identified. + +REVIEW OF SYSTEMS: + + The patient denied diarrhea, abdominal pain, fever, weight loss, dysphagia before this event. Denied any exertional chest pain or shortness of breath. No headache, limb weakness. No joint pain or muscle ache. No dysuria. + +PAST MEDICAL HISTORY: + +Remarkable for: + +1. Asthma. + +2. Hepatitis C - 1995. + +3. HIV + + known since 1995 and followed up by Dr. X, ABCD Medical Center, the last visit was 08/09. The patient does not take HIV medications against medical advice. + +4. Hypertension, known since 2008. + +5. Negative PPD test, 10/08. + +PAST SURGICAL HISTORY: + + Remarkable for hysterectomy in 2001, pilonidal cyst surgery in 2005. + +FAMILY HISTORY: + + Mother deceased at age 68 of cirrhosis. She had history of alcohol abuse. Father deceased at age 45, also has a history of alcohol abuse, cardiac disease, and hypertension. + +ALLERGIES: + + Not known allergies. + +MEDICATIONS AT HOME: + + Lisinopril 5 mg daily; metoprolol 25 mg twice daily; furosemide 40 mg once daily; Isentress 400 mg once daily, the patient does not take this medication for the last 3 months; Norvir 100 mg once daily; Prezista 400 mg once daily. The patient does not take her HIV medications for the last 2 to 3 months. Occasionally, she takes inhalation of albuterol and Ambien 10 mg once daily. + +SOCIAL HISTORY: + + She is single, lives with her 21-year-old daughter, works as CNA + + smokes one pack per day for the last 8 years. She had periods when she quit smoking and started again 2-1/2 years ago. She denied alcohol abuse and she was using cocaine in the past, last time she used cocaine 10 years ago. + +PHYSICAL EXAMINATION: + + Temperature 99.8, pulse 106, respiratory rate 18, blood pressure 162/97, saturation 99 on room air. African American female, not in acute respiratory distress, but uncomfortable, and showing some signs of back discomfort. Oriented x3, mildly drowsy, calm and cooperative. Eyes, EOMI + + PERRLA. Tympanic membranes normal appearance bilaterally. External canal, no erythema or discharge. Nose, no erythema or discharge. Throat, dry mucous, no exudates. No ulcers in oral area. Full upper denture and extensive decayed lower teeth. No cervical lymphadenopathy, no carotid bruits bilaterally. Heart: RRR + + S1 and S2 appreciated. No additional sounds or murmurs were auscultated. Lung: Good air entrance bilaterally. No rales or rhonchi. Abdomen: Soft, nontender, nondistended. No masses or organomegaly were palpated. Legs: No signs of DVT + + peripheral pulses full, posterior dorsalis pedis 2+. Skin: No rashes or other lesions, warm and well perfused. Nails: No clubbing. No other signs of skin infection. Neurological exam: Cranial nerves II through XII grossly intact. No motor or sensory deficit was found. + +CAT scan of the chest, which was done at 8 o'clock in the morning on 01/12/10. Impression: Cardiomegaly, normal aorta, large distention of esophagus containing food. Chest x-ray: Cardiomegaly, no evidence of CHF or pneumonia. EKG: Normal sinus rhythm, no signs of ischemia. + +LABORATORY DATA: + + Hemoglobin 10.4, hematocrit 30.6, white blood cells 7.3, neutrophils 75, platelets 197. Sodium 140, potassium 3.1, chloride 104, bicarb 25, glucose 113, BUN 19, creatinine 1.1, GFR 55, calcium 8.8, total protein 8.1, albumin 3.1, globulin 5.0, bilirubin 0.3, alk phos 63, GOT 23, GPT 22, lipase 104, amylase 85, protime 10.2, INR 1, PTT 25.8. Urine: Negative for ketones, protein, glucose, blood, and nitrite, bacteria 2+. Troponin 0.040. BNP 1328. + +PLAN: + +1. Diffuse esophageal dilatation/hematemesis. We will put her n.p.o. + + we will give IV fluid, half normal saline D5 100 mL per hour. I discussed the case with Dr. Y, gastroenterologist. The patient planned for EGD starting today. Differential diagnosis may include foreign body, achalasia, Candida infection, or CMV esophagitis. We will treat according to the EGD findings. We will give IV Nexium 40 mg daily for GI prophylaxis. We will hold all p.o. medication. + +2. CHF. Cardiomegaly on x-ray. She is clinically stable. Lungs are clear. No radiological sign of CHF exacerbation. We will restart lisinopril and metoprolol after EGD study will be completed. + +3. HIV - follow up by Dr. X, (ABCD Medical Center). The last visit was on 08/08. The patient was not taking her HIV medications for the last 3 months and does not know her CD4 number or viral load. We will check CD4 number and viral load. We will contact Dr. X (ID specialist in ABCD Med). + +4. Hypertension. We will control blood pressor with Lopressor 5 mg IV p.r.n. If blood pressure more than 160/90, we will hold metoprolol and lisinopril. + +5. Hepatitis C, known since 1995. The patient does not take any treatment. + +6. Tobacco abuse. The patient refused nicotine patch. + +7. GI prophylaxis as stated above; and DVT prophylaxis, compression socks. We will restrain from using heparin or Lovenox. + +ADDENDUM: + + The patient was examined by Dr. Y, gastroenterologist, who ordered a CAT scan with oral contrast, which showed persistent distention of the esophagus with elementary debris within the lumen of the esophagus. There is no evidence of leakage of the oral contrast. There is decrease in size of periaortic soft tissue density around the descending aorta, this is associated with increase in very small left pleural effusion in the intervening time. There is no evidence of pneumomediastinum or pneumothorax, lungs are clear, contrast is present in stomach. After procedure, the patient had profuse vomiting with bloody content and spiked fever 102. The patient felt relieved after vomiting. The patient was started on aztreonam 1 g IV every 8 hours, Flagyl 500 mg IV every 8 hours. ID consult was called and thoracic surgeon consult was ordered. \ No newline at end of file diff --git a/3596_Gastroenterology.txt b/3596_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..ba91a38567b41cffa30af41a6cf3d0ebe3a57a4b --- /dev/null +++ b/3596_Gastroenterology.txt @@ -0,0 +1,35 @@ +ADMITTING DIAGNOSES: + + Hiatal hernia, gastroesophageal reflux disease reflux. + +DISCHARGE DIAGNOSES: + + Hiatal hernia, gastroesophageal reflux disease reflux. + +SECONDARY DIAGNOSIS: + + Postoperative ileus. + +PROCEDURES DONE: + + Hiatal hernia repair and Nissen fundoplication revision. + +BRIEF HISTORY: + + The patient is an 18-year-old male who has had a history of a Nissen fundoplication performed six years ago for gastric reflux. Approximately one year ago, he was involved in a motor vehicle accident and CT scan at that time showed that he had a hiatal hernia. Over the past year, this has caused him an increasing number of problems, including chest pain when he eats, and shortness of breath after large meals. He is also having reflux symptoms again. He presents to us for repair of the hiatal hernia and revision of the Nissen fundoplication. + +HOSPITAL COURSE: + + Mr. A was admitted to the adolescent floor by Brenner Children's Hospital after his procedure. He was stable at that time. He did complain of some nausea. However, he did not have any vomiting at that time. He had an NG tube in and was n.p.o. He also had a PCA for pain management as well as Toradol. On postoperative day #1, he complained of not being able to urinate, so a Foley catheter was placed. Over the next several days, his hospital course proceeded as follows. He continued to complain of some nausea; however, he did not ever have any vomiting. Eventually, the Foley catheter was discontinued and he had excellent urine output without any complications. He ambulated frequently. He remained n.p.o. for three days. He also had the NG tube in during that time. On postoperative day #4, he began to have some flatus, and the NG tube was discontinued. He was advanced to a liquid diet and tolerated this without any complications. At this time, he was still using the PCA for pain control. However, he was using it much less frequently than on days #1 and #2 postoperatively. After tolerating the full liquid diet without any complications, he was advanced to a soft diet and his pain medications were transitioned to p.o. medications rather than the PCA. The PCA was discontinued. He tolerated the soft diet without any complications and continued to have flatus frequently. On postoperative day #6, it was determined that he was stable for discharge to home as he was taking p.o. without any complications. His pain was well controlled with p.o. pain medications. He was passing gas frequently, had excellent urine output, and was ambulating frequently without any issues. + +DISCHARGE CONDITION: + + Stable. + +DISPOSITION: + + Discharged to home. + +DISCHARGE INSTRUCTIONS: + + The patient was discharged to home with instructions for maintaining a soft diet. It was also recommended that he does not drink any soda postoperatively. He is instructed to keep his incision site clean and dry and it was also recommended that he avoid any heavy lifting. He will be able to attend school when it starts in a few weeks. However, he is not going to be able to play football in the near future. He was given prescription for pain medication upon discharge. He is instructed to contact Pediatric Surgery if he has any fevers, any nausea and vomiting, any chest pain, any constipation, or any other concerns. \ No newline at end of file diff --git a/3599_Gastroenterology.txt b/3599_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..de3688b9f976be34a2489bedc0c893a1951cb763 --- /dev/null +++ b/3599_Gastroenterology.txt @@ -0,0 +1,29 @@ +CT ABDOMEN WITH AND WITHOUT CONTRAST AND CT PELVIS WITH CONTRAST + +REASON FOR EXAM: + + Generalized abdominal pain, nausea, diarrhea, and recent colonic resection in 11/08. + +TECHNIQUE: + + Axial CT images of the abdomen were obtained without contrast. Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue-300. + +FINDINGS: + + The liver is normal in size and attenuation. + +The gallbladder is normal. + +The spleen is normal in size and attenuation. + +The adrenal glands and pancreas are unremarkable. + +The kidneys are normal in size and attenuation. + +No hydronephrosis is detected. Free fluid is seen within the right upper quadrant within the lower pelvis. A markedly thickened loop of distal small bowel is seen. This segment measures at least 10-cm long. No definite pneumatosis is appreciated. No free air is apparent at this time. Inflammatory changes around this loop of bowel. Mild distention of adjacent small bowel loops measuring up to 3.5 cm is evident. No complete obstruction is suspected, as there is contrast material within the colon. Postsurgical changes compatible with the partial colectomy are noted. Postsurgical changes of the anterior abdominal wall are seen. Mild thickening of the urinary bladder wall is seen. + +IMPRESSION: + +1. Marked thickening of a segment of distal small bowel is seen with free fluid within the abdomen and pelvis. An inflammatory process such as infection or ischemia must be considered. Close interval followup is necessary. + +2. Thickening of the urinary bladder wall is nonspecific and may be due to under distention. However, evaluation for cystitis is advised. \ No newline at end of file diff --git a/3600_Gastroenterology.txt b/3600_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..82b7a65cb5a32a772fe4a5f0957da66936c98745 --- /dev/null +++ b/3600_Gastroenterology.txt @@ -0,0 +1,27 @@ +CT ABDOMEN WITH CONTRAST AND CT PELVIS WITH CONTRAST + +REASON FOR EXAM: + + Generalized abdominal pain with swelling at the site of the ileostomy. + +TECHNIQUE: + + Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300. + +CT ABDOMEN: + +The liver, spleen, pancreas, adrenal glands, and kidneys are unremarkable. Punctate calcifications in the gallbladder lumen likely represent a gallstone. + +CT PELVIS: + +Postsurgical changes of a left lower quadrant ileostomy are again seen. There is no evidence for an obstruction. A partial colectomy and diverting ileostomy is seen within the right lower quadrant. The previously seen 3.4 cm subcutaneous fluid collection has resolved. Within the left lower quadrant, a 3.4 cm x 2.5 cm loculated fluid collection has not significantly changed. This is adjacent to the anastomosis site and a pelvic abscess cannot be excluded. No obstruction is seen. The appendix is not clearly visualized. The urinary bladder is unremarkable. + +IMPRESSION: + +1. Resolution of the previously seen subcutaneous fluid collection. + +2. Left pelvic 3.4 cm fluid collection has not significantly changed in size or appearance. These findings may be due to a pelvic abscess. + +3. Right lower quadrant ileostomy has not significantly changed. + +4. Cholelithiasis. \ No newline at end of file diff --git a/3601_Gastroenterology.txt b/3601_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..62ea4b65fa6c2c02623376ccf9991d4d52888574 --- /dev/null +++ b/3601_Gastroenterology.txt @@ -0,0 +1,33 @@ +EXAM: + + CT examination of the abdomen and pelvis with intravenous contrast. + +INDICATIONS: + + Abdominal pain. + +TECHNIQUE: + +CT examination of the abdomen and pelvis was performed after 100 mL of intravenous Isovue-300 contrast administration. Oral contrast was not administered. There was no comparison of studies. + +FINDINGS + +CT PELVIS: + +Within the pelvis, the uterus demonstrates a thickened-appearing endometrium. There is also a 4.4 x 2.5 x 3.4 cm hypodense mass in the cervix and lower uterine segment of uncertain etiology. There is also a 2.5 cm intramural hypodense mass involving the dorsal uterine fundus likely representing a fibroid. Several smaller fibroids were also suspected. + +The ovaries are unremarkable in appearance. There is no free pelvic fluid or adenopathy. + +CT ABDOMEN: + +The appendix has normal appearance in the right lower quadrant. There are few scattered diverticula in the sigmoid colon without evidence of diverticulitis. The small and large bowels are otherwise unremarkable. The stomach is grossly unremarkable. There is no abdominal or retroperitoneal adenopathy. There are no adrenal masses. The kidneys, liver, gallbladder, and pancreas are in unremarkable appearance. The spleen contains several small calcified granulomas, but no evidence of masses. It is normal in size. The lung bases are clear bilaterally. The osseous structures are unremarkable other than mild facet degenerative changes at L4-L5 and L5-S1. + +IMPRESSION: + +1. Hypoattenuating mass in the lower uterine segment and cervix of uncertain etiology measuring approximately 4.4 x 2.5 x 3.4 cm. + +2. Multiple uterine fibroids. + +3. Prominent endometrium. + +4. Followup pelvic ultrasound is recommended. \ No newline at end of file diff --git a/3603_Gastroenterology.txt b/3603_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..60020371fb167723baac3045fcb48a0a7af402ed --- /dev/null +++ b/3603_Gastroenterology.txt @@ -0,0 +1,23 @@ +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. \ No newline at end of file diff --git a/3607_Gastroenterology.txt b/3607_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..01f9e1cd21d934b8f8cce9c09faad40cfa8ed205 --- /dev/null +++ b/3607_Gastroenterology.txt @@ -0,0 +1,64 @@ +CHIEF COMPLAINT: + + "I want my colostomy reversed." + +HISTORY OF PRESENT ILLNESS: + + Mr. A is a pleasant 43-year-old African-American male who presents to our clinic for a colostomy reversal as well as repair of an incisional hernia. The patient states that in November 2007, he presented to High Point Regional Hospital with sharp left lower quadrant pain and was emergently taken to Surgery where he woke up with a "bag." According to some notes that were faxed to our office from the surgeon in High Point who performed his initial surgery, Dr. X, the patient had diverticulitis with perforated sigmoid colon, and underwent a sigmoid colectomy with end colostomy and Hartmann's pouch. The patient was unaware of his diagnosis; therefore, we discussed that with him today in clinic. The patient also complains of the development of an incisional hernia since his surgery in November. He was seen back by Dr. X in April 2008 and hopes that Dr. X may reverse his colostomy and repair his hernia since he did his initial surgery, but because the patient has lost his job and has no insurance, he was referred to our clinic by Dr. X. Currently, the patient does state that his hernia bothers him more so than his colostomy, and if it were not for the hernia then he may just refrain from having his colostomy reversed; however, the hernia has grown in size and causing him significant discomfort. He feels that he always has to hold his hand over the hernia to prevent it from prolapsing and causing him even more discomfort. + +PAST MEDICAL AND SURGICAL HISTORY: + +1. Gastroesophageal reflux disease. + +2. Question of hypertension. + +3. Status post sigmoid colectomy with end colostomy and Hartmann's pouch in November 2007 at High Point Regional. + +4. Status post cholecystectomy. + +7. Status post unknown foot surgery. + +MEDICATIONS: + + None. + +ALLERGIES: + + No known drug allergies. + +SOCIAL HISTORY: + + The patient lives in Greensboro. He smokes one pack of cigarettes a day and has done so for 15 years. He denies any IV drug use and has an occasional alcohol. + +FAMILY HISTORY: + +Positive for diabetes, hypertension, and coronary artery disease. + +REVIEW OF SYSTEMS: + + Please see history of present illness; otherwise, the review of systems is negative. + +PHYSICAL EXAMINATION: + +VITAL SIGNS: Temperature 95.9, pulse 67, blood pressure 135/79, and weight 208 pounds. + +GENERAL: This is a pleasant African-American male appearing his stated age in no acute distress. + +HEENT: Normocephalic, atraumatic. Pupils are equal, round, and reactive to light and accommodation. Moist mucous membranes. Extraocular movements intact. + +NECK: Supple, no JVD + + and no lymphadenopathy. + +CARDIOVASCULAR: Regular rate and rhythm. + +LUNGS: Clear to auscultation bilaterally. + +ABDOMEN: Soft, nontender, and nondistended with a left lower quadrant stoma. The stoma is pink, protuberant, and productive. The patient also has a midline incisional hernia approximately 6 cm in diameter. It is reducible. Otherwise, there are no further hernias or masses noted. + +EXTREMITIES: No clubbing, cyanosis or edema. + +ASSESSMENT AND PLAN: + +This is a 43-year-old gentleman who underwent what sounds like a sigmoid colectomy with end colostomy and Hartmann's pouch in November of 2007 secondary to perforated colon from diverticulitis. The patient presents for reversal of his colostomy as well as repair of his incisional hernia. I have asked the patient to return to High Point Regional and get his medical records including the operative note and pathology results from his initial surgery so that I would have a better idea of what was done during his initial surgery. He stated that he would try and do this and bring the records to our clinic on his next appointment. I have also set him up for a barium enema to study the rectal stump. He will return to us in two weeks at which time we will review his radiological studies and his medical records from the outside hospital and determine the best course of action from that point. This was discussed with the patient as well as his sister and significant other in the clinic today. They were in agreement with this plan. We also called the social worker to come and help the patient get more ostomy appliances, as he stated that he had no more and he was having to reuse the existing ostomy bag. To my understanding, his social worker, as well as the ostomy nurses were able to get him some assistance with this. + diff --git a/3610_Gastroenterology.txt b/3610_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..c2e9537db21dff968a073a54e95527de7913f35b --- /dev/null +++ b/3610_Gastroenterology.txt @@ -0,0 +1,51 @@ +HISTORY: + + A is a 55-year-old who I know well because I have been taking care of her husband. She comes for discussion of a screening colonoscopy. Her last colonoscopy was in 2002, and at that time she was told it was essentially normal. Nonetheless, she has a strong family history of colon cancer, and it has been almost four to five years so she wants to have a repeat colonoscopy. I told her that the interval was appropriate and that it made sense to do so. She denies any significant weight change that she cannot explain. She has had no hematochezia. She denies any melena. She says she has had no real change in her bowel habit but occasionally does have thin stools. + +PAST MEDICAL HISTORY: + + On today's visit we reviewed her entire health history. Surgically she has had a stomach operation for ulcer disease back in 1974, she says. She does not know exactly what was done. It was done at a hospital in California which she says no longer exists. This makes it difficult to find out exactly what she had done. She also had her gallbladder and appendix taken out in the 1970s at the same hospital. Medically she has no significant problems and no true medical illnesses. She does suffer from some mild gastroparesis, she says. + +MEDICATIONS: + + Reglan 10 mg once a day. + +ALLERGIES: + + She denies any allergies to medications but is sensitive to medications that cause her to have ulcers, she says. + +SOCIAL HISTORY: + + She still smokes one pack of cigarettes a day. She was counseled to quit. She occasionally uses alcohol. She has never used illicit drugs. She is married, is a housewife, and has four children. + +FAMILY HISTORY: + + Positive for diabetes and cancer. + +REVIEW OF SYSTEMS: + + Essentially as mentioned above. + +PHYSICAL EXAMINATION: + +GENERAL: A is a healthy appearing female in no apparent distress. + +VITAL SIGNS: Her vital signs reveal a weight of 164 pounds, blood pressure 140/90, temperature of 97.6 degrees F. + +HEENT: No cervical bruits, thyromegaly, or masses. She has no lymphadenopathy in the head and neck, supraclavicular, or axillary spaces bilaterally. + +LUNGS: Clear to auscultation bilaterally with no wheezes, rubs, or rhonchi. + +HEART: Regular rate and rhythm without murmur, rub, or gallop. + +ABDOMEN: Soft, nontender, nondistended. + +EXTREMITIES: No cyanosis, clubbing, or edema, with good pulses in the radial arteries bilaterally. + +NEURO: No focal deficits, is intact to soft touch in all four. + +ASSESSMENT AND RECOMMENDATIONS: + + In light of her history and physical, clearly the patient would be well served with an upper and lower endoscopy. We do not know what the anatomy is, and if she did have an antrectomy, she needs to be checked for marginal ulcers. She also complains of significant reflux and has not had an upper endoscopy in over five to six years as well. I discussed the risks, benefits, and alternatives to upper and lower endoscopy, and these include over sedation, perforation, and dehydration, and she wants to proceed. + +We will schedule her for an upper and lower endoscopy at her convenience. \ No newline at end of file diff --git a/3611_Gastroenterology.txt b/3611_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..57d17aa6866922b8f527d645afb4735645f3b5f4 --- /dev/null +++ b/3611_Gastroenterology.txt @@ -0,0 +1,43 @@ +EXAM: + + CT pelvis with contrast and ct abdomen with and without contrast. + +INDICATIONS: + +Abnormal liver enzymes and diarrhea. + +TECHNIQUE: + + CT examination of the abdomen and pelvis was performed after 100 mL of intravenous contrast administration and oral contrast administration. Pre-contrast images through the abdomen were also obtained. + +COMPARISON: + +There were no comparison studies. + +FINDINGS: + +The lung bases are clear. + +The liver demonstrates mild intrahepatic biliary ductal dilatation. These findings may be secondary to the patient's post cholecystectomy state. The pancreas, spleen, adrenal glands, and kidneys are unremarkable. + +There is a 13 mm peripheral-enhancing fluid collection in the anterior pararenal space of uncertain etiology. There are numerous nonspecific retroperitoneal and mesenteric lymph nodes. These may be reactive; however, an early neoplastic process would be difficult to totally exclude. + +There is a right inguinal hernia containing a loop of small bowel. This may produce a partial obstruction as there is mild fluid distention of several small bowel loops, particularly in the right lower quadrant. The large bowel demonstrates significant diverticulosis coli of the sigmoid and distal descending colon without evidence of diverticulitis. + +There is diffuse osteopenia along with significant degenerative changes in the lower lumbar spine. + +The urinary bladder is unremarkable. The uterus is not visualized. + +IMPRESSION: + +1. Right inguinal hernia containing small bowel. Partial obstruction is suspected. + +2. Nonspecific retroperitoneal and mesenteric lymph nodes. + +3. Thirteen millimeter of circumscribed fluid collection in the anterior pararenal space of uncertain etiology. + +4. Diverticulosis without evidence of diverticulitis. + +5. Status post cholecystectomy with mild intrahepatic biliary ductal dilatation. + +6. Osteopenia and degenerative changes of the spine and pelvis. \ No newline at end of file diff --git a/3612_Gastroenterology.txt b/3612_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..5aaca5dfa59bedf9244a0f77d4e3a3816ea20494 --- /dev/null +++ b/3612_Gastroenterology.txt @@ -0,0 +1,58 @@ +HISTORY OF PRESENT ILLNESS: + + See chart attached. + +MEDICATIONS: + + Tramadol 50 mg every 4 to 6 hours p.r.n. + + hydrocodone 7.5 mg/500 mg every 6 hours p.r.n. + + zolpidem 10 mg at bedtime, triamterene 37.5 mg, atenolol 50 mg, vitamin D, TriCor 145 mg, simvastatin 20 mg, ibuprofen 600 mg t.i.d. + + and Lyrica 75 mg. + +FAMILY HISTORY: + + Mother is age 78 with history of mesothelioma. Father is alive, but unknown medical history as they have been estranged. She has a 51-year-old sister with history of multiple colon polyps. She has 2 brothers, 1 of whom has schizophrenia, but she knows very little about their medical history. To the best of her knowledge, there are no family members with stomach cancer or colon cancer. + +SOCIAL HISTORY: + + She was born in Houston, Texas and moved to Florida about 3 years ago. She is divorced. She has worked as a travel agent. She has 2 sons ages 24 and 26, both of whom are alive and well. She smokes a half a pack of cigarettes per day for more than 35 years. She does not consume alcohol. + +REVIEW OF SYSTEMS: + + As per the form filled out in our office today is positive for hypertension, weakness in arms and legs, arthritis, pneumonia, ankle swelling, getting full quickly after eating, loss of appetite, weight loss, which is stated as fluctuating up and down 4 pounds, trouble swallowing, heartburn, indigestion, belching, nausea, diarrhea, constipation, change in bowel habits, change in consistency, rectal bleeding, hemorrhoids, abdominal discomfort and cramping associated with constipation, hepatitis A or infectious hepatitis in the past, and smoking and alcohol as previously stated. Otherwise, review of systems is negative for strokes, paralysis, gout, cataracts, glaucoma, respiratory difficulties, tuberculosis, chest pain, heart disease, kidney stones, hematuria, rheumatic fever, scarlet fever, cancer, diabetes, thyroid disease, seizure disorder, blood transfusions, anemia, jaundice, or pruritus. + +PHYSICAL EXAMINATION: + +Weight 152 pounds. Height is 5 feet 3 inches. Blood pressure 136/80. Pulse 68. In general: She is a well-developed and well-nourished female who ambulates with the assistance of a cane. Neurologically nonfocal. Awake, alert, and oriented x 3. HEENT: Head normocephalic, atraumatic. Sclerae anicteric. Conjunctivae are pink. Mouth is moist without any obvious oral lesions. Neck is supple. There is no submandibular, submaxillary, axillary, supraclavicular, or epitrochlear adenopathy appreciable. Lungs are clear to auscultation bilaterally. Heart: Regular rate and rhythm without obvious gallops or murmurs. Abdomen is soft, nontender with good bowel sounds. No organomegaly or masses are appreciable. Extremities are without clubbing, cyanosis, and/or edema. Skin is warm and dry. Rectal was deferred and will be done at the time of the colonoscopy. + +IMPRESSION: + +1. A 50-year-old female whose 51-year-old sister has a history of multiple colon polyps, which may slightly increase her risk for colon cancer in the future. + +2. Reports of recurrent bright red blood per rectum, mostly on the toilet paper over the past year. Bleeding most likely consistent with internal hemorrhoids; however, she needs further evaluation for colon polyps or colon cancer. + +3. Alternations between constipation and diarrhea for the past several years with some lower abdominal cramping and discomfort particularly associated with constipation. She is on multiple medications including narcotics and may have developed narcotic bowel syndrome. + +4. A long history of pyrosis, dyspepsia, nausea, and belching for many years relieved by antacids. She may likely have underlying gastroesophageal reflux disease. + +5. A 1-year history of some early satiety and fluctuations in her weight up and down 4 pounds. She may also have some GI dysmotility including gastroparesis. + +6. Report of dysphagia to solids over the past several years with a history of a bone spur in her cervical spine. If this bone spur is pressing anteriorly, it could certainly cause recurrent symptoms of dysphagia. Differential also includes peptic stricture or Schatzki's ring, and even remotely, the possibility of an esophageal malignancy. + +7. A history of infectious hepatitis in the past with some recent mild elevations in AST and ALT levels without clear etiology. She may have some reaction to her multiple medications including her statin drugs, which can cause mild elevations in transaminases. She may have some underlying fatty liver disease and differential could include some form of viral hepatitis such as hepatitis B or even C. + +PLAN: + +1. We have asked her to follow up with her primary care physician with regard to this recent elevation in her transaminases. She will likely have the lab tests repeated in the future, and if they remain persistently elevated, we will be happy to see her in the future for further evaluation if her primary care physician would like. + +2. Discussed reflux precautions and gave literature for further review. + +3. Schedule an upper endoscopy with possible esophageal dilatation, as well as colonoscopy with possible infrared coagulation of suspected internal hemorrhoids. Both procedures were explained in detail including risks and complications such as adverse reaction to medication, as well as respiratory embarrassment, infection, bleeding, perforation, and possibility of missing a small polyp or tumor. + +4. Alternatives including upper GI series, flexible sigmoidoscopy, barium enema, and CT colonography were discussed; however, the patient agrees to proceed with the plan as outlined above. + +5. Due to her sister's history of colon polyps, she will likely be advised to have a repeat colonoscopy in 5 years or perhaps sooner pending the results of her baseline examination. + diff --git a/3614_Gastroenterology.txt b/3614_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..2cca5bddc48ba76f8eb338680abb17a5c1178273 --- /dev/null +++ b/3614_Gastroenterology.txt @@ -0,0 +1,39 @@ +EXAM: + + CT scan of the abdomen and pelvis without and with intravenous contrast. + +CLINICAL INDICATION: + + Left lower quadrant abdominal pain. + +COMPARISON: + + None. + +FINDINGS: + + CT scan of the abdomen and pelvis was performed without and with intravenous contrast. Total of 100 mL of Isovue was administered intravenously. Oral contrast was also administered. + +The lung bases are clear. The liver is enlarged and decreased in attenuation. There are no focal liver masses. + +There is no intra or extrahepatic ductal dilatation. + +The gallbladder is slightly distended. + +The adrenal glands, pancreas, spleen, and left kidney are normal. + +A 12-mm simple cyst is present in the inferior pole of the right kidney. There is no hydronephrosis or hydroureter. + +The appendix is normal. + +There are multiple diverticula in the rectosigmoid. There is evidence of focal wall thickening in the sigmoid colon (image #69) with adjacent fat stranding in association with a diverticulum. These findings are consistent with diverticulitis. No pneumoperitoneum is identified. There is no ascites or focal fluid collection. + +The aorta is normal in contour and caliber. + +There is no adenopathy. + +Degenerative changes are present in the lumbar spine. + +IMPRESSION: + + Findings consistent with diverticulitis. Please see report above. \ No newline at end of file diff --git a/3615_Gastroenterology.txt b/3615_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..3e3fa43bc537a89331d897a65cb97fada37023d1 --- /dev/null +++ b/3615_Gastroenterology.txt @@ -0,0 +1,35 @@ +EXAM: + + CT Abdomen and Pelvis with contrast + +REASON FOR EXAM: + + Nausea, vomiting, diarrhea for one day. Fever. Right upper quadrant pain for one day. + +COMPARISON: + + None. + +TECHNIQUE: + + CT of the abdomen and pelvis performed without and with approximately 54 ml Isovue 300 contrast enhancement. + +CT ABDOMEN: + + Lung bases are clear. The liver, gallbladder, spleen, pancreas, and bilateral adrenal/kidneys are unremarkable. The aorta is normal in caliber. There is no retroperitoneal lymphadenopathy. + +CT PELVIS: + + The appendix is visualized along its length and is diffusely unremarkable with no surrounding inflammatory change. Per CT + + the colon and small bowel are unremarkable. The bladder is distended. No free fluid/air. Visualized osseous structures demonstrate no definite evidence for acute fracture, malalignment, or dislocation. + +IMPRESSION: + +1. Unremarkable exam; specifically no evidence for acute appendicitis. + +2. No acute nephro-/ureterolithiasis. + +3. No secondary evidence for acute cholecystitis. + +Results were communicated to the ER at the time of dictation. \ No newline at end of file diff --git a/3617_Gastroenterology.txt b/3617_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..7a36cf9e9982a199fbf8d3ec56a7f32842688550 --- /dev/null +++ b/3617_Gastroenterology.txt @@ -0,0 +1,38 @@ +PAST MEDICAL HISTORY: + + Significant for arthritis in her knee, anxiety, depression, high insulin levels, gallstone attacks, and PCOS. + +PAST SURGICAL HISTORY: + + None. + +SOCIAL HISTORY: + + Currently employed. She is married. She is in sales. She does not smoke. She drinks wine a few drinks a month. + +CURRENT MEDICATIONS: + + She is on Carafate and Prilosec. She was on metformin, but she stopped it because of her abdominal pains. + +ALLERGIES: + + She is allergic to PENICILLIN. + +REVIEW OF SYSTEMS: + + Negative for heart, lungs, GI + + GU + + cardiac, or neurologic. Denies specifically asthma, allergies, high blood pressure, high cholesterol, diabetes, chronic lung disease, ulcers, headache, seizures, epilepsy, strokes, thyroid disorder, tuberculosis, bleeding, clotting disorder, gallbladder disease, positive liver disease, kidney disease, cancer, heart disease, and heart attack. + +PHYSICAL EXAMINATION: + + She is afebrile. Vital Signs are stable. HEENT: EOMI. PERRLA. Neck is soft and supple. Lungs clear to auscultation. She is mildly tender in the abdomen in the right upper quadrant. No rebound. Abdomen is otherwise soft. Positive bowel sounds. Extremities are nonedematous. Ultrasound reveals gallstones, no inflammation, common bile duct in 4 mm. + +IMPRESSION/PLAN: + + I have explained the risks and potential complications of laparoscopic cholecystectomy in detail including bleeding, infection, deep venous thrombosis, pulmonary embolism, cystic leak, duct leak, possible need for ERCP + + and possible need for further surgery among other potential complications. She understands and we will proceed with the surgery in the near future. + diff --git a/3618_Gastroenterology.txt b/3618_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..0684207dc375b1190db56a52fab983d8e5613b1c --- /dev/null +++ b/3618_Gastroenterology.txt @@ -0,0 +1,22 @@ +Patient was informed by Dr. ABC that he does not need sleep study as per patient. + +PHYSICAL EXAMINATION: + +General: Pleasant, brighter. + +Vital signs: 117/78, 12, 56. + +Abdomen: Soft, nontender. Bowel sounds normal. + +ASSESSMENT AND PLAN: + +1. Constipation. Milk of Magnesia 30 mL daily p.r.n. + + Dulcolax suppository twice a week p.r.n. + +2. CAD/angina. See cardiologist this afternoon. + +Call me if constipation not resolved by a.m. + + consider a Fleet enema then as discussed. + diff --git a/3619_Gastroenterology.txt b/3619_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..d00f01282945ceaaf5f7bfb4e23ee274874213cc --- /dev/null +++ b/3619_Gastroenterology.txt @@ -0,0 +1,33 @@ +PREOPERATIVE DIAGNOSIS: + + Blood loss anemia. + +POSTOPERATIVE DIAGNOSES: + +1. Diverticulosis coli. + +2. Internal hemorrhoids. + +3. Poor prep. + +PROCEDURE PERFORMED: + + Colonoscopy with photos. + +ANESTHESIA: + + Conscious sedation per Anesthesia. + +SPECIMENS: + + None. + +HISTORY: + + The patient is an 85-year-old female who was admitted to the hospital with a markedly decreased hemoglobin and blood loss anemia. She underwent an EGD and attempted colonoscopy; however, due to a very poor prep, only a flexible sigmoidoscopy was performed at that time. A coloscopy is now being performed for completion. + +PROCEDURE: + + After proper informed consent was obtained, the patient was brought to the Endoscopy Suite. She was placed in the left lateral position and was given sedation by the Anesthesia Department. A digital rectal exam was performed and there was no evidence of mass. The colonoscope was then inserted into the rectum. There was some solid stool encountered. The scope was maneuvered around this. There was relatively poor prep as the scope was advanced through the sigmoid colon and portions of the descending colon. The scope was then passed through the transverse colon and ascending colon to the cecum. No masses or polyps were noted. Visualization of the portions of the colon was however somewhat limited. There were scattered diverticuli noted in the sigmoid. + +The scope was slowly withdrawn carefully examining all walls. Once in the rectum, the scope was retroflexed and nonsurgical internal hemorrhoids were noted. The scope was then completely withdrawn. The patient tolerated the procedure well and was transferred to recovery room in stable condition. She will be placed on a high-fiber diet and Colace and we will continue to monitor her hemoglobin. \ No newline at end of file diff --git a/3623_Gastroenterology.txt b/3623_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..18d04dd317c327f224183b4e2f03d1661357f390 --- /dev/null +++ b/3623_Gastroenterology.txt @@ -0,0 +1,11 @@ +PREPROCEDURE DIAGNOSIS: + + Abdominal pain, diarrhea, and fever. + +POSTPROCEDURE DIAGNOSIS: + + Pending pathology. + +PROCEDURES PERFORMED: + + Colonoscopy with multiple biopsies, including terminal ileum, cecum, hepatic flexure, and sigmoid colon. \ No newline at end of file diff --git a/3624_Gastroenterology.txt b/3624_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..a020f5b1101936d09b1fcee42f09afd57d7f73d6 --- /dev/null +++ b/3624_Gastroenterology.txt @@ -0,0 +1,5 @@ +A colonoscope was then passed through the rectum, all the way toward the cecum, which was identified by the presence of the appendiceal orifice and ileocecal valve. This was done without difficulty and the bowel preparation was good. The ileocecal valve was intubated and the distal 2 to 3 cm of terminal ileum was inspected and was normal. The colonoscope was then slowly withdrawn and a careful examination of the mucosa was performed. + +COMPLICATIONS: + + None. \ No newline at end of file diff --git a/3627_Gastroenterology.txt b/3627_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..cd4092565f43f8787c417b86dae83a6eb9f6e9f8 --- /dev/null +++ b/3627_Gastroenterology.txt @@ -0,0 +1,27 @@ +INDICATIONS FOR PROCEDURE: + + A 79-year-old Filipino woman referred for colonoscopy secondary to heme-positive stools. Procedure done to rule out generalized diverticular change, colitis, and neoplasia. + +DESCRIPTION OF PROCEDURE: + + The patient was explained the procedure in detail, possible complications including infection, perforation, adverse reaction of medication, and bleeding. Informed consent was signed by the patient. + +With the patient in left decubitus position, had received a cumulative dose of 4 mg of Versed and 75 mg of Demerol, using Olympus video colonoscope under direct visualization was advanced to the cecum. Photodocumentation of appendiceal orifice and the ileocecal valve obtained. Cecum was slightly obscured with stool but the colon itself was adequately prepped. There was no evidence of overt colitis, telangiectasia, or overt neoplasia. There was moderately severe diverticular change, which was present throughout the colon and photodocumented. The rectal mucosa was normal and retroflexed with mild internal hemorrhoids. The patient tolerated the procedure well without any complications. + +IMPRESSION: + +1. Colonoscopy to the cecum with adequate preparation. + +2. Long tortuous spastic colon. + +3. Moderately severe diverticular changes present throughout. + +4. Mild internal hemorrhoids. + +RECOMMENDATIONS: + +1. Clear liquid diet today. + +2. Follow up with primary care physician as scheduled from time to time. + +3. Increase fiber in diet, strongly consider fiber supplementation. \ No newline at end of file diff --git a/3631_Gastroenterology.txt b/3631_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..62f344ce9cd519719b51d77e320935632c4d239d --- /dev/null +++ b/3631_Gastroenterology.txt @@ -0,0 +1,43 @@ +PREOPERATIVE DIAGNOSIS: + + Alternating hard and soft stools. + +POSTOPERATIVE DIAGNOSIS: + +Sigmoid diverticulosis. + +Sessile polyp of the sigmoid colon. + +Pedunculated polyp of the sigmoid colon. + +PROCEDURE: + + Total colonoscopy with biopsy and snare polypectomy. + +PREP: + + 4/4. + +DIFFICULTY: + + 1/4. + +PREMEDICATION AND SEDATION: + + Fentanyl 100, midazolam 5. + +INDICATION FOR PROCEDURE: + + A 64-year-old male who has developed alternating hard and soft stools. He has one bowel movement a day. + +FINDINGS: + + There is extensive sigmoid diverticulosis, without evidence of inflammation or bleeding. There was a small, sessile polyp in the sigmoid colon, and a larger pedunculated polyp in the sigmoid colon, both appeared adenomatous. + +DESCRIPTION OF PROCEDURE: + + Preoperative counseling, including an explicit discussion of the risk and treatment of perforation was provided. Preoperative physical examination was performed. Informed consent was obtained. The patient was placed in the left lateral decubitus position. Premedications were given slowly by intravenous push. Rectal examination was performed, which was normal. The scope was introduced and passed with minimal difficulty to the cecum. This was verified anatomically and video photographs were taken of the ileocecal valve and appendiceal orifice. The scope was slowly withdrawn, the mucosa carefully visualized. It was normal in its entirety until reaching the sigmoid colon. Sigmoid colon had extensive diverticular disease, small-mouth, without inflammation or bleeding. In addition, there was a small sessile polyp, which was cold biopsied and recovered, and approximately an 8 mm pedunculated polyp. A snare was placed on the stalk of the polyp and divided with electrocautery. The polyp was recovered and sent for pathologic examination. Examination of the stalk showed good hemostasis. The scope was slowly withdrawn and the remainder of the examination was normal. + +ASSESSMENT: + + Diverticular disease. A diverticular disease handout was given to the patient's wife and a high fiber diet was recommended. In addition, 2 polyps, one of which is assuredly an adenoma. Patient needs a repeat colonoscopy in 3 years. \ No newline at end of file diff --git a/3633_Gastroenterology.txt b/3633_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..ef74c41f76a1ff9cda8c1c0ac03b1230bdb987a6 --- /dev/null +++ b/3633_Gastroenterology.txt @@ -0,0 +1,23 @@ +PROCEDURES PERFORMED: + + Colonoscopy. + +INDICATIONS: + + Renewed symptoms likely consistent with active flare of Inflammatory Bowel Disease, not responsive to conventional therapy including sulfasalazine, cortisone, local therapy. + +PROCEDURE: + + Informed consent was obtained prior to the procedure with special attention to benefits, risks, alternatives. Risks explained as bleeding, infection, bowel perforation, aspiration pneumonia, or reaction to the medications. Vital signs were monitored by blood pressure, heart rate, and oxygen saturation. Supplemental O2 given. Specifics discussed. Preprocedure physical exam performed. Stable vital signs. Lungs clear. Cardiac exam showed regular rhythm. Abdomen soft. Her past history, her past workup, her past visitation with me for Inflammatory Bowel Disease, well responsive to sulfasalazine reviewed. She currently has a flare and is not responding, therefore, likely may require steroid taper. At the same token, her symptoms are mild. She has rectal bleeding, essentially only some rusty stools. There is not significant diarrhea, just some lower stools. No significant pain. Therefore, it is possible that we are just dealing with a hemorrhoidal bleed, therefore, colonoscopy now needed. Past history reviewed. Specifics of workup, need for followup, and similar discussed. All questions answered. + +A normal digital rectal examination was performed. The PCF-160 AL was inserted into the anus and advanced to the cecum without difficulty, as identified by the ileocecal valve, cecal stump, and appendical orifice. All mucosal aspects thoroughly inspected, including a retroflexed examination. Withdrawal time was greater than six minutes. Unfortunately, the terminal ileum could not be intubated despite multiple attempts. + +Findings were those of a normal cecum, right colon, transverse colon, descending colon. A small cecal polyp was noted, this was biopsy-removed, placed in bottle #1. Random biopsies from the cecum obtained, bottle #2; random biopsies from the transverse colon obtained, as well as descending colon obtained, bottle #3. There was an area of inflammation in the proximal sigmoid colon, which was biopsied, placed in bottle #4. There was an area of relative sparing, with normal sigmoid lining, placed in bottle #5, randomly biopsied, and then inflammation again in the distal sigmoid colon and rectum biopsied, bottle #6, suggesting that we may be dealing with Crohn disease, given the relative sparing of the sigmoid colon and junk lesion. Retroflexed showed hemorrhoidal disease. Scope was then withdrawn, patient left in good condition. + +IMPRESSION: + + Active flare of Inflammatory Bowel Disease, question of Crohn disease. + +PLAN: + + I will have the patient follow up with me, will follow up on histology, follow up on the polyps. She will be put on a steroid taper and make an appointment and hopefully steroids alone will do the job. If not, she may be started on immune suppressive medication, such as azathioprine, or similar. All of this has been reviewed with the patient. All questions answered. \ No newline at end of file diff --git a/3634_Gastroenterology.txt b/3634_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..939c8abdca8d8248fee701e931ad0f2b44d37ca1 --- /dev/null +++ b/3634_Gastroenterology.txt @@ -0,0 +1,21 @@ +PREOPERATIVE DIAGNOSIS: + + Diarrhea, suspected irritable bowel. + +POSTOPERATIVE DIAGNOSIS: + + Normal colonoscopy. + + PREMEDICATIONS: + + Versed 5 mg, Demerol 75 mg IV. + +REPORTED PROCEDURE: + + The rectal exam revealed no external lesions. The prostate was normal in size and consistency. + +The colonoscope was inserted into the cecum with ease. The cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, sigmoid colon, and rectum were normal. The scope was retroflexed in the rectum and no abnormality was seen, so the scope was straightened, withdrawn, and the procedure terminated. + +ENDOSCOPIC IMPRESSION: + + Normal colonoscopy - no evidence of inflammatory disease, polyp, or other neoplasm. These findings are certainly consistent with irritable bowel syndrome. \ No newline at end of file diff --git a/3638_Gastroenterology.txt b/3638_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..225471fa0702052c6ed3d4d5bcc68d20a1a153c5 --- /dev/null +++ b/3638_Gastroenterology.txt @@ -0,0 +1,39 @@ +PROCEDURE: + + Colonoscopy. + +PREOPERATIVE DIAGNOSIS: + + Follow up adenomas. + +POSTOPERATIVE DIAGNOSES: + +1. Two colon polyps, removed. + +2. Small internal hemorrhoids. + +3. Otherwise normal examination of cecum. + +MEDICATIONS: + + Fentanyl 150 mcg and Versed 7 mg slow IV push. + +INDICATIONS: + + This is a 60-year-old white female with a history of adenomas. She does have irregular bowel habits. + +FINDINGS: + + The patient was placed in the left lateral decubitus position and the above medications were administered. The colonoscope was advanced to the cecum as identified by the ileocecal valve, appendiceal orifice, and blind pouch. The colonoscope was slowly withdrawn and a careful examination of the colonic mucosa was made, including a retroflexed view of the rectum. There was a 4 mm descending colon polyp, which was removed with jumbo forceps, and sent for histology in bottle one. There was a 10 mm pale, flat polyp in the distal rectum, which was removed with jumbo forceps, and sent for histology in bottle 2. There were small internal hemorrhoids. The remainder of the examination was normal to the cecum. The patient tolerated the procedure well without complication. + +IMPRESSION: + +1. Two colon polyps, removed. + +2. Small internal hemorrhoids. + +3. Otherwise normal examination to cecum. + +PLAN: + + I will await the results of the colon polyp histology. The patient was told the importance of daily fiber. \ No newline at end of file diff --git a/3640_Gastroenterology.txt b/3640_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..05b4d6589da3a0f1dbe81bf9b66dfbaed9841d6c --- /dev/null +++ b/3640_Gastroenterology.txt @@ -0,0 +1,19 @@ +INDICATIONS: + + This is a 55-year-old female who is having a colonoscopy to screen for colon cancer. There is no family history of colon cancer and there has been no blood in the stool. + +PROCEDURE PERFORMED: + +Colonoscopy. + +PREP: + + Fentanyl 100 mcg IV and 3 mg Versed IV. + +PROCEDURE: + + The tip of the endoscope was introduced into the rectum. Retroflexion of the tip of the endoscope failed to reveal any distal rectal lesions. The rest of the colon through to the cecum was well visualized. The cecal strap, ileocecal valve, and light reflex in the right lower quadrant were all identified. There was no evidence of tumor, polyp, mass, ulceration, or other focus of inflammation. Adverse reactions none. + +IMPRESSION: + + Normal colonic mucosa through to the cecum. There was no evidence of tumor or polyp. \ No newline at end of file diff --git a/3648_Gastroenterology.txt b/3648_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..9ca27e5c8012464530a554d54661bb9c404d956a --- /dev/null +++ b/3648_Gastroenterology.txt @@ -0,0 +1,21 @@ +PREOPERATIVE DIAGNOSES: + + Prior history of anemia, abdominal bloating. + +POSTOPERATIVE DIAGNOSIS: + + External hemorrhoids, otherwise unremarkable colonoscopy. + +PREMEDICATIONS: + + Versed 5 mg, Demerol 50 mg IV. + +REPORT OF PROCEDURE: + + Digital rectal exam revealed external hemorrhoids. The colonoscope was inserted into the rectal ampulla and advanced to the cecum. The position of the scope within the cecum was verified by identification of the appendiceal orifice. The cecum, the ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, and rectum were normal. The scope was retroflexed in the rectum and no abnormality was seen. So the scope was straightened, withdrawn, and the procedure terminated. + +ENDOSCOPIC IMPRESSION: + +1. Normal colonoscopy. + +2. External hemorrhoids. \ No newline at end of file diff --git a/3651_Gastroenterology.txt b/3651_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..6f5de8d76d91e7e749edca6446d965f5c5684eaa --- /dev/null +++ b/3651_Gastroenterology.txt @@ -0,0 +1,19 @@ +PROCEDURE: + + Colonoscopy. + +PREOPERATIVE DIAGNOSES: + + Change in bowel habits and rectal prolapse. + +POSTOPERATIVE DIAGNOSIS: + + Normal colonoscopy. + +PROCEDURE: + +The Olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve and the appendiceal orifice. The preparation was poor, but mucosa was visible after lavage and suction. Small lesions might have been missed in certain places, but no large lesions are likely to have been missed. The mucosa was normal, was visualized. In particular, there was no mucosal abnormality in the rectum and distal sigmoid, which is reported to be prolapsing. Biopsies were taken from the rectal wall to look for microscopic changes. The anal sphincter was considerably relaxed, with no tone and a gaping opening. The patient tolerated the procedure well and was sent to recovery room. + +FINAL DIAGNOSIS: + + Normal colonic mucosa to the cecum. No contraindications to consideration of a repair of the prolapse. \ No newline at end of file diff --git a/3654_Gastroenterology.txt b/3654_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..5f8feaa575c45473791630f4e80a0b287c9cd10a --- /dev/null +++ b/3654_Gastroenterology.txt @@ -0,0 +1,5 @@ +PROCEDURE IN DETAIL: + + Following instructions and completion of an oral colonoscopy prep, the patient, having been properly informed of, with signature consenting to total colonoscopy and indicated procedures, the patient received premedications of Vistaril 50 mg, Atropine 0.4 mg IM + + and then intravenous medications of Demerol 50 mg and Versed 5 mg IV. Perirectal inspection was normal. The Olympus video colonoscope then was introduced into the rectum and passed by directed vision to the cecum and into the terminal ileum. No abnormalities were seen of the terminal ileum, the ileocecal valve, cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, rectosigmoid and rectum. Retroflexion exam in the rectum revealed no other abnormality and withdrawal terminated the procedure. \ No newline at end of file diff --git a/3659_Gastroenterology.txt b/3659_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..ea0f02e1858ab8661006a35da76114f8993933e9 --- /dev/null +++ b/3659_Gastroenterology.txt @@ -0,0 +1,31 @@ +REASON FOR CONSULT: + + Genetic counseling. + +HISTORY OF PRESENT ILLNESS: + + The patient is a very pleasant 61-year-old female with a strong family history of colon polyps. The patient reports her first polyps noted at the age of 50. She has had colonoscopies required every five years and every time she has polyps were found. She reports that of her 11 brothers and sister 7 have had precancerous polyps. She does have an identical twice who is the one of the 11 who has never had a history of polyps. She also has history of several malignancies in the family. Her father died of a brain tumor at the age of 81. There is no history of knowing whether this was a primary brain tumor or whether it is a metastatic brain involvement. Her sister died at the age of 65 breast cancer. She has two maternal aunts with history of lung cancer both of whom were smoker. Also a paternal grandmother who was diagnosed with breast cancer at 86 and a paternal grandfather who had lung cancer. There is no other cancer history. + +PAST MEDICAL HISTORY: + + Significant for asthma. + +CURRENT MEDICATIONS: + + Include Serevent two puffs daily and Nasonex two sprays daily. + +ALLERGIES: + + Include penicillin. She is also allergic seafood; crab and mobster. + +SOCIAL HISTORY: + + The patient is married. She was born and raised in South Dakota. She moved to Colorado 37 years ago. She attended collage at the Colorado University. She is certified public account. She does not smoke. She drinks socially. + +REVIEW OF SYSTEMS: + +The patient denies any dark stool or blood in her stool. She has had occasional night sweats and shortness of breath, and cough associated with her asthma. She also complains of some acid reflux as well as anxiety. She does report having knee surgery for torn ACL on the left knee and has some arthritis in that knee. The rest of her review of systems is negative. + +PHYSICAL EXAM: + +VITALS: \ No newline at end of file diff --git a/3664_Gastroenterology.txt b/3664_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..700bc96c8a14e18e1b19fa59ff28c4dfea00c4fb --- /dev/null +++ b/3664_Gastroenterology.txt @@ -0,0 +1,95 @@ +CHIEF COMPLAINT: + + Bright red blood per rectum + +HISTORY OF PRESENT ILLNESS: + +This 73-year-old woman had a recent medical history significant for renal and bladder cancer, deep venous thrombosis of the right lower extremity, and anticoagulation therapy complicated by lower gastrointestinal bleeding. Colonoscopy during that admission showed internal hemorrhoids and diverticulosis, but a bleeding site was not identified. Five days after discharge to a nursing home, she again experienced bloody bowel movements and returned to the emergency department for evaluation. + +REVIEW OF SYMPTOMS: + +No chest pain, palpitations, abdominal pain or cramping, nausea, vomiting, or lightheadedness. Positive for generalized weakness and diarrhea the day of admission. + +PRIOR MEDICAL HISTORY: + + Long-standing hypertension, intermittent atrial fibrillation, and hypercholesterolemia. Renal cell carcinoma and transitional cell bladder cancer status post left nephrectomy, radical cystectomy, and ileal loop diversion 6 weeks prior to presentation, postoperative course complicated by pneumonia, urinary tract infection, and retroperitoneal bleed. Deep venous thrombosis 2 weeks prior to presentation, management complicated by lower gastrointestinal bleeding, status post inferior vena cava filter placement. + +MEDICATIONS: + +Diltiazem 30 mg tid, pantoprazole 40 mg qd, epoetin alfa 40,000 units weekly, iron 325 mg bid, cholestyramine. Warfarin discontinued approximately 10 days earlier. + +ALLERGIES: + +Celecoxib (rash). + +SOCIAL HISTORY: + + Resided at nursing home. Denied alcohol, tobacco, and drug use. + +FAMILY HISTORY: + + Non-contributory. + +PHYSICAL EXAM: + +Temp = 38.3C BP =146/52 HR= 113 RR = 18 SaO2 = 98% room air + +General: Pale, ill-appearing elderly female. + +HEENT: Pale conjunctivae, oral mucous membranes moist. + +CVS: Irregularly irregular, tachycardia. + +Lungs: Decreased breath sounds at the bases. + +Abdomen: Positive bowel sounds, soft, nontender, nondistended, gross blood on rectal exam. + +Extremities: No cyanosis, clubbing, or edema. + +Skin: Warm, normal turgor. + +Neuro: Alert and oriented. Nonfocal. + +LABS: + +CBC: + +WBC count: 6,500 per mL + +Hemoglobin: 10.3 g/dL + +Hematocrit:31.8% + +Platelet count: 248 per mL + +Mean corpuscular volume: 86.5 fL + +RDW: 18% + +CHEM 7: + +Sodium: 131 mmol/L + +Potassium: 3.5 mmol/L + +Chloride: 98 mmol/L + +Bicarbonate: 23 mmol/L + +BUN: 11 mg/dL + +Creatinine: 1.1 mg/dL + +Glucose: 105 mg/dL + +COAGULATION STUDIES: + +PT 15.7 sec + +INR 1.6 + +PTT 29.5 sec + +HOSPITAL COURSE: + +The patient received 1 liter normal saline and diltiazem (a total of 20 mg intravenously and 30 mg orally) in the emergency department. Emergency department personnel made several attempts to place a nasogastric tube for gastric lavage, but were unsuccessful. During her evaluation, the patient was noted to desaturate to 80% on room air, with an increase in her respiratory rate to 34 breaths per minute. She was administered 50% oxygen by nonrebreadier mask, with improvement in her oxygen saturation to 89%. Computed tomographic angiography was negative for pulmonary embolism. \ No newline at end of file diff --git a/3665_Gastroenterology.txt b/3665_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..b63ed6edd459698121f28c61f5ecb52ef36db44f --- /dev/null +++ b/3665_Gastroenterology.txt @@ -0,0 +1,25 @@ +PREOPERATIVE DIAGNOSIS: + + Cecal polyp. + +POSTOPERATIVE DIAGNOSIS: + + Cecal polyp. + +PROCEDURE: + + Laparoscopic resection of cecal polyp. + +COMPLICATIONS: + + None. + + + +ANESTHESIA: + +General oral endotracheal intubation. + +PROCEDURE: + + After adequate general anesthesia was administered the patient's abdomen was prepped and draped aseptically. Local anesthetic was infiltrated into the right upper quadrant where a small incision was made. Blunt dissection was carried down to the fascia which was grasped with Kocher clamps. A bladed 11-mm port was inserted without difficulty. Pneumoperitoneum was obtained using C02. Under direct vision 2 additional, non-bladed, 11-mm trocars were placed, one in the left lower quadrant and one in the right lower quadrant. There was some adhesion noted to the anterior midline which was taken down using the harmonic scalpel. The cecum was visualized and found to have tattoo located almost opposite the ileocecal valve. This was in what appeared to be an appropriate location for removal of this using the Endo GIA stapler without impinging on the ileocecal valve or the appendiceal orifice. The appendix was somewhat retrocecal in position but otherwise looked normal. The patient was also found to have ink marks in the peritoneal cavity diffusely indicating possible extravasation of dye. There was enough however in the wall to identify the location of the polyp. The lesion was grasped with a Babcock clamp and an Endo GIA stapler used to fire across this transversely. The specimen was then removed through the 12-mm port and examined on the back table. The lateral margin was found to be closely involved with the specimen so I did not feel that it was clear. I therefore lifted the lateral apex of the previous staple line and created a new staple line extending more laterally around the colon. This new staple line was then opened on the back table and examined. There was some residual polypoid material noted but the margins this time appeared to be clear. The peritoneal cavity was then lavaged with antibiotic solution. There were a few small areas of bleeding along the staple line which were treated with pinpoint electrocautery. The trocars were removed under direct vision. No bleeding was noted. The bladed trocar site was closed using a figure-of-eight O Vicryl suture. All skin incisions were closed with running 4-0 Monocryl subcuticular sutures. Mastisol and Steri-Strips were placed followed by sterile Tegaderm dressing. The patient tolerated the procedure well without any complications. \ No newline at end of file diff --git a/3667_Gastroenterology.txt b/3667_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..406efdc1f2ff217a90b200537c176eb56bb7737e --- /dev/null +++ b/3667_Gastroenterology.txt @@ -0,0 +1,41 @@ +PREOPERATIVE DIAGNOSIS: + +Gallstone pancreatitis. + +POSTOPERATIVE DIAGNOSIS: + + Gallstone pancreatitis. + +PROCEDURE PERFORMED: + + Laparoscopic cholecystectomy. + +ANESTHESIA: + + General endotracheal and local injectable Marcaine. + +ESTIMATED BLOOD LOSS: + + Minimal. + +SPECIMEN: + + Gallbladder. + +COMPLICATIONS: + +None. + +OPERATIVE FINDINGS: + + Video laparoscopy revealed dense omental adhesions surrounding the gallbladder circumferentially. These dense adhesions were associated with chronic inflammatory edematous changes. The cystic duct was easily identifiable and seen entering into the gallbladder and clipped two proximally and one distally. The cystic artery was an anomalous branch that was anterior to the cystic duct and was identified, clipped with two clips proximally and one distally. The remainder of the evaluation of the abdomen revealed no evidence of nodularity or masses in the liver. There was no evidence of adhesions from the abdominal wall to the liver. The remainder of the abdomen was unremarkable. + +BRIEF HISTORY: + +This is a 17-year-old African-American female who presented to ABCD General Hospital on 08/20/2003 with complaints of intractable right upper quadrant abdominal pain. She had been asked to follow up and scheduled for surgery previously. Her pain had now been intractable associated with anorexia. She was noted on physical examination to be afebrile; however, she was having severe right upper quadrant pain with examination as well as a Murphy's sign and voluntary guarding with examination. Her transaminases were markedly elevated. She also developed pancreatitis secondary to gallstones. Her common bile duct was dilated to 1 cm with no evidence of wall thickening, but evidence of cholelithiasis. She was seen by the gastroenterologist and underwent a sphincterotomy with balloon extraction of gallstones secondary to choledocholithiasis. Following this, she was scheduled for operative laparoscopic cholecystectomy. Her parents were explained the risks, benefits, and complications of the procedure. She gave us informed consent to proceed with surgery. + +OPERATIVE PROCEDURE: + +The patient brought to the operative suite and placed in the supine position. Preoperatively, the patient received IV antibiotics of Ancef, sequential compression devices and subcutaneous heparin. The abdomen was prepped and draped in the normal sterile fashion with Betadine solution. Utilizing a #15 blade scalpel, a transverse infraumbilical incision was created. Utilizing a Veress needle with anterior traction on the anterior abdominal wall with a towel clamp, the Veress needle was inserted without difficulty. Hanging water drop test was performed with notable air aspiration through the Veress needle and the saline passed through the Veress needle without difficulty. The abdomen was then insufflated to 15 mmHg with carbon-dioxide. Once the abdomen was sufficiently insufflated, a #10 mm bladed trocar was inserted into the abdomen without difficulty. Video laparoscope was inserted and the above notable findings were identified in the operative findings. The patient to proceed with laparoscopic cholecystectomy was decided and a subxiphoid port was placed. A #15 bladed scalpel was used to make a transverse incision in the subxiphoid region within the midline. The trocar was then inserted into the abdomen under direct visualization with the video laparoscope and seen to go to the right of falciform ligament. Next, two 5 mm trocars were inserted under direct visualization, one in the midclavicular and one in the anterior midaxillary line. These were inserted without difficulty. The liver edge was lifted and revealed a markedly edematous gallbladder with severe omental adhesions encapsulating the gallbladder. Utilizing Endoshears scissor, a plane was created circumferentially to the dome of the gallbladder to allow assistance and dissection of these dense adhesions. Next, the omental adhesions adjacent to the infundibulum were taken down and allowed to expose the cystic duct. A small vessel was seen anterior to the cystic duct and this was clipped two proximally and one distally and noted to be an anomalous arterial branch. This was transected with Endoshears scissor and visualized the pulsatile branch with two clips securely in place. Next, the cystic duct was carefully dissected with Maryland dissectors and was visualized clearly both anterior and posteriorly. Endoclips were placed two proximally and one distally and then the cystic duct was transected with Endoshears scissor. + +Once the clips were noted to be in place, utilizing electrocautery another Dorsey dissector was used to carefully dissect the gallbladder off the liver bed wall. The gallbladder was removed and the bleeding from the gallbladder wall was easily controlled with electrocautery. The abdomen was then irrigated with copious amounts of normal saline. The gallbladder was grasped with a gallbladder grasper and removed from the subxiphoid port. There was noted to be gallstones within the gallbladder. Once the abdomen was re-insufflated after removing the gallbladder and copious irrigation was performed, all ports were then removed under direct visualization with no evidence of bleeding from the anterior abdominal wall. Utilizing #0 Vicryl suture, a figure-of-eight was placed to the subxiphoid and infraumbilical fascia and this was approximated without difficulty. The subxiphoid port was irrigated with copious amounts of normal saline prior to closure of the fascia. A #4-0 Vicryl suture was used to approximate all incisions. The incisions were then injected with local injectable 0.25% Marcaine. All ports were then cleaned dry. Steri-Strips were placed across and sterile pressure dressings were placed on top of this. The patient tolerated the entire procedure well. She was transferred to the Postanesthesia Care Unit in stable condition. She will be followed closely in the postoperative course in General Medical Floor. \ No newline at end of file diff --git a/3668_Gastroenterology.txt b/3668_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..cf4e2d05fcf61f0cd64903f1f27abe77a7eefbbe --- /dev/null +++ b/3668_Gastroenterology.txt @@ -0,0 +1,39 @@ +REASON FOR CONSULTATION: + + Newly diagnosed cholangiocarcinoma. + +HISTORY OF PRESENT ILLNESS: + + The patient is a very pleasant 77-year-old female who is noted to have an increase in her liver function tests on routine blood work in December 2009. Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis. Common bile duct was noted to be 10 mm in size on that ultrasound. She then underwent a CT scan of the abdomen in July 2010, which showed intrahepatic ductal dilatation with the common bile duct size being 12.7 mm. She then underwent an MRI MRCP + + which was notable for stricture of the distal common bile duct. She was then referred to gastroenterology and underwent an ERCP. On August 24, 2010, she underwent the endoscopic retrograde cholangiopancreatography. She was noted to have a stricturing mass of the mid-to-proximal common bile duct consistent with cholangiocarcinoma. A temporary biliary stent was placed across the biliary stricture. Blood work was obtained during the hospitalization. She was also noted to have an elevated CA99. She comes in to clinic today for initial Medical Oncology consultation. After she sees me this morning, she has a follow-up consultation with a surgeon. + +PAST MEDICAL HISTORY: + +Significant for hypertension and hyperlipidemia. In July, she had eye surgery on her left eye for a muscle repair. Other surgeries include left ankle surgery for a fractured ankle in 2000. + +CURRENT MEDICATIONS: + + Diovan 80/12.5 mg daily, Lipitor 10 mg daily, Lutein 20 mg daily, folic acid 0.8 mg daily and multivitamin daily. + +ALLERGIES: + +No known drug allergies. + +FAMILY HISTORY: + + Notable for heart disease. She had three brothers that died of complications from open heart surgery. Her parents and brothers all had hypertension. Her younger brother died at the age of 18 of infection from a butcher's shop. He was cutting Argentinean beef and contracted an infection and died within 24 hours. She has one brother that is living who has angina and a sister who is 84 with dementia. She has two adult sons who are in good health. + +SOCIAL HISTORY: + + The patient has been married to her second husband for the past ten years. Her first husband died in 1995. She does not have a smoking history and does not drink alcohol. + +REVIEW OF SYSTEMS: + +The patient reports a change in her bowels ever since she had the stent placed. She has noted some weight loss, but she notes that that is due to not eating very well. She has had some mild fatigue, but prior to her diagnosis she had absolutely no symptoms. As mentioned above, she was noted to have abnormal alkaline phosphatase and total bilirubin, AST and ALT + + which prompted the followup. She has had some difficulty with her vision that has improved with her recent surgical procedure. She denies any fevers, chills, night sweats. She has had loose stools. The rest of her review of systems is negative. + +PHYSICAL EXAM: + +VITALS: \ No newline at end of file diff --git a/3674_Gastroenterology.txt b/3674_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..747e51bac23bbe8be8a6ab1cfa3864b7ddc6f97f --- /dev/null +++ b/3674_Gastroenterology.txt @@ -0,0 +1,37 @@ +PREOPERATIVE DIAGNOSIS: + + Acute appendicitis. + +POSTOPERATIVE DIAGNOSES: + +1. Pelvic inflammatory disease. + +2. Periappendicitis. + +PROCEDURE PERFORMED: + +1. Laparoscopic appendectomy. + +2. Peritoneal toilet and photos. + +ANESTHESIA: + +General. + +COMPLICATIONS: + + None. + +ESTIMATED BLOOD LOSS: + + Less than 10 cc. + +INDICATIONS FOR PROCEDURE: + + The patient is a 31-year-old African-American female who presented with right lower quadrant abdominal pain presented with acute appendicitis. She also had mild leukocytosis with bright blood cell count of 12,000. The necessity for diagnostic laparoscopy was explained and possible appendectomy. The patient is agreeable to proceed and signed preoperatively informed consent. + +PROCEDURE: + + The patient was taken to the operative suite and placed in the supine position under general anesthesia by Anesthesia Department. + +The preoperative Foley, antibiotics, and NG tube are placed for decompression and the anterior abdominal wall was prepped and draped in the usual sterile fashion and infraumbilical incision is performed with a #10 blade scalpel with anterior and superior traction on the abdominal wall. A Veress needle was introduced and 15 mm pneumoperitoneum is created with CO2 insufflation. At this point, the Veress needle was removed and a 10 mm trocar is introduced intraperitoneally. A second 5 mm port was introduced in the right upper quadrant under direct visualization and blunted graspers were introduced to bring the appendix into view. With the aid of a laparoscope, the pelvis was visualized. The ovaries are brought in views and photos are taken. There is evidence of a purulence in the cul-de-sac and ________ with a right ovarian hemorrhagic cyst. Attention was then turned on the right lower quadrant. The retrocecal appendix is freed with peritoneal adhesions removed with Endoshears. Attention was turned to the suprapubic area. The 12 mm port was introduced under direct visualization and the mesoappendix was identified. A 45 mm endovascular stapling device was fired across the mesoappendix and the base of the appendix sequentially with no evidence of bleeding or leakage from the staple line. Next, ________ tube was used to obtain Gram stain and cultures of the pelvic fluid and a pelvic toilet was performed with copious irrigation of sterile saline. Next, attention was turned to the right upper quadrant. There is evidence of adhesions from the liver surface to the anterior abdominal wall consistent with Fitz-Hugh-Curtis syndrome also a prior pelvic inflammatory disease. All free fluid is aspirated and patient's all port sites are removed under direct visualization and the appendix is submitted to pathology for final pathology. Once the ports are removed the pneumoperitoneum is allowed to escape for patient's postoperative comfort and two larger port sites at the suprapubic and infraumbilical sites are closed with #0 Vicryl suture on a UR-6 needle. Local anesthetic is infiltrated at L3 port sites for postoperative analgesia and #4-0 Vicryl subcuticular closure is performed with undyed Vicryl. Steri-Strips are applied along with sterile dressings. The patient was awakened from anesthesia without difficulty and transferred to recovery room with postoperative broad-spectrum IV antibiotics in the General Medical Floor. Routine postoperative care will be continued on this patient. \ No newline at end of file diff --git a/3678_Gastroenterology.txt b/3678_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..0157299e63b02e16c138ba46293bd34f7ca52e12 --- /dev/null +++ b/3678_Gastroenterology.txt @@ -0,0 +1,59 @@ +CURRENT MEDICATIONS: + + Lortab. + +PREVIOUS MEDICAL HISTORY: + + Cardiac stent in 2000. + +PATIENT'S GOAL: + + To eat again by mouth. + +STUDY: + +A trial of Passy-Muir valve was completed to allow the patient to achieve hands-free voicing and also to improve his secretion management. A clinical swallow evaluation was not completed due to the severity of the patient's mucus and lack of saliva control. + +The patient's laryngeal area was palpated during a dry swallow and he does have significantly reduced laryngeal elevation and radiation fibrosis. The further evaluate of his swallowing function is safety; a modified barium swallow study needs to be concluded to objectively evaluate his swallow safety, and to rule out aspiration. A trial of neuromuscular electrical stimulation therapy was completed to determine if this therapy protocol will be beneficial and improving the patient's swallowing function and safety. + +For his neuromuscular electrical stimulation therapy, the type was BMR with a single mode cycle time is 4 seconds and 12 seconds off with frequency was 60 __________ with a ramp of 2 seconds, phase duration was 220 with an output of 99 milliamps. Electrodes were placed on the suprahyoid/submandibular triangle with an upright body position, trial length was 10 minutes. On a pain scale, the patient reported no pain with the electrical stimulation therapy. + +FINDINGS: + +The patient was able to tolerate a 5-minute placement of the Passy-Muir valve. He reported no discomfort on the inhalation; however, he felt some resistance on exhalation. Instructions were given on care placement and cleaning of the Passy-Muir valve. The patient was instructed to buildup tolerance over the next several days of his Passy-Muir valve and to remove the valve at anytime or he is going to be sleeping or napping throughout the day. The patient's voicing did improve with the Passy-Muir valve due to decreased leakage from his trach secondary to finger occlusion. Mucus production also seemed to decrease when the Passy-Muir was placed. + +On the dry swallow during this evaluation, the patient's laryngeal area is reduced and tissues around his larynx and showed radiation fibrosis. The patient's neck range of motion appears to be adequate and within normal limits. + +A trial of neuromuscular electrical stimulation therapy: + +The patient tolerating the neuromuscular electrical stimulation, we did achieve poor passive response, but these muscles were contracting and the larynx was moving upon stimulation. The patient was able to actively swallow with stimulation approximately 30% of presentation. + +DIAGNOSTIC IMPRESSION: + + The patient with a history of head and neck cancer status post radiation and chemotherapy with radiation fibrosis, which is impeding his swallowing abilities. The patient would benefit from outpatient skilled speech therapy for neuromuscular electrical stimulation for muscle reeducation to improve his swallowing function and safety and he would benefit from a placement of a Passy-Muir valve to have hands-free communication. + +PLAN OF CARE: + + Outpatient skilled speech therapy two times a week to include neuromuscular electrical stimulation therapy, Passy-Muir placement and a completion of the modified barium swallow study. + +SHORT-TERM GOALS (6 WEEKS): + +1. Completion of modified barium swallow study. + +2. The patient will coordinate volitional swallow with greater than 75% of the neuromuscular electrical stimulations. + +3. The patient will increase laryngeal elevation by 50% for airway protection. + +4. The patient will tolerate placement of Passy-Muir valve for greater than 2 hours during awaking hours. + +5. The patient will tolerate therapeutic feedings with the speech and language pathologist without signs and symptoms of aspiration. + +6. The patient will decrease mild facial restrictions to the anterior neck by 50% to increase laryngeal movement. + +LONG-TERM GOALS (8 WEEKS): + +1. The patient will improve secretion management to tolerable levels. + +2. The patient will increase amount and oral consistency of p.o. intake tolerated without signs and symptoms of aspirations. + +3. The patient will be able to communicate without using finger occlusion with the assistance of a Passy-Muir valve. \ No newline at end of file diff --git a/3683_Gastroenterology.txt b/3683_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..0e5e78de2ba1da0b9ed759d045c84f3dd607cdda --- /dev/null +++ b/3683_Gastroenterology.txt @@ -0,0 +1,59 @@ +CHIEF COMPLAINT: + + Abdominal pain. + +HISTORY OF PRESENT ILLNESS: + + The patient is a 71-year-old female patient of Dr. X. The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent. She was seen 3 to 4 days ago at ABC ER and underwent evaluation and discharged and had a CT scan at that time and she was told it was "normal." She was given oral antibiotics of Cipro and Flagyl. She has had no nausea and vomiting, but has had persistent associated anorexia. She is passing flatus, but had some obstipation symptoms with the last bowel movement two days ago. She denies any bright red blood per rectum and no history of recent melena. Her last colonoscopy was approximately 5 years ago with Dr. Y. She has had no definite fevers or chills and no history of jaundice. The patient denies any significant recent weight loss. + +PAST MEDICAL HISTORY: + +Significant for history of atrial fibrillation, under good control and now in normal sinus rhythm and on metoprolol and also on Premarin hormone replacement. + +PAST SURGICAL HISTORY: + + Significant for cholecystectomy, appendectomy, and hysterectomy. She has a long history of known grade 4 bladder prolapse and she has been seen in the past by Dr. Chip Winkel, I believe that he has not been re-consulted. + +ALLERGIES: + + SHE IS ALLERGIC OR SENSITIVE TO MACRODANTIN. + +SOCIAL HISTORY: + + She does not drink or smoke. + +REVIEW OF SYSTEMS: + + Otherwise negative for any recent febrile illnesses, chest pains or shortness of breath. + +PHYSICAL EXAMINATION: + +GENERAL: The patient is an elderly thin white female, very pleasant, in no acute distress. + +VITAL SIGNS: Her temperature is 98.8 and vital signs are all stable, within normal limits. + +HEENT: Head is grossly atraumatic and normocephalic. Sclerae are anicteric. The conjunctivae are non-injected. + +NECK: Supple. + +CHEST: Clear. + +HEART: Regular rate and rhythm. + +ABDOMEN: Generally nondistended and soft. She is focally tender in the left lower quadrant to deep palpation with a palpable fullness or mass and focally tender, but no rebound tenderness. There is no CVA or flank tenderness, although some very minimal left flank tenderness. + +PELVIC: Currently deferred, but has history of grade 4 urinary bladder prolapse. + +EXTREMITIES: Grossly and neurovascularly intact. + +LABORATORY VALUES: + +White blood cell count is 5.3, hemoglobin 12.8, and platelet count normal. Alkaline phosphatase elevated at 184. Liver function tests otherwise normal. Electrolytes normal. Glucose 134, BUN 4, and creatinine 0.7. + +DIAGNOSTIC STUDIES: + + EKG shows normal sinus rhythm. + +IMPRESSION AND PLAN: + + A 71-year-old female with greater than one-week history of abdominal pain now more localized to the left lower quadrant. Currently is a nonacute abdomen. The working diagnosis would be sigmoid diverticulitis. She does have a history in the distant past of sigmoid diverticulitis. I would recommend a repeat stat CT scan of the abdomen and pelvis and keep the patient nothing by mouth. The patient was seen 5 years ago by Dr. Y in Colorectal Surgery. We will consult her also for evaluation. The patient will need repeat colonoscopy in the near future and be kept nothing by mouth now empirically. The case was discussed with the patient's primary care physician, Dr. X. Again, currently there is no indication for acute surgical intervention on today's date, although the patient will need close observation and further diagnostic workup. \ No newline at end of file diff --git a/3685_Gastroenterology.txt b/3685_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..91842d892bb2600314b2b4a25d21ec11d8e70d3f --- /dev/null +++ b/3685_Gastroenterology.txt @@ -0,0 +1,51 @@ +CHIEF COMPLAINT: + + Nausea. + +PRESENT ILLNESS: + + The patient is a 28-year-old, who is status post gastric bypass surgery nearly one year ago. He has lost about 200 pounds and was otherwise doing well until yesterday evening around 7:00-8:00 when he developed nausea and right upper quadrant pain, which apparently wrapped around toward his right side and back. He feels like he was on it but has not done so. He has overall malaise and a low-grade temperature of 100.3. He denies any prior similar or lesser symptoms. His last normal bowel movement was yesterday. He denies any outright chills or blood per rectum. + +PAST MEDICAL HISTORY: + + Significant for hypertension and morbid obesity, now resolved. + +PAST SURGICAL HISTORY: + + Gastric bypass surgery in December 2007. + +MEDICATIONS: + +Multivitamins and calcium. + +ALLERGIES: + + None known. + +FAMILY HISTORY: + +Positive for diabetes mellitus in his father, who is now deceased. + +SOCIAL HISTORY: + + He denies tobacco or alcohol. He has what sounds like a data entry computer job. + +REVIEW OF SYSTEMS: + +Otherwise negative. + +PHYSICAL EXAMINATION: + + His temperature is 100.3, blood pressure 129/59, respirations 16, heart rate 84. He is drowsy, but easily arousable and appropriate with conversation. He is oriented to person, place, and situation. He is normocephalic, atraumatic. His sclerae are anicteric. His mucous membranes are somewhat tacky. His neck is supple and symmetric. His respirations are unlabored and clear. He has a regular rate and rhythm. His abdomen is soft. He has diffuse right upper quadrant tenderness, worse focally, but no rebound or guarding. He otherwise has no organomegaly, masses, or abdominal hernias evident. His extremities are symmetrical with no edema. His posterior tibial pulses are palpable and symmetric. He is grossly nonfocal neurologically. + +STUDIES: + + His white blood cell count is 8.4 with 79 segs. His hematocrit is 41. His electrolytes are normal. His bilirubin is 2.8. His AST 349, ALT 186, alk-phos 138 and lipase is normal at 239. + +ASSESSMENT: + + Choledocholithiasis, ? cholecystitis. + +PLAN: + + He will be admitted and placed on IV antibiotics. We will get an ultrasound this morning. He will need his gallbladder out, probably with intraoperative cholangiogram. Hopefully, the stone will pass this way. Due to his anatomy, an ERCP would prove quite difficult if not impossible unless laparoscopic assisted. Dr. X will see him later this morning and discuss the plan further. The patient understands. \ No newline at end of file diff --git a/3689_Gastroenterology.txt b/3689_Gastroenterology.txt new file mode 100644 index 0000000000000000000000000000000000000000..ced0df0d32224aee1a47be30136f76f2debc57f2 --- /dev/null +++ b/3689_Gastroenterology.txt @@ -0,0 +1,29 @@ +PREOPERATIVE DIAGNOSES: + +1. Congenital chylous ascites and chylothorax. + +2. Rule out infradiaphragmatic lymphatic leak. + +POSTOPERATIVE DIAGNOSES: + + Diffuse intestinal and mesenteric lymphangiectasia. + +ANESTHESIA: + + General. + +INDICATION: + +The patient is an unfortunate 6-month-old baby boy, who has been hospitalized most of his life with recurrent chylothoraces and chylous ascites. The patient has been treated somewhat successfully with TPN and voluntary restriction of enteral nutrition, but he had repeated chylothoraces. Last week, Dr. X took the patient to the operating room in hopes that with thoracotomy, a thoracic duct leak could be found, which would be successfully closed surgically. However at the time of his thoracotomy exploration what was discovered was a large amount of transdiaphragmatic transition of chylous ascites coming from the abdomen. Dr. X opened the diaphragm and could literally see a fountain of chylous fluid exiting through the diaphragmatic hole. This was closed, and we decided that perhaps an abdominal exploration as a last stage effort would allow us to find an area of lymphatic leak that could potentially help the patient from this dismal prognostic disease. We met with his parents and talked to them about this, and he is here today for that attempt. + +OPERATIVE FINDINGS: + +The patient's abdomen was relatively soft, minimally distended. Exploration through supraumbilical transverse incision immediately revealed a large amount of chylous ascites upon entering into the peritoneal cavity. What we found which explains the chronic chylous ascites and chylothorax was a diffuse lymphangiectatic picture involving the small bowel mesentery approximately two thirds to three quarters of the distal small bowel including all of the ileum, the cecum, and the portion of the ascending colon. It appeared that any attempt to resect this area would have been met with failure because of the extensive lymphatic dilatation all the way down towards the root of the supramesenteric artery. There was about one quarter to one third of the jejunum that did not appear to be grossly involved, but I did not think that resection of three quarters of the patient's small bowel would be viable surgical option. Instead, we opted to close his abdomen and refer for potential small intestine transplantation procedure in the future if he is a candidate for that. + +The lymphatic abnormality was extensive. They were linear dilated lymphatic channels on the serosal surface of the bowel in the mesentery. They were small aneurysm-like pockets of chyle all along the course of the mesenteric structures and in the mesentery medially adjacent to the bowel as well. No other major retroperitoneal structure or correctable structure was identified. Both indirect inguinal hernias were wide open and could be palpated from an internal aspect as well. + +DESCRIPTION OF OPERATION: + +The patient was brought from the Pediatric Intensive Care Unit to the operating room within an endotracheal tube im place and with enteral feeds established at full flow to provide maximum fat content and maximum lymphatic flow. We conducted a surgical time-out and reiterated all of the patient's important identifying information and confirmed the operative plan as described above. Preparation and draping of his abdomen was done with chlorhexidine based prep solution and then we opened his peritoneal cavity through a transverse supraumbilical incision dividing both rectus muscles and all layers of the abdominal wall fascia. As the peritoneal cavity was entered, we divided the umbilical vein ligamentum teres remnant between Vicryl ties, and we were able to readily identify a large amount of chylous ascites that had been previously described. The bowel was eviscerated, and then with careful inspection, we were able to identify this extensive area of intestinal and mesenteric lymphangiectasia that was a source of the patient's chylous ascites. The small bowel from the ligament of Treitz to the proximal to mid jejunum was largely unaffected, but did not appear that resection of 75% of the small intestine and colon would be a satisfactory tradeoff for The patient, but would likely render him with significant short bowel and nutritional and metabolic problems. Furthermore, it might burn bridges necessary for consideration of intestinal transplantation in the future if that becomes an option. We suctioned free all of the chylous accumulations, replaced the intestines to their peritoneal cavity, and then closed the patient's abdominal incision with 4-0 PDS on the posterior sheath and 3-0 PDS on the anterior rectus sheath. Subcuticular 5-0 Monocryl and Steri-Strips were used for skin closure. + +The patient tolerated the procedure well. He lost minimal blood, but did lose approximately 100 mL of chylous fluid from the abdomen that was suctioned free as part of the chylous ascitic leak. The patient was returned to the Pediatric Intensive Care Unit with his endotracheal tube in place and to consider the next stage of management, which might be an attempted additional type of feeding or referral to an Intestinal Transplantation Center to see if that is an option for the patient because he has no universally satisfactory medical or surgical treatment for this at this time. \ No newline at end of file diff --git a/3877_Discharge Summary.txt b/3877_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..762fb1132985963d5aa5fed9b1f71f653ad12470 --- /dev/null +++ b/3877_Discharge Summary.txt @@ -0,0 +1 @@ +The patient made some progress during therapy. She accomplished two and a half out of her five short-term therapy goals. We did complete an oral mechanism examination and clinical swallow evaluation, which showed her swallowing to be within functional limits. The patient improved on her turn taking skills during conversation, and she was able to listen to a narrative and recall the main idea plus five details after a three-minute delay independently. The patient continues to have difficulty with visual scanning in cancellation task, secondary to her significant left neglect. She also did not accomplish her sustained attention goal, which required her to complete tasks greater than 80% accuracy for at least 15 minutes independently. Thus she also continued to have difficulty with reading, comprehension, secondary to the significance of her left neglect. The patient was initially authorized for 12 outpatient speech therapy sessions, but once again she only attended 9. Her last session occurred on 01/09/09. She has not made any additional followup sessions with me for over three weeks, so she is discharged from my services at this time. \ No newline at end of file diff --git a/3880_Discharge Summary.txt b/3880_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..1cf82f1958352a14286cf4b31f646604664414b5 --- /dev/null +++ b/3880_Discharge Summary.txt @@ -0,0 +1,49 @@ +ADMISSION DIAGNOSES: + +1. Severe menometrorrhagia unresponsive to medical therapy. + +2. Severe anemia. + +3. Symptomatic fibroid uterus. + +DISCHARGE DIAGNOSES: + +1. Severe menometrorrhagia unresponsive to medical therapy. + +2. Severe anemia. + +3. Symptomatic fibroid uterus. + +4. Extensive adenomyosis by pathological report. + +OPERATION PERFORMED: + + On 6/10/2009 total abdominal hysterectomy (TAH). + +COMPLICATIONS: + + None. + +BLOOD TRANSFUSIONS: + + None. + +INFECTIONS: + + None. + +SIGNIFICANT LAB AND X-RAY: + + On admission hemoglobin and hematocrit was 10.5 and 32.8 respectively. On discharge, hemoglobin and hematocrit 7.9 and 25.2. + +HOSPITAL COURSE AND TREATMENT: + +The patient was admitted to the surgical suite and taken to the operating room on 6/10/2009 where a total abdominal hysterectomy (TAH) with low intraoperative complication was performed. The patient tolerated all procedures well. On the 1st postoperative day, the patient was afebrile and all vital signs were stable. On the 3rd postoperative day, the patient was ambulating with difficulty and tolerating clear liquid diet. On the 4th postoperative day, the patient was complaining of pain in her back and abdomen as well as incisional wound tenderness. On the 5th postoperative day, the patient was afebrile. Vital signs were stable. The patient was tolerating a diet and ambulating without difficulty. The patient was desirous of going home. The patient denied any abdominal pain or flank pain. The patient had minimal incisional wound tenderness. The patient was desirous of going home and was discharged home. + +DISCHARGE CONDITION: + + Stable. + +DISCHARGE INSTRUCTIONS: + + Regular diet, bedrest x1 week with slow return to normal activity over the ensuing 4 to 6 weeks, pelvic rest for 6 weeks. Motrin 600 mg tablets 1 tablet p.o. q.8h. p.r.n. pain, Colace 100 mg tablets 1 tablet p.o. daily p.r.n. constipation and ferrous sulfate 60 mg tablets 1 tablet p.o. daily, and multiple vitamin 1 tablet p.o. daily. The patient is to return on Wednesday 6/17/2009 for removal of staples. The patient was given a full explanation of her clinical condition. The patient was given full and complete postoperative and discharge instructions. All her questions were answered. \ No newline at end of file diff --git a/3881_Discharge Summary.txt b/3881_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..beb396b25296d874e54be43748f9ce69019b794f --- /dev/null +++ b/3881_Discharge Summary.txt @@ -0,0 +1,29 @@ +PROCEDURES: + + Cystourethroscopy and transurethral resection of prostate. + +COMPLICATIONS: + + None. + +ADMITTING DIAGNOSIS: + + Difficulty voiding. + +HISTORY: + + This 67-year old Hispanic male patient was admitted because of enlarged prostate and symptoms of bladder neck obstruction. Physical examination revealed normal heart and lungs. Abdomen was negative for abnormal findings. + +LABORATORY DATA: + + BUN 19 and creatinine 1.1. Blood group was A, Rh positive, Hemoglobin 13, Hematocrit 32.1, Prothrombin time 12.6 seconds, PTT 37.1. Discharge hemoglobin 11.4, and hematocrit 33.3. Chest x-ray calcified old granulomatous disease, otherwise normal. EKG was normal. + +COURSE IN THE HOSPITAL: + + The patient had a cysto and TUR of the prostate. Postoperative course was uncomplicated. The pathology report is pending at the time of dictation. He is being discharged in satisfactory condition with a good urinary stream, minimal hematuria, and on Bactrim DS one a day for ten days with a standard postprostatic surgery instruction sheet. + +DISCHARGE DIAGNOSIS: + + Enlarged prostate with benign bladder neck obstruction. + +To be followed in my office in one week and by Dr. ABC next available as an outpatient. \ No newline at end of file diff --git a/3884_Discharge Summary.txt b/3884_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..c65c9625ef7d5c111e600c979c4e6bde3fd7906e --- /dev/null +++ b/3884_Discharge Summary.txt @@ -0,0 +1,51 @@ +ADMISSION DIAGNOSES: + +1. Syncope. + +2. End-stage renal disease requiring hemodialysis. + +3. Congestive heart failure. + +4. Hypertension. + +DISCHARGE DIAGNOSES: + +1. Syncope. + +2. End-stage renal disease requiring hemodialysis. + +3. Congestive heart failure. + +4. Hypertension. + +CONDITION ON DISCHARGE: + + Stable. + +PROCEDURE PERFORMED: + + None. + +HOSPITAL COURSE: + + The patient is a 44-year-old African-American male who was diagnosed with end-stage renal disease requiring hemodialysis three times per week approximately four to five months ago. He reports that over the past month, he has been feeling lightheaded when standing and has had three syncopal episodes during this time with return of consciousness after several minutes. He reportedly had this even while seated and denied overt dizziness. He reports this lightheadedness is made even worse when standing. He has had these symptoms almost daily over the past month. He does report some confusion when he awakens. He reports that he loses consciousness for two to three minutes. Denies any bowel or bladder loss, although he reports very little urine output secondary to his end-stage renal disease. He denied any palpitations, warmth, or diaphoresis, which is indicative of vasovagal syncope. There were no witnesses to his syncopal episodes. He also denied any clonic activity and no history of seizures. In the emergency room, the patient was given fluids and orthostatics were checked. At that time, orthostatics were negative; however, due to the fact that fluid had been given before, it is impossible to rule out orthostatic hypotension. The patient presented to the hospital on Coreg 12.5 mg b.i.d. and lisinopril 10 mg daily secondary to his hypertension, congestive heart failure with dilated cardiomyopathy and end-stage renal disease. Regarding his syncopal episodes, he was admitted with likely orthostatic hypotension. Cardiology was consulted and their recommendations were to reduce the lisinopril to 5 mg daily. At that time, the Coreg had been held secondary to hypotension. Cardiology also ordered a nuclear medicine myocardial perfusion stress test. Regarding the end-stage renal disease, Nephrology was consulted as the patient was due for hemodialysis treatment the day following admission. Nephrology was able to perform dialysis on the patient and Renal concurred that the presyncopal symptoms were likely due to decreased intravascular volume in the postdialytic time frame. Renal agreed with decreasing his lisinopril to 5 mg daily and decreasing the Coreg to 6.25 mg b.i.d. They reported that the Procrit should be continued. As previously indicated regarding the dilated cardiomyopathy, Cardiology ordered a nuclear medicine stress test to be performed. Also, regarding the patient's hypertension, he actually was noted to have hypotension on admission, and as previously stated, the Coreg was originally discontinued and then it was restarted at 6.25 mg b.i.d. and the patient tolerated this well. The patient's hospital course remained uncomplicated until September 17, 2007, the day the nuclear medicine stress test was scheduled. The patient stated that he was reluctant to proceed with the test and he was afraid of needles and the risks associated with the test although the procedure was explained to the patient and the risks of the procedure were quit low, the patient proceeded to discharge himself against medical advice. + +DISCHARGE INSTRUCTIONS/MEDICATIONS: + +The patient left AMA. No specific discharge instructions and medications were given. At the time of the patient leaving AMA + + his medications were as follows: + +1. Aspirin 81 mg p.o. daily. + +2. Multivitamin, Nephrocaps one cap p.o. daily. + +3. Fosrenol 500 mg chewable t.i.d. + +4. Lisinopril 2.5 mg daily. + +6. Coreg 3.125 mg p.o. b.i.d. + +7. Procrit 10,000 units inject every Tuesday, Thursday, and Saturday. + +8. Heparin 5000 units q.8h. subcutaneous for DVT prophylaxis. \ No newline at end of file diff --git a/3885_Discharge Summary.txt b/3885_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..74e30e4de9a3fb89e8f4cbda8f412e7c43fe2846 --- /dev/null +++ b/3885_Discharge Summary.txt @@ -0,0 +1,13 @@ +HISTORY: + + The patient is a 67-year-old female, was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety. At the onset of therapy, on 03/26/08, the patient was NPO with a G-tube and the initial speech and language evaluation revealed global aphasia with an aphasia quotient of 3.6/100 based on the Western Aphasia Battery. Since the initial evaluation, the patient has attended 60 outpatient speech therapy sessions, which have focussed on her receptive communication, expressive language, multimodality communication skills, and swallowing function and safety. + +SHORT-TERM GOALS: + +1. The patient met 3 out of 4 original short-term therapy goals, which were to complete a modified barium swallow study, which she did do and which revealed no aspiration. At this time, the patient is eating and drinking and taking all medications by mouth; however, her G-tube is still present. The patient was instructed to talk to the primary care physician about removal of her feeding tube. + +2. The patient will increase accuracy of yes-no responses to greater than 80% accuracy. She did accomplish this goal. The patient is also able to identify named objects with greater than 80% accuracy. + +ADDITIONAL GOALS: + + Following the completion of these goals, additional goals were established. Based on reevaluation, the patient met 2 out of these 3 initial goals and she is currently able to read and understand simple sentences with greater than 90% accuracy independently and she is able to write 10 words related to basic wants and needs with greater than 80% accuracy independently. The patient continues to have difficulty stating verbally, yes or no, to questions as well as accurately using head gestures and to respond to yes-no questions. The patient continues to have marked difficulty with her expressive language abilities. She is able to write simple words to help express her basic wants and needs. She has made great strides; however, with her receptive communication, she is able to read words as well as short phrases and able to point to named objects and answer simple-to-moderate complex yes-no questions. A reevaluation completed on 12/01/08, revealed an aphasia quotient of 26.4. Once again, she made significant improvement and comprehension, but continues to have unintelligible speech. An alternative communication device was discussed with the patient and her husband, but at this time, the patient does not want to utilize a communication device. If, in the future, the patient continues to struggle with her expressive communication, an alternative augmented communication device would be a benefit to her. Please reconsult at that time if and when the patient is ready to use a speech generating device. The patient is discharged from my services at this time due to a plateau in her progress. Numerous home activities were recommended to allow her to continue to make progress at home. \ No newline at end of file diff --git a/3886_Discharge Summary.txt b/3886_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..47c65714d5da49faea1289b90dfaf69a0fcc8044 --- /dev/null +++ b/3886_Discharge Summary.txt @@ -0,0 +1,35 @@ +DISCHARGE DISPOSITION: + + The patient was discharged by court as a voluntary drop by prosecution. This was AMA against hospital advice. + +DISCHARGE DIAGNOSES: + +AXIS I: Schizoaffective disorder, bipolar type. + +AXIS II: Deferred. + +AXIS III: Hepatitis C. + +AXIS IV: Severe. + +AXIS V: 19. + +CONDITION OF PATIENT ON DISCHARGE: + + The patient remained disorganized. The patient was suffering from prolactinemia secondary to medications. + +DISCHARGE FOLLOWUP: + +To be arranged per the patient as the patient was discharged by court. + +DISCHARGE MEDICATIONS: + + A 2-week supply of the following was phoned into the patient's pharmacy: Seroquel 25 mg p.o. nightly. Zyprexa 5 mg p.o. b.i.d. + +MENTAL STATUS AT THE TIME OF DISCHARGE: + + Attitude was cooperative. Appearance showed fair hygiene and grooming. Psychomotor behavior showed restlessness. No EPS or TD was noted. Affect was restricted. Mood remained anxious and speech was pressured. Thoughts remained tangential, and the patient endorsed paranoid delusions. The patient denied auditory hallucinations. The patient denied suicidal or homicidal ideation, was oriented to person and place. Overall, insight into her illness remained impaired. + +HISTORY AND HOSPITAL COURSE: + + The patient is a 22-year-old female with a history of bipolar affective disorder, was initially admitted for evaluation of increasing mood lability, disorganization, and inappropriate behaviors. The patient reportedly was asking her father to have sex with her and tried to pull down her mother's pants. The patient took her clothing off, was noted to be very disorganized sexually, and religiously preoccupied, and endorsed auditory hallucinations of voices telling her to calm herself and others. The patient has a history of depression versus bipolar disorder, last hospitalized in Pierce County in 2008, but without recent treatment. The patient on admission interview was noted to be labile and disorganized. The patient was initiated on Risperdal M-Tab 2 mg p.o. b.i.d. for psychosis and mood lability, and also medically evaluated by Rebecca Richardson, MD. The patient remained labile and suspicious during her hospital stay. The patient continued to be sexually preoccupied and had poor insight into her need for treatment. The patient denied further auditory hallucinations. The patient was treated with Seroquel for persistent mood lability and psychosis. The patient was noted to develop prolactinemia with Risperdal and this was changed to Zyprexa prior to discharge. The patient remained disorganized, but was given a voluntary drop by prosecution against medical advice when she went to court on 01/11/2010. The patient was discharged to return home to her parents and was referred to Community Mental Health Agencies. The patient was thus discharged in symptomatic condition. \ No newline at end of file diff --git a/3888_Discharge Summary.txt b/3888_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..05e737c53a9e3cb05ddabc75dd38627c512d4887 --- /dev/null +++ b/3888_Discharge Summary.txt @@ -0,0 +1,7 @@ +LONG-TERM GOALS: + + Both functional and cognitive-linguistic ability to improve safety and independence at home and in the community. This goal has been met based on the patient and husband reports the patient is able to complete all activities, which she desires to do at home. During the last reevaluation, the patient had a significant progress and all cognitive domains evaluated, which are attention, memory, executive functions, language, and visuospatial skill. She continues to have an overall mild cognitive-linguistic deficit, but this is significantly improved from her initial evaluation, which showed severe impairment. + + + +The patient does no longer need a skilled speech therapy because she has accomplished all of her goals and her progress has plateaued. The patient and her husband both agreed with the patient's discharge. \ No newline at end of file diff --git a/3889_Discharge Summary.txt b/3889_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..e38923f7dfaf8c18dac3e32bd2e1c79111e4a014 --- /dev/null +++ b/3889_Discharge Summary.txt @@ -0,0 +1,25 @@ +ADMISSION DIAGNOSES: + +1. Pyelonephritis. + +2. History of uterine cancer and ileal conduit urinary diversion. + +3. Hypertension. + +4. Renal insufficiency. + +5. Anemia. + +DISCHARGE DIAGNOSES: + +1. Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit. + +2. Hypertension. + +3. Mild renal insufficiency. + +4. Anemia, which has been present chronically over the past year. + +HOSPITAL COURSE: + + The patient was admitted with suspected pyelonephritis. Renal was consulted. It was thought that there was a thick mucous plug in the Foley in the ileal conduit that was irrigated by Dr. X. Her symptoms responded to IV antibiotics and she remained clinically stable. Klebsiella was isolated in this urine, which was sensitive to Bactrim and she was discharged on p.o. Bactrim. She was scheduled on 08/07/2007 for further surgery. She is to follow up with Dr. Y in 7-10 days. She also complained of right knee pain and the right knee showed no sign of effusion. She was exquisitely tender to touch of the patellar tendon. It was thought that this did not represent intraarticular process. She was advised to use ibuprofen over-the-counter two to three tabs t.i.d. \ No newline at end of file diff --git a/3892_Discharge Summary.txt b/3892_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..11b43bfa79c655cdf623eb1dc8e1dced0a3fb4b4 --- /dev/null +++ b/3892_Discharge Summary.txt @@ -0,0 +1,19 @@ +HISTORY OF PRESENT ILLNESS: + + The patient is a 48-year-old man who has had abdominal pain since October of last year associated with a 30-pound weight loss and then developed jaundice. He had epigastric pain and was admitted to the hospital. A thin-slice CT scan was performed, which revealed a 4 x 3 x 2 cm pancreatic mass with involved lymph nodes and ring enhancing lesions consistent with liver metastases. The patient, additionally, had a questionable pseudocyst in the tail of the pancreas. The patient underwent ERCP on 04/04/2007 with placement of a stent. This revealed a strictured pancreatic duct, as well as strictured bile duct. A 10-french x 9 cm stent was placed with good drainage. The next morning, the patient felt quite a bit more comfortable. He additionally had a modest drop in his bilirubin and other liver tests. Of note, the patient has been having quite a bit of nausea during his admission. This responded to Zofran. It did not, initially, respond well to Phenergan, though after stent placement, he was significantly more comfortable and had less nausea, and in fact, had better response to the Phenergan itself. At the time of discharge, the patient's white count was 9.4, hemoglobin 10.8, hematocrit 32 with a MCV of 79, platelet count of 585,000. His sodium was 132, potassium 4.1, chloride 95, CO2 27, BUN of 8 with a creatinine of 0.3. His bilirubin was 17.1, alk phos 273, AST 104, ALT 136, total protein 7.8 and albumin of 3.8. He was tolerating a regular diet. The patient had been on oral hypoglycemics as an outpatient, but in hospital, he was simply managed with an insulin sliding scale. The patient will be transferred back to Pelican Bay, under the care of Dr. X at the infirmary. He will be further managed for his diabetes there. The patient will additionally undergo potential end of life meetings. I discussed the potentials of chemotherapy with patient. Certainly, there are modest benefits, which can be obtained with chemotherapy in metastatic pancreatic cancer, though at some cost with morbidity. The patient will consider this and will discuss this further with Dr. X. + +DISCHARGE MEDICATIONS: + +1. Phenergan 25 mg q.6. p.r.n. + +2. Duragesic patch 100 mcg q.3.d. + +3. Benadryl 25-50 mg p.o. q.i.d. for pruritus. + +4. Sliding scale will be discontinued at the time of discharge and will be reinstituted on arrival at Pelican Bay Infirmary. + +5. The patient had initially been on enalapril here. His hypertension will be managed by Dr. X as well. + +PLAN: + + The patient should return for repeat ERCP if there are signs of stent occlusion such as fever, increased bilirubin, worsening pain. In the meantime, he will be kept on a regular diet and activity per Dr. X. \ No newline at end of file diff --git a/3893_Discharge Summary.txt b/3893_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..d0f74ad3b109f96d707cee649b867629eef2d765 --- /dev/null +++ b/3893_Discharge Summary.txt @@ -0,0 +1,45 @@ +ADMITTING DIAGNOSES: + +1. Fever. + +2. Otitis media. + +3. Possible sepsis. + +HISTORY OF PRESENT ILLNESS: + +The patient is a 10-month-old male who was seen in the office 1 day prior to admission. He has had a 2-day history of fever that has gone up to as high as 103.6 degrees F. He has also had intermittent cough, nasal congestion, and rhinorrhea and no history of rashes. He has been taking Tylenol and Advil to help decrease the fevers, but the fever has continued to rise. He was noted to have some increased workup of breathing and parents returned to the office on the day of admission. + +PAST MEDICAL HISTORY: + + Significant for being born at 33 weeks' gestation with a birth weight of 5 pounds and 1 ounce. + +PHYSICAL EXAMINATION: + + On exam, he was moderately ill appearing and lethargic. HEENT: Atraumatic, normocephalic. Pupils are equal, round, and reactive to light. Tympanic membranes were red and yellow, and opaque bilaterally. Nares were patent. Oropharynx was slightly moist and pink. Neck was soft and supple without masses. Heart is regular rate and rhythm without murmurs. Lungs showed increased workup of breathing, moderate tachypnea. No rales, rhonchi or wheezes were noted. Abdomen: Soft, nontender, nondistended. Active bowel sounds. Neurologic exam showed good muscle strength, normal tone. Cranial nerves II through XII are grossly intact. + +LABORATORY FINDINGS: + + He had electrolytes, BUN and creatinine, and glucose all of which were within normal limits. White blood cell count was 8.6 with 61% neutrophils, 21% lymphocytes, 17% monocytes, suggestive of a viral infection. Urinalysis was completely unremarkable. Chest x-ray showed a suboptimal inspiration, but no evidence of an acute process in the chest. + +HOSPITAL COURSE: + + The patient was admitted to the hospital and allowed a clear liquid diet. Activity is as tolerates. CBC with differential, blood culture, electrolytes, BUN + + and creatinine, glucose, UA + + and urine culture all were ordered. Chest x-ray was ordered as well with 2 views to evaluate for a possible pneumonia. Pulse oximetry checks were ordered every shift and as needed with O2 ordered per nasal cannula if O2 saturations were less that 94%. Gave D5 and quarter of normal saline at 45 mL per hour, which was just slightly above maintenance rate to help with hydration. He was given ceftriaxone 500 mg IV once daily to treat otitis media and possible sepsis, and I will add Tylenol and ibuprofen as needed for fevers. Overnight, he did have his oxygen saturations drop and went into oxygen overnight. His lungs remained clear, but because of the need for O2, we instituted albuterol aerosols every 6 hours to help maintain good lung function. The nurses were instructed to attempt to wean O2 if possible and advance the diet. He was doing clear liquids well and so I saline locked to help to accommodate improve the mobility with the patient. He did well the following evening with no further oxygen requirement. He continued to spike fevers but last fever was around 13:45 on the previous day. At the time of exam, he had 100% oxygen saturations on room air with temperature of 99.3 degrees F. with clear lungs. He was given additional dose of Rocephin when it was felt that it would be appropriate for him to be discharged that morning. + +CONDITION OF THE PATIENT AT DISCHARGE: + + He was at 100% oxygen saturations on room air with no further dips at night. He has become afebrile and was having no further increased work of breathing. + +DISCHARGE DIAGNOSES: + +1. Bilateral otitis media. + +2. Fever. + +PLAN: + +Recommended discharge. No restrictions in diet or activity. He was continued Omnicef 125 mg/5 mL one teaspoon p.o. once daily and instructed to follow up with Dr. X, his primary doctor, on the following Tuesday. Parents were instructed also to call if new symptoms occurred or he had return if difficulties with breathing or increased lethargy. \ No newline at end of file diff --git a/3894_Discharge Summary.txt b/3894_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..a9785ad6f62a300e58637cf341483e2f8d1aa5f5 --- /dev/null +++ b/3894_Discharge Summary.txt @@ -0,0 +1,43 @@ +ADMISSION DIAGNOSIS: + + Right tibial plateau fracture. + +DISCHARGE DIAGNOSES: + + Right tibial plateau fracture and also medial meniscus tear on the right side. + +PROCEDURES PERFORMED: + + Open reduction and internal fixation (ORIF) of right Schatzker III tibial plateau fracture with partial medial meniscectomy. + +CONSULTATIONS: + + To rehab, Dr. X and to Internal Medicine for management of multiple medical problems including hypothyroid, diabetes mellitus type 2, bronchitis, and congestive heart failure. + +HOSPITAL COURSE: + + The patient was admitted and consented for operation, and taken to the operating room for open reduction and internal fixation of right Schatzker III tibial plateau fracture and partial medial meniscectomy performed without incidence. The patient seemed to be recovering well. The patient spent the next several days on the floor, nonweightbearing with CPM machine in place, developed a brief period of dyspnea, which seems to have resolved and may have been a combination of bronchitis, thick secretions, and fluid overload. The patient was given nebulizer treatment and Lasix increased the same to resolve the problem. The patient was comfortable, stabilized, breathing well. On day #12, was transferred to ABCD. + +DISCHARGE INSTRUCTIONS: + + The patient is to be transferred to ABCD after open reduction and internal fixation of right tibial plateau fracture and partial medial meniscectomy. + +DIET: + + Regular. + +ACTIVITY AND LIMITATIONS: + + Nonweightbearing to the right lower extremity. The patient is to continue CPM machine while in bed along with antiembolic stockings. The patient will require nursing, physical therapy, occupational therapy, and social work consults. + +DISCHARGE MEDICATIONS: + + Resume home medications, but increase Lasix to 80 mg every morning, Lovenox 30 mg subcu daily x2 weeks, Vicodin 5/500 mg one to two every four to six hours p.r.n. pain, Combivent nebulizer every four hours while awake for difficulty breathing, Zithromax one week 250 mg daily, and guaifenesin long-acting one twice a day b.i.d. + +FOLLOWUP: + + Follow up with Dr. Y in 7 to 10 days in office. + +CONDITION ON DISCHARGE: + + Stable. \ No newline at end of file diff --git a/3895_Discharge Summary.txt b/3895_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..24cc7eb9aca9a02e1675ad683aa0943a24fb7dae --- /dev/null +++ b/3895_Discharge Summary.txt @@ -0,0 +1,83 @@ +ADMISSION DIAGNOSES: + +1. Pneumonia, likely secondary to aspiration. + +2. Chronic obstructive pulmonary disease (COPD) exacerbation. + +3. Systemic inflammatory response syndrome. + +4. Hyperglycemia. + +DISCHARGE DIAGNOSES: + +1. Aspiration pneumonia. + +2. Aspiration disorder in setting of severe chronic obstructive pulmonary disease. + +3. Chronic obstructive pulmonary disease (COPD) exacerbation. + +4. Acute respiratory on chronic respiratory failure secondary to chronic obstructive pulmonary disease exacerbation. + +5. Hypercapnia on admission secondary to chronic obstructive pulmonary disease. + +6. Systemic inflammatory response syndrome secondary to aspiration pneumonia. No bacteria identified with blood cultures or sputum culture. + +7. Atrial fibrillation with episodic rapid ventricular rate, now rate control. + +8. Hyperglycemia secondary to poorly controlled type ii diabetes mellitus, insulin requiring. + +9. Benign essential hypertension, poorly controlled on admission, now well controlled on discharge. + +10. Aspiration disorder exacerbated by chronic obstructive pulmonary disease and acute respiratory failure. + +11. Hyperlipidemia. + +12. Acute renal failure on chronic renal failure on admission, now resolved. + +HISTORY OF PRESENT ILLNESS: + + Briefly, this is 73-year-old white male with history of multiple hospital admissions for COPD exacerbation and pneumonia who presented to the emergency room on 04/23/08, complaining of severe shortness of breath. The patient received 3 nebulizers at home without much improvement. He was subsequently treated successfully with supplemental oxygen provided by normal nasal cannula initially and subsequently changed to BiPAP. + +HOSPITAL COURSE: + +The patient was admitted to the hospitalist service, treated with frequent small volume nebulizers, treated with IV Solu-Medrol and BiPAP support for COPD exacerbation. The patient also noted with poorly controlled atrial fibrillation with a rate in the low 100s to mid 100s. The patient subsequently received diltiazem, also received p.o. digoxin. The patient subsequently responded well as well received IV antibiotics including Levaquin and Zosyn. The patient made slow, but steady improvement over the course of his hospitalization. The patient subsequently was able to be weaned off BiPAP during the day, but continued BiPAP at night and will continue with BiPAP if needed. The patient may require a sleep study after discharge, but by the third day prior to discharge he was no longer utilizing BiPAP + + was simply using supplemental O2 at night and was able to maintain appropriate and satisfactory O2 saturations on one-liter per minute supplemental O2 per nasal cannula. The patient was able to participate with physical therapy, able to ambulate from his bed to the bathroom, and was able to tolerate a dysphagia 2 diet. Note that speech therapy did provide a consultation during this hospitalization and his modified barium swallow was thought to be unremarkable and really related only to the patient's severe shortness of breath during meal time. The patient's chest x-ray on admission revealed some mild vascular congestion and bilateral pleural effusions that appeared to be unchanged. There was also more pronounced patchy alveolar opacity, which appeared to be, "mass like" in the right suprahilar region. This subsequently resolved and the patient's infiltrate slowly improved over the course of his hospitalization. On the day prior to discharge, the patient had a chest x-ray 2 views, which allowing for differences in technique revealed little change in the bibasilar infiltrates and atelectatic changes at the bases bilaterally. This was compared with an examination performed 3 days prior. The patient also had minimal bilateral effusions. The patient will continue with clindamycin for the next 2 weeks after discharge. Home health has been ordered and the case has been discussed in detail with Shaun Eagan, physician assistant at Eureka Community Health Center. The patient was discharged as well on a dysphagia 2 diet, thin liquids are okay. The patient discharged on the following medications. + +DISCHARGE MEDICATIONS: + +1. Home oxygen 1 to 2 liters to maintain O2 saturations at 89 to 91% at all times. + +2. Ativan 1 mg p.o. t.i.d. + +3. Metformin 1000 mg p.o. b.i.d. + +4. Glucotrol 5 mg p.o. daily. + +5. Spiriva 1 puff b.i.d. + +6. Lantus 25 units subcu q.a.m. + +7. Cardizem CD 180 mg p.o. q.a.m. + +8. Advair 250/50 mcg, 1 puff b.i.d. The patient is instructed to rinse with mouthwash after each use. + +9. Iron 325 mg p.o. b.i.d. + +10. Aspirin 325 mg p.o. daily. + +11. Lipitor 10 mg p.o. bedtime. + +12. Digoxin 0.25 mg p.o. daily. + +13. Lisinopril 20 mg p.o. q.a.m. + +14. DuoNeb every 4 hours for the next several weeks, then q.6 h. thereafter, dispensed 180 DuoNeb ampule's with one refill. + +15. Prednisone 40 mg p.o. q.a.m. x3 days followed by 30 mg p.o. q.a.m. x3 days, then followed by 20 mg p.o. q.a.m. x5 days, then 10 mg p.o. q.a.m. x14 days, then discontinue, #30 days supply given. No refills. + +16. Clindamycin 300 mg p.o. q.i.d. x2 weeks, dispensed #64 with one refill. + +The patient's aspiration pneumonia was discussed in detail. He is agreeable to obtaining a chest x-ray PA and lateral after 2 weeks of treatment. Note that this patient did not have community-acquired pneumonia. His discharge diagnosis is aspiration pneumonia. The patient will continue with a dysphagia 2 diet with thin liquids after discharge. The patient discharged with home health. A dietary and speech therapy evaluation has been ordered. Speech therapy to treat for chronic dysphagia and aspiration in the setting of severe chronic obstructive pulmonary disease. + +Total discharge time was greater than 30 minutes. \ No newline at end of file diff --git a/3896_Discharge Summary.txt b/3896_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..9db95f4a6995350f75e9eaeb4f3331206fbe6d59 --- /dev/null +++ b/3896_Discharge Summary.txt @@ -0,0 +1,29 @@ +PRELIMINARY DIAGNOSES: + +1. Contusion of the frontal lobe of the brain. + +2. Closed head injury and history of fall. + +3. Headache, probably secondary to contusion. + +FINAL DIAGNOSES: + +1. Contusion of the orbital surface of the frontal lobes bilaterally. + +2. Closed head injury. + +3. History of fall. + +COURSE IN THE HOSPITAL: + + This is a 29-year-old male, who fell at home. He was seen in the emergency room due to headache. CT of the brain revealed contusion of the frontal lobe near the falx. The patient did not have any focal signs. He was admitted to ABCD. Neurology consultation was obtained. Neuro checks were done. The patient continued to remain stable, although he had some frontal headache. He underwent an MRI to rule out extension of the contusion or the possibility of a bleed and the MRI of the brain without contrast revealed findings consistent with contusion of the orbital surface of the frontal lobes bilaterally near the interhemispheric fissure. The patient remained clinically stable and his headache resolved. He was discharged home on 11/6/2008. + +PLAN: + + Discharge the patient to home. + +ACTIVITY: + +As tolerated. + +The patient has been advised to call if the headache is recurrent and Tylenol 650 mg 1 p.o. q.6 h. p.r.n. headache. The patient has been advised to follow up with me as well as the neurologist in about 1 week. \ No newline at end of file diff --git a/3897_Discharge Summary.txt b/3897_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..6aa518d824872a89602fcc71864f2532977c0cd2 --- /dev/null +++ b/3897_Discharge Summary.txt @@ -0,0 +1,13 @@ +DIAGNOSES: + + Traumatic brain injury, cervical musculoskeletal strain. + +DISCHARGE SUMMARY: + + The patient was seen for evaluation on 12/11/06 followed by 2 treatment sessions. Treatment consisted of neuromuscular reeducation including therapeutic exercise to improve range of motion, strength, and coordination; functional mobility training; self-care training; cognitive retraining; caregiver instruction; and home exercise program. Goals were not achieved, as the patient was admitted to inpatient rehabilitation center. + +RECOMMENDATIONS: + + Discharged from OT this date, as the patient has been admitted to Inpatient Rehabilitation Center. + +Thank you for this referral. \ No newline at end of file diff --git a/3898_Discharge Summary.txt b/3898_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..ba2b141f87a27d7ef555dfda3cbc99b59d7ef19b --- /dev/null +++ b/3898_Discharge Summary.txt @@ -0,0 +1,21 @@ +ADMISSION DIAGNOSES: + +1. Pneumonia, failed outpatient treatment. + +2. Hypoxia. + +3. Rheumatoid arthritis. + +DISCHARGE DIAGNOSES: + +1. Atypical pneumonia, suspected viral. + +2. Hypoxia. + +3. Rheumatoid arthritis. + +4. Suspected mild stress-induced adrenal insufficiency. + +HOSPITAL COURSE: + + This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission. She was seen on multiple occasions at Urgent Care and in her physician's office. Initial x-ray showed some mild diffuse patchy infiltrates. She was first started on Avelox, but had a reaction, switched to Augmentin, which caused loose stools, and then three days prior to admission was given daily 1 g Rocephin and started on azithromycin. Her O2 saturations drifted downward. They were less than 88% when active; at rest, varied between 88% and 92%. Decision was made because of failed outpatient treatment of pneumonia. Her medical history is significant for rheumatoid arthritis. She is on 20 mg of methotrexate every week as well as Remicade every eight weeks. Her last dose of Remicade was in the month of June. Hospital course was relatively unremarkable. CT scan was performed and no specific focal pathology was seen. Dr. X, pulmonologist was consulted. He also was uncertain as to the exact etiology, but viral etiology was most highly suspected. Because of her loose stools, C. difficile toxin was ordered, although that is pending at the time of discharge. She was continued on Rocephin IV and azithromycin. Her fever broke 18 hours prior to discharge, and O2 saturations improved, as did her overall strength and clinical status. She was instructed to finish azithromycin. She has two pills left at home. She is to follow up with Dr. X in two to three days. Because she is on chronic prednisone therapy, it was suspected that she was mildly adrenal insufficient from the stress of her pneumonia. She is to continue the increased dose of prednisone at 20 mg (up from 5 mg per day). We will consult her rheumatologist as to whether to continue her methotrexate, which we held this past Friday. Methotrexate is known on some occasions to cause pneumonitis. \ No newline at end of file diff --git a/3899_Discharge Summary.txt b/3899_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..059a454e88e512a1fd8855f396c39d35446a7358 --- /dev/null +++ b/3899_Discharge Summary.txt @@ -0,0 +1,19 @@ +ADMISSION DIAGNOSIS: + + Symptomatic thyroid goiter. + +DISCHARGE DIAGNOSIS: + +Symptomatic thyroid goiter. + +PROCEDURE PERFORMED DURING THIS HOSPITALIZATION: + + Total thyroidectomy. + +INDICATIONS FOR THE SURGERY: + +Briefly, the patient is a 71-year-old female referred with increasingly symptomatic large nodular thyroid goiter. She presented now after informed consent for the above procedure, understanding the inherent risks and complications and risk-benefit ratio. + +HOSPITAL COURSE: + +The patient underwent total thyroidectomy on 09/22/08, which she tolerated very well and remained stable in the postoperative period. On postoperative day #1, she was tolerating her diet, began on thyroid hormone replacement, and remained afebrile with stable vital signs. She required intravenous narcotics for pain control. She was judged stable for discharge home on 09/25/08, tolerating a diet well, having no fever, stable vital signs, and good pain control. The wound was clean and dry. The drain was removed. She was instructed to follow up in the surgical office within one week after discharge. She was given prescription for Vicodin for pain and Synthroid thyroid hormone, and otherwise the appropriate wound care instructions per my routine wound care sheet. \ No newline at end of file diff --git a/3900_Discharge Summary.txt b/3900_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..11fc88420d52ae27a50d3d3fa02242c9b9c362fd --- /dev/null +++ b/3900_Discharge Summary.txt @@ -0,0 +1,57 @@ +DISCHARGE DIAGNOSES: + +1. Suspected mastoiditis ruled out. + +2. Right acute otitis media. + +3. Severe ear pain resolving. + +HISTORY OF PRESENT ILLNESS: + + The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis. The child has had very severe ear pain and blood draining from the right ear. The child had a temperature maximum of 101.4 in the ER. The patient was admitted and started on IV Unasyn, which he tolerated well and required Morphine and Vicodin for pain control. In the first 12 hours after admission, the patient's pain decreased and also swelling of his cervical area decreased. The patient was evaluated by Dr. X from the ENT while in house. After reviewing the CT scan, it was felt that the CT scan was not consistent with mastoiditis. The child was continued on IV fluid and narcotics for pain as well as Unasyn until the time of discharge. At the time of discharge his pain is markedly decreased about 2/10 and swelling in the area has improved. The patient is also able to take p.o. well. + +DISCHARGE PHYSICAL EXAMINATION: + +GENERAL: The patient is alert, in no respiratory distress. + +VITAL SIGNS: His temperature is 97.6, heart rate 83, blood pressure 105/57, respiratory rate 16 on room air. + +HEENT: Right ear shows no redness. The area behind his ear is nontender. There is a large posterior chains node that is nontender and the swelling in this area has decreased markedly. + +NECK: Supple. + +CHEST: Clear breath sounds. + +CARDIAC: Normal S1, S2 without murmur. + +ABDOMEN: Soft. There is no hepatosplenomegaly or tenderness. + +SKIN: Warm and well perfused. + +DISCHARGE WEIGHT: + + 38.7 kg. + +DISCHARGE CONDITION: + + Good. + +DISCHARGE DIET: + + Regular as tolerated. + +DISCHARGE MEDICATIONS: + +1. Ciprodex Otic Solution in the right ear twice daily. + +2. Augmentin 500 mg three times daily x10 days. + +FOLLOW UP: + +1. Dr. Y in one week (ENT). + +2. The primary care physician in 2 to 3 days. + +TIME SPENT: + + Approximate discharge time is 28 minutes. \ No newline at end of file diff --git a/3901_Discharge Summary.txt b/3901_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..1d7ab7f774915c775da7c73ec05c41648613c3d0 --- /dev/null +++ b/3901_Discharge Summary.txt @@ -0,0 +1,41 @@ +PRINCIPAL DIAGNOSIS: + + Mullerian adenosarcoma. + +HISTORY OF PRESENT ILLNESS: + + The patient is a 56-year-old presenting with a large mass aborted through the cervix. + +PHYSICAL EXAM: + +CHEST: Clear. There is no heart murmur. + +ABDOMEN: Nontender. + +PELVIC: There is a large mass in the vagina. + +HOSPITAL COURSE: + + The patient went to surgery on the day of admission. The postoperative course was marked by fever and ileus. The patient regained bowel function. She was discharged on the morning of the seventh postoperative day. + +OPERATIONS: + + July 25, 2006: Total abdominal hysterectomy, bilateral salpingo-oophorectomy. + +DISCHARGE CONDITION: + + Stable. + + + +PLAN: + + The patient will remain at rest initially with progressive ambulation thereafter. She will avoid lifting, driving, stairs, or intercourse. She will call me for fevers, drainage, bleeding, or pain. Family history, social history, and psychosocial needs per the social worker. The patient will follow up in my office in one week. + +PATHOLOGY: + + Mullerian adenosarcoma. + +MEDICATIONS: + + Percocet 5, #40, one q.3 h. p.r.n. pain. \ No newline at end of file diff --git a/3902_Discharge Summary.txt b/3902_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..99085792184d38e5f2d3883b0d4c434f47ba045d --- /dev/null +++ b/3902_Discharge Summary.txt @@ -0,0 +1,56 @@ +ADMITTING DIAGNOSES: + + Respiratory distress syndrome, intrauterine growth restriction, thrombocytopenia, hypoglycemia, retinal immaturity. + +HISTORY OF PRESENTING ILLNESS: + + The baby is an ex-32 weeks small for gestational age infant with birth weight 1102. Baby was born at ABCD Hospital at 1333 on 07/14/2006. Mother is a 20-year-old gravida 1, para 0 female who received prenatal care. Prenatal course was complicated by low amniotic fluid index and hypertension. She was evaluated for evolving preeclampsia and had a C-section secondary to the nonreassuring fetal status. Baby delivered operatively, Apgar scores were 8 and 9 initially taken to level 2 satellite nursery and arrangements were to transfer to Children's Hospital. Infant was transferred to Children's Hospital for higher level of care, stayed at Children's Hospital for approximately 2 weeks, and was transferred back to ABCD where he stayed until he was discharged on 08/16/2006. + +HOSPITAL COURSE: + + At the time of transfer to ABCD + + these were the following issues. + +FEEDING AND NUTRITION: + + Baby was on TPN and p.o. feeds had been started and were advanced 1 ml q.6h. Baby was tolerating p.o. feeds of expressed breast milk and baby began to experience some abdominal distention. The p.o. feeds were held and IV D10 water was given. Baby was started on Mylicon drops and glycerin suppositories. Abdominal ultrasound showed gaseous distention without signs of obstruction. OG tube was passed. Baby improved after couple of days when p.o. feedings were restarted. Baby was also given Reglan. At the time of discharge, baby was tolerating p.o. feeds well of BM fortified with 22-cal NeoSure. Feeding amounts at the time of discharge was between 35 to 50 mL per feed and weight was 1797 grams. + +RESPIRATIONS: + + At the time of admission, baby was not having any apnea spells, no bradycardia or desaturations, was saturating well on room air and continued to do well on room air until the time of discharge. + +HYPOGLYCEMIA: + + Baby began to experience hypoglycemic episodes on 07/24/2006. Blood glucose level was as low as 46. D10 was given initially as bolus. Baby continued to experience hypoglycemic episodes. Diazoxide was started 5 mg/kg per os every 8 hours and fingersticks were done to monitor blood glucose level. The baby improved with diazoxide, hypoglycemic issues resolved and then began again. Diazoxide was discontinued, but the hypoglycemic issues restarted. The Diazoxide was restarted again. Blood glucose level stabilized and then diazoxide was weaned off until daily dose of 6 mg/kg and then the diazoxide was discontinued. At the time of discharge, blood glucose levels were not being stable for 24 hours. + +CARDIOVASCULAR: + + Infant was hemodynamically stable on admission from Madera. Infant has a closed PDA. Infant had two cardiac echograms done. The lab showing normal antegrade flow across the right coronary artery as well as the left main and left anterior descending coronary artery, then the circumflex coronary artery. + +CNS: + + Infant had a head ultrasound done to rule out intracranial abnormalities and intracranial hemorrhage. The ultrasound was negative for intracranial hemorrhage. + +INFECTIOUS DISEASE: + + The patient had been on antibiotics during the stay at Madera. At the time of admission to the ABCD + + the patient was not on any antibiotics and his clinically condition has remained stable. + +HEMATOLOGY: + + The patient is status post phototherapy at Madera and was started on iron. + +OPHTHALMOLOGY: + + Exam on 07/17/2006 showed immature retina. The patient is to get followup exam after discharge. + +DISCHARGE DIAGNOSIS: + + Stable ex-32-weeks preemie. + +DISCHARGE INSTRUCTIONS: + + The patient has been educated on CPR measures. Followup appointment has been made at Kid's Care. Calcium challenge has been done. The patient's parents are comfortable with feeding. The patient has been discharged on NeoSure and expressed breast milk. + diff --git a/3903_Discharge Summary.txt b/3903_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..7a21a0a6e3d33073775adb414c92232bdf5ff77d --- /dev/null +++ b/3903_Discharge Summary.txt @@ -0,0 +1,61 @@ +ADMITTING DIAGNOSES: + +1. Leiomyosarcoma. + +2. History of pulmonary embolism. + +3. History of subdural hematoma. + +4. Pancytopenia. + +5. History of pneumonia. + +PROCEDURES DURING HOSPITALIZATION: + +1. Cycle six of CIVI-CAD (Cytoxan, Adriamycin, and DTIC) from 07/22/2008 to 07/29/2008. + +2. CTA + + chest PE study showing no evidence for pulmonary embolism. + +3. Head CT showing no evidence of acute intracranial abnormalities. + +4. Sinus CT + + normal mini-CT of the paranasal sinuses. + +HISTORY OF PRESENT ILLNESS: + +Ms. ABC is a pleasant 66-year-old Caucasian female who first palpated a mass in the left posterior arm in spring of 2007. The mass increased in size and she was seen by her primary care physician and referred to orthopedic surgeon. MRI showed inflammation and was thought to be secondary to rheumatoid arthritis. The mass increased in size. She eventually underwent a partial resection found to have pathologic grade 2 leiomyosarcoma, margins were impossible to assess, but were likely positive. She was evaluated by Dr. X and Dr. Y and a decision was made to proceed with preoperative chemotherapy. She began treatment with CIVI-CAD in December 2007. Her course was complicated by pulmonary embolus, pneumonia, and subdural hematoma while on anticoagulation. She eventually underwent surgical resection on May 1, 2008 with small area of residual disease, but otherwise clear margins. + +HOSPITAL COURSE: + +1. Leiomyosarcoma, the patient was admitted to Hem/Onco B Service under attending Dr. XYZ for cycle six of continuous IV infusion Cytoxan, Adriamycin, and DTIC + + which she tolerated well. + +2. History of pulmonary embolism. Upon admission, the patient reported an approximate two-week history of dyspnea on exertion and some mild chest pain. She underwent a CTA + + which showed no evidence of pulmonary embolism and the patient was started on prophylactic doses of Lovenox at 40 mg a day. She had no further complaints throughout the hospitalization with any shortness of breath or chest pain. + +3. History of subdural hematoma, also on admission the patient noted some mild intermittent headaches that were fleeting in nature, several a day that would resolve on their own. Her headaches were not responding to pain medication and so on 07/24/2008, we obtained a head CT that showed no evidence of acute intracranial abnormalities. The patient also had a history of sinusitis and so a sinus CT scan was obtained, which was normal. + +4. Pancytopenia. On admission, the patient's white blood count was 3.4, hemoglobin 11.3, platelet count 82, and ANC of 2400. The patient's counts were followed throughout admission. She did not require transfusion of red blood cells or platelets; however, on 07/26/2008 her ANC did dip to 900 and she was placed on neutropenic diet. At discharge her ANC is back up to 1100 and she is taken off neutropenic diet. Her white blood cell count at discharge was 1.4 and her hemoglobin was 11.2 with a platelet count of 140. + +5. History of pneumonia. During admission, the patient did not exhibit any signs or symptoms of pneumonia. + +DISPOSITION: + + Home in stable condition. + +DIET: + + Regular and less neutropenic. + +ACTIVITY: + + Resume same activity. + +FOLLOWUP: + +The patient will have lab work at Dr. XYZ on 08/05/2008 and she will also return to the cancer center on 08/12/2008 at 10:20 a.m. The patient is also advised to monitor for any fevers greater than 100.5 and should she have any further problems in the meantime to please call in to be seen sooner. \ No newline at end of file diff --git a/3904_Discharge Summary.txt b/3904_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..ec14a6516280cdfa773ad633ac6c9ade3ded83ca --- /dev/null +++ b/3904_Discharge Summary.txt @@ -0,0 +1,91 @@ +ADMISSION DIAGNOSES: + +1. Seizure. + +2. Hypoglycemia. + +3. Anemia. + +4. Hypotension. + +5. Dyspnea. + +6. Edema. + +DISCHARGE DIAGNOSES: + +1. Colon cancer, status post right hemicolectomy. + +2. Anemia. + +3. Hospital-acquired pneumonia. + +4. Hypertension. + +5. Congestive heart failure. + +6. Seizure disorder. + +PROCEDURES PERFORMED: + +1. Colonoscopy. + +2. Right hemicolectomy. + +HOSPITAL COURSE: + + The patient is a 59-year-old female with multiple medical problems including diabetes mellitus requiring insulin for 26 years, previous MI and coronary artery disease, history of seizure disorder, GERD + + bipolar disorder, and anemia. She was admitted due to a seizure and myoclonic jerks as well as hypoglycemia and anemia. Regarding the seizure disorder, Neurology was consulted. Noncontrast CT of the head was negative. Neurology felt that the only necessary intervention at that time would be to increase her Lamictal to 150 mg in the morning and 100 mg in the evening with gradual increase of the dosage until she was on 200 mg b.i.d. Regarding the hypoglycemia, the patient has diabetic gastroparesis and was being fed on J-tube intermittent feedings throughout the night at the rate of 120 an hour. Her insulin pump had a basal rate of roughly three at night during the feedings. While in the hospital, the insulin pump rate was turned down to 1.5 and then subsequently decreased a few other times. She seemed to tolerate the insulin pump rate well throughout her hospital course. There were a few episodes of hypoglycemia as well as hyperglycemia, but the episode seem to be related to the patient's n.p.o. status and the changing rates of tube feedings throughout her hospital course. + +At discharge, her endocrinologist was contacted. It was decided to change her insulin pump rate to 3 units per hour from midnight till 6 a.m. + + from 0.8 units per hour from 6 a.m. until 8 a.m. + + and then at 0.2 units per hour from 8 a.m. until 6 p.m. The insulin was to be NovoLog. Regarding the anemia, the gastroenterologists were consulted regarding her positive Hemoccult stools. A colonoscopy was performed, which found a mass at the right hepatic flexure. General Surgery was then consulted and a right hemicolectomy was performed on the patient. The patient tolerated the procedure well and tube feeds were slowly restarted following the procedure, and prior to discharge were back at her predischarge rates of 120 per hour. Regarding the cancer itself, it was found that 1 out of 53 nodes were positive for cancer. CT of the abdomen and pelvis revealed no metastasis, a CT of the chest revealed possible lung metastasis. Later in hospital course, the patient developed a septic-like picture likely secondary to hospital-acquired pneumonia. She was treated with Zosyn, Levaquin, and vancomycin, and tolerated the medications well. Her symptoms decreased and serial chest x-rays were followed, which showed some resolution of the illness. The patient was seen by the Infectious Disease specialist. The Infectious Disease specialist recommended vancomycin to cover MRSA bacteria, which was found at the J-tube site. At discharge, the patient was given three additional days of p.o. Levaquin 750 mg as well as three additional days of Bactrim DS every 12 hours. The Bactrim was used to cover the MRSA at the J-tube site. It was found that MRSA was sensitive to Bactrim. Throughout her hospital course, the patient continued to receive Coreg 12.5 mg daily and Lasix 40 mg twice a day for her congestive heart failure, which remains stable. She also received Lipitor for her high cholesterol. Her seizure disorder remained stable and she was discharged on a dose of 100 mg in the morning and 150 mg at night. The dosage increases can begin on an outpatient basis. + +DISCHARGE INSTRUCTIONS/MEDICATIONS: + + The patient was discharged to home. She was told to shy away from strenuous activity. Her discharge diet was to be her usual diet of isotonic fiber feeding through the J-tube at a rate of 120 per hour throughout the night. The discharge medications were as follows: + +1. Coreg 12.5 mg p.o. b.i.d. + +2. Lipitor 10 mg p.o. at bedtime. + +3. Nitro-Dur patch 0.3 mg per hour one patch daily. + +4. Phenergan syrup 6.25 mg p.o. q.4h. p.r.n. + +5. Synthroid 0.175 mg p.o. daily. + +6. Zyrtec 10 mg p.o. daily. + +7. Lamictal 100 mg p.o. daily. + +8. Lamictal 150 mg p.o. at bedtime. + +9. Ferrous sulfate drops 325 mg, PEG tube b.i.d. + +10. Nexium 40 mg p.o. at breakfast. + +11. Neurontin 400 mg p.o. t.i.d. + +12. Lasix 40 mg p.o. b.i.d. + +13. Fentanyl 50 mcg patch transdermal q.72h. + +14. Calcium and vitamin D combination, calcium carbonate 500 mg/vitamin D 200 units one tab p.o. t.i.d. + +15. Bactrim DS 800mg/160 mg tablet one tablet q.12h. x3 days. + +16. Levaquin 750 mg one tablet p.o. x3 days. + +The medications listed above, one listed as p.o. are to be administered via the J-tube. + +FOLLOWUP: + +The patient was instructed to see Dr. X in approximately five to seven days. She was given a lab sheet to have a CBC with diff as well as a CMP to be drawn prior to her appointment with Dr. X. She is instructed to follow up with Dr. Y if her condition changes regarding her colon cancer. She was instructed to follow up with Dr. Z, her oncologist, regarding the positive lymph nodes. We were unable to contact Dr. Z, but his telephone number was given to the patient and she was instructed to make a followup appointment. She was also instructed to follow up with her endocrinologist, Dr. A, regarding any insulin pump adjustments, which were necessary and she was also instructed to follow up with Dr. B, her gastroenterologist, regarding any issues with her J-tube. + +CONDITION ON DISCHARGE: + + Stable. \ No newline at end of file diff --git a/3905_Discharge Summary.txt b/3905_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..e5550ff5f8ccd76cbb23c203c4afec146ca2e5a8 --- /dev/null +++ b/3905_Discharge Summary.txt @@ -0,0 +1,25 @@ +DIAGNOSIS: + + Chronic laryngitis, hoarseness. + +HISTORY: + +The patient is a 68-year-old male, was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties. The patient attended initial evaluation plus 3 outpatient speech therapy sessions, which focused on training the patient to complete resonant voice activities and to improve his vocal hygiene. The patient attended therapy one time a week and was given numerous home activities to do in between therapy sessions. The patient made great progress and he came in to discuss with an appointment on 12/23/08 stating that his voice had finally returned to "normal". + +SHORT-TERM GOALS: + +1. To be independent with relaxation and stretching exercises and Lessac-Madsen Resonant Voice Therapy Protocol. + +2. He also met short-term goal therapy 3 and he is independent with resonant voice therapy tasks. + +3. We did not complete his __________ ratio during his last session; so, I am unsure if he had met his short-term goal number 2. + +4. To be referred for a videostroboscopy, but at this time, the patient is not in need of this evaluation. However, in the future if hoarseness returns, it is strongly recommended that he be referred for a videostroboscopy prior to returning to additional outpatient therapy. + +LONG-TERM GOALS: + +1. The patient did reach his long-term goal of improved vocal quality to return to prior level of function and to utilize his voice in all settings without vocal hoarseness or difficulty. + +2. The patient appears very pleased with his return of his normal voice and feels that he no longer needs outpatient skilled speech therapy. + +The patient is discharged from my services at this time with a home program to continue to promote normal voicing. \ No newline at end of file diff --git a/3907_Discharge Summary.txt b/3907_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..627247f7f09c241bf30087178c19f9e47c95f988 --- /dev/null +++ b/3907_Discharge Summary.txt @@ -0,0 +1,31 @@ +ADMISSION DIAGNOSES + +1. Neck pain with right upper extremity radiculopathy. + +2. Cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis. + +DISCHARGE DIAGNOSES + +1. Neck pain with right upper extremity radiculopathy. + +2. Cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis. + +OPERATIVE PROCEDURES + +1. Anterior cervical discectomy with decompression C4-C5, C5-C6, and C6-C7. + +2. Arthrodesis with anterior interbody fusion C4-C5, C5-C6, and C6-C7. + +3. Spinal instrumentation C4 through C7. + +4. Implant. + +5. Allograft. + +COMPLICATIONS: + + None. + +COURSE ON ADMISSION: + + This is the case of a very pleasant 41-year-old Caucasian female who was seen in clinic as an initial consultation on 09/13/07 complaining of intense neck pain radiating to the right shoulder blade to top of the right shoulder in to the right upper extremity to the patient's hand. The patient's symptoms have been persistent and had gotten worse with subjective weakness of the right upper extremity since its onset for several weeks now. The patient has been treated with medications, which has been unrelenting. The patient had imaging studies that showed evidence of cervical spondylosis with herniated disk and stenosis at C4-C5, C5-C6 and C6-C7. The patient underwent liver surgery and postoperatively her main issue was that of some degree of on and off right shoulder pain and some operative site soreness, which was treated well with IV morphine. The patient has resolution of the pain down the arm, but she does have some tingling of the right thumb and right index finger. The patient apparently is doing well with slight dysphagia, we treated her with Decadron and we will send her home with Medrol. The patient will have continued pain medication coverage with Darvocet and Flexeril. The patient will follow up with me as scheduled. Instructions have been given. \ No newline at end of file diff --git a/3908_Discharge Summary.txt b/3908_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..1c7f45fe75a438e671085c74ce26f3bd2a30b677 --- /dev/null +++ b/3908_Discharge Summary.txt @@ -0,0 +1,73 @@ +CHIEF COMPLAINT: + + Decreased ability to perform daily living activities secondary to right knee surgery. + +HISTORY OF PRESENT ILLNESS: + + The patient is a 61-year-old white female status post right total knee replacement secondary to degenerative joint disease performed by Dr. A at ABCD Hospital on 08/21/2007. The patient was transfused with 2 units of autologous blood postoperatively. She received DVT prophylaxis with a combination of Coumadin, Lovenox, SCD boots, and TED stockings. The remainder of her postoperative course was uneventful. She was discharged on 08/24/2007 from ABCD Hospital and admitted to the transitional care unit at XYZ Services for evaluation and rehabilitation. The patient reports that her last bowel movement was on 08/24/2007 just prior to her discharge from ABCD Hospital. She denies any urological symptoms such as dysuria, incomplete bladder emptying or other voiding difficulties. She reports having some right knee pain, which is most intense at a "certain position." The patient is unable to elaborate on which "certain position" causes her the most discomfort. + +ALLERGIES: + + NKDA. + +PAST MEDICAL HISTORY: + + Hypertension, hypothyroidism, degenerative joint disease, GERD + + anxiety disorder, Morton neuroma of her feet bilaterally, and distant history of migraine headaches some 30 years ago. + +MEDICATIONS: + + On transfer, Celebrex, Coumadin, Colace, Synthroid, Lovenox, Percocet, Toprol XL + + niacin, and trazodone. + +PHYSICAL EXAMINATION: + +VITAL SIGNS: Temperature 96.5, blood pressure 127/72, pulse 70, respiratory rate 20, 95% O2 saturation on room air. + +GENERAL: No acute distress at the time of the exam except as mentioned above complains of right knee pain at "certain position." + +HEENT: Normocephalic. Sclerae nonicteric. EOMI. Dentition in good repair. Tongue is in midline with no evidence of thrush. + +NECK: No thyroid enlargement. Trachea is midline. + +LUNGS: Clear to auscultation. + +HEART: Regular rate and rhythm. Normal S1 and S2. + +ABDOMEN: Soft, nontender, and nondistended. No organomegaly. + +EXTREMITIES: The right knee incision is intact. Steri-Strips are in place. There is some diffuse right knee edema and some limited ecchymosis as well. No calf tenderness bilaterally. Pedal pulses are palpable bilaterally. + +MENTAL STATUS: The patient appears slightly anxious during the interview and exam, but she was alert and oriented. + +HOSPITAL COURSE: + + As mentioned above, the patient was admitted on 08/24/2007 to the Transitional Care Unit at XYZ Services for evaluation and rehabilitation. She was seen in consultation by Physical Therapy and Occupational Therapy and had begun her rehabilitation till recovery. The patient had been properly instructed regarding using the CPM machine and she had been instructed as well to limit each CPM session to two hours. Very early in her hospitalization, the patient enthusiastically used the CPM much longer than two hours and consequently had increased right knee pain. She remarked that she had a better degree of flexibility, but she did report an increased need for pain management. Additionally, she required Ativan and at one point scheduled the doses of Ativan to treat her known history of anxiety disorder. On the fourth hospital day, she was noted to have some rashes about the right upper extremity and right side of her abdomen. The patient reported that this rash was itchy. She reports that she had been doing quite a bit of gardening just prior to surgery and this was most likely contact dermatitis, most likely due to her gardening activities preoperatively. She was treated with betamethasone cream applied to the rash b.i.d. The patient's therapy had progressed and she continued to make a good progress. At one point, the patient reported some insomnia due to right knee pain. She was switched from Percocet to oxycodone SR 20 mg b.i.d. and she had good pain control with this using the Percocet only for breakthrough pain. The DVT prophylaxis was maintained with Lovenox 40 mg subcu daily until the INR was greater than 1.7 and it was discontinued on 08/30/2007 when the INR was 1.92 within therapeutic range. The Coumadin was adjusted accordingly according to the INRs during her hospital course. Early in the hospital course, the patient had reported right calf tenderness and a venous Doppler study obtained on 08/27/2007 showed no DVT bilaterally. Initial laboratory data includes a UA on 08/28/2007, which was negative. Additionally, CBC showed a white count of 6.3, hemoglobin was 12.1, hematocrit was 35.3, and platelets were 278,000. Chemistries were within normal limits. Creatinine was 0.8, BUN was 8, anion gap was slightly decreased at 5, fasting glucose was 102. The remainder of chemistries was unremarkable. The patient continued to make great progress with her therapies so much so that we are anticipating her discharge on Monday, 09/03/2007. + +DISCHARGE DIAGNOSES: + +1. Status post right total knee replacement secondary to degenerative joint disease performed on 08/21/2007. + +2. Anxiety disorder. + +3. Insomnia secondary to pain and anxiety postoperatively. + +4. Postoperative constipation. + +5. Contact dermatitis secondary to preoperative gardening activities. + +6. Hypertension. + +7. Hypothyroidism. + +8. Gastroesophageal reflux disease. + +9. Morton neuroma of the feet bilaterally. + +10. Distant history of migraine headaches. + +INSTRUCTIONS GIVEN TO THE PATIENT AT THE TIME OF DISCHARGE: + + The patient is advised to continue taking the following medications: Celebrex 200 mg daily, for one month, Colace 100 mg b.i.d. for one month, Protonix 40 mg b.i.d. for one month, Synthroid 137 mcg daily, Diprosone cream 0.05% cream b.i.d. to the right arm and right abdomen, oxycodone SR 20 mg p.o. q.12h. for five days, then decrease to oxycodone SR 10 mg p.o. q.12h. for five days, Percocet 5/325 mg one to two tablets q.6h. to be used p.r.n. for breakthrough pain, trazodone 50 mg p.o. at bedtime p.r.n. for two weeks, Ativan 0.25 mg b.i.d. for two weeks, and Toprol-XL 50 mg daily. The patient will also take Coumadin and the dose will be adjusted according to the INRs, which will be obtained every Monday and Thursday with results being sent to Dr. A and his fax number is 831-5926. At the present time, the patient is taking Coumadin 7 mg daily. She will remain on Coumadin for 30 days. An INR is to be obtained on 09/03/2007 and should the Coumadin dose be changed, an addendum will be dictated to accompany this discharge summary. Finally, the patient has a followup appointment with Dr. A on 09/21/2007 at noon at his office. The patient is encouraged to follow up with her primary care physician, Dr. B. As mentioned above, the patient will be discharged on 09/03/2007 in stable and improved condition since she is status post right total knee replacement and has made good progress with her therapies and rehabilitation. \ No newline at end of file diff --git a/3909_Discharge Summary.txt b/3909_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..dcc9c22b8708139ba0eb71b74e0056e8ce44884b --- /dev/null +++ b/3909_Discharge Summary.txt @@ -0,0 +1,29 @@ +ADMITTING DIAGNOSIS: + + Kawasaki disease. + +DISCHARGE DIAGNOSIS: + + Kawasaki disease, resolving. + +HOSPITAL COURSE: + + This is a 14-month-old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR. When he was sent to the hospital, he had a fever of 102. Subsequently, the patient was evaluated and based on the criteria, he was started on high dose of aspirin and IVIG. Echocardiogram was also done, which was negative. IVIG was done x1, and between 12 hours of IVIG + + he spiked fever again; it was repeated twice, and then after second IVIG + + he did not spike any more fever. Today, his fever and his rash have completely resolved. He does not have any conjunctivitis and no redness of mucous membranes. He is more calm and quite and taking good p.o.; so with a very close followup and a cardiac followup, he will be sent home. + +DISCHARGE ACTIVITIES: + + Ad-lib. + +DISCHARGE DIET: + + PO ad-lib. + +DISCHARGE MEDICATIONS: + + Aspirin high dose 340 mg q.6h. for 1 day and then aspirin low dose 40 mg q.d. for 14 days and then Prevacid also to prevent his GI from aspirin 15 mg p.o. once a day. He will be followed by his primary doctor in 2 to 3 days. Cardiology for echo followup in 4 to 6 weeks and instructed not to give any vaccine in less than 11 months because of IVIG + + all the live virus vaccine, and if he gets any rashes, any fevers, should go to primary care doctor as soon as possible. \ No newline at end of file diff --git a/3910_Discharge Summary.txt b/3910_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..e8d3a70d94da574035be19a8732c74ea2b4c3476 --- /dev/null +++ b/3910_Discharge Summary.txt @@ -0,0 +1,43 @@ +ADMISSION DIAGNOSIS: + + Microinvasive carcinoma of the cervix. + +DISCHARGE DIAGNOSIS: + + Microinvasive carcinoma of the cervix. + +PROCEDURE PERFORMED: + + Total vaginal hysterectomy. + +HISTORY OF PRESENT ILLNESS: + + The patient is a 36-year-old, white female, gravida 7, para 5, last period mid March, status post tubal ligation. She had an abnormal Pap smear in the 80s, which she failed to followup on until this year. Biopsy showed a microinvasive carcinoma of the cervix and a cone biopsy was performed on 02/12/2007 also showing microinvasive carcinoma with a 1 mm invasion. She has elected definitive therapy with a total vaginal hysterectomy. She is aware of the future need of Pap smears. + +PAST MEDICAL HISTORY: + + Past history is significant for seven pregnancies, five term deliveries, and significant past history of tobacco use. + +PHYSICAL EXAMINATION: + + Physical exam is within normal limits with a taut normal size uterus and a small cervix, status post cone biopsy. + +LABORATORY DATA AND DIAGNOSTIC STUDIES: + + Chest x-ray was clear. Discharge hemoglobin 10.8. + +HOSPITAL COURSE: + + She was taken to the operating room on 04/02/2007 where a total vaginal hysterectomy was performed under general anesthesia. There was an incidental cystotomy at the time of the creation of the bladder flap. This was repaired intraoperatively without difficulty. Postoperative, she did very well. Bowel and bladder function returned quickly. She is ambulating well and tolerating a regular diet. + +Routine postoperative instructions given and understood. Followup will be in ten days for a cystogram and catheter removal with followup in the office at that time. + +DISCHARGE MEDICATIONS: + + Vicodin, Motrin, and Macrodantin at bedtime for urinary tract infection suppression. + +DISCHARGE CONDITION: + + Good. + +Final pathology report was free of residual disease. \ No newline at end of file diff --git a/3911_Discharge Summary.txt b/3911_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..9872d002782512723ae8975e9be5698f8a45c69d --- /dev/null +++ b/3911_Discharge Summary.txt @@ -0,0 +1,25 @@ +PROCEDURE: + + Laparoscopic cholecystectomy. + +DISCHARGE DIAGNOSES: + +1. Acute cholecystitis. + +2. Status post laparoscopic cholecystectomy. + +3. End-stage renal disease on hemodialysis. + +4. Hyperlipidemia. + +5. Hypertension. + +6. Congestive heart failure. + +7. Skin lymphoma 5 years ago. + +8. Hypothyroidism. + +HOSPITAL COURSE: + + This is a 78-year-old female with past medical condition includes hypertension, end-stage renal disease, hyperlipidemia, hypothyroidism, and skin lymphoma who had a left AV fistula done about 3 days ago by Dr. X and the patient went later on home, but started having epigastric pain and right upper quadrant pain and mid abdominal pain, some nauseated feeling, and then she could not handle the pain, so came to the emergency room, brought by the family. The patient's initial assessment, the patient's vital signs were stable, showed temperature 97.9, pulse was 106, and blood pressure was 156/85. EKG was not available and ultrasound of the abdomen showed there is a renal cyst about 2 cm. There is sludge in the gallbladder wall versus a stone in the gallbladder wall. Thickening of the gallbladder wall with positive Murphy sign. She has a history of cholecystitis. Urine shows positive glucose, but negative for nitrite and creatinine was 7.1, sodium 131, potassium was 5.2, and lipase and amylase were normal. So, the patient admitted to the Med/Surg floor initially and the patient was started on IV fluid as well as low-dose IV antibiotic and 2-D echocardiogram and EKG also was ordered. The patient also had history of CHF in the past and recently had some workup done. The patient does not remember initially. Surgical consult also requested and blood culture and urine culture also ordered. The same day, the patient was seen by Dr. Y and the patient should need cholecystectomy, but the patient also needs dialysis and also needs to be cleared by the cardiologist, so the patient later on seen by Dr. Z and cleared the patient for the surgery with moderate risk and the patient underwent laparoscopic cholecystectomy. The patient also seen by nephrologist and underwent dialysis. The patient's white count went down 6.1, afebrile. On postop day #1, the patient started eating and also walking. The patient also had chronic bronchitis. The patient was later on feeling fine, discussed with surgery. The patient was then able to discharge to home and follow with the surgeon in about 3-5 days. Discharged home with Synthroid 0.5 mg 1 tablet p.o. daily, Plavix 75 mg p.o. daily, folic acid 1 mg p.o. daily, Diovan 80 mg p.o. daily, Renagel 2 tablets 800 mg p.o. twice a day, Lasix 40 mg p.o. 2 tablets twice a day, lovastatin 20 mg p.o. daily, Coreg 3.125 mg p.o. twice a day, nebulizer therapy every 3 hours as needed, also Phenergan 25 mg p.o. q.8 hours for nausea and vomiting, Pepcid 20 mg p.o. daily, Vicodin 1 tablet p.o. q.6 hours p.r.n. as needed, and Levaquin 250 mg p.o. every other day for the next 5 days. The patient also had Premarin that she was taking, advised to discontinue because of increased risk of heart disease and stroke explained to the patient. Discharged home. \ No newline at end of file diff --git a/3912_Discharge Summary.txt b/3912_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..521b9b5179a8c79210e8743efa70df915ff4b08b --- /dev/null +++ b/3912_Discharge Summary.txt @@ -0,0 +1,29 @@ +ADMISSION DIAGNOSIS: + + Painful right knee status post total knee arthroplasty many years ago. The patient had gradual onset of worsening soreness and pain in this knee. X-ray showed that the poly seems to be worn out significantly in this area. + +DISCHARGE DIAGNOSIS: + + Status post poly exchange, right knee, total knee arthroplasty. + +CONDITION ON DISCHARGE: + + Stable. + +PROCEDURES PERFORMED: + + Poly exchange total knee, right. + +CONSULTATIONS: + + Anesthesia managed femoral nerve block on the patient. + +HOSPITAL COURSE: + +The patient was admitted with revision right total knee arthroplasty and replacement of patellar and tibial poly components. The patient recovered well after this. Working with PT + + she was able to ambulate with minimal assistance. Nerve block was removed by anesthesia. The patient did well on oral pain medications. The patient was discharged home. She is actually going to home with her son who will be able to assist her and look after her for anything she might need. The patient is comfortable with this, understands the therapy regimen, and is very satisfied after the procedure. + +DISCHARGE INSTRUCTIONS AND MEDICATIONS: + + The patient is to be discharged home to the care of the son. Diet is regular. Activity, weight bear as tolerated right lower extremity. Continue to do physical therapy exercises. The patient will be discharged home on Coumadin 4 mg a day as the INR was 1.9 on discharge with twice weekly lab checks. Vicodin 5/500 mg take one to two tablets p.o. q.4-6h. Resume home medications. Call the office or return to the emergency room for any concerns including increased redness, swelling, drainage, fever, or any concerns regarding operation or site of incision. The patient is to follow up with Dr. ABC in two weeks. \ No newline at end of file diff --git a/3913_Discharge Summary.txt b/3913_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..d0dfecc795eb2a15f5de7b87aa942f5530e2c41f --- /dev/null +++ b/3913_Discharge Summary.txt @@ -0,0 +1,54 @@ +PRINCIPAL DIAGNOSIS: + + Knee osteoarthrosis. + +PRINCIPAL PROCEDURE: + + Total knee arthroplasty. + +HISTORY AND PHYSICAL: + + A 66-year-old female with knee osteoarthrosis. Failed conservative management. Risks and benefits of different treatment options were explained. Informed consent was obtained. + +PAST SURGICAL HISTORY: + + Right knee surgery, cosmetic surgery, and carotid sinus surgery. + +MEDICATIONS: + + Mirapex, ibuprofen, and Ambien. + +ALLERGIES: + + QUESTIONABLE PENICILLIN ALLERGIES. + +PHYSICAL EXAMINATION: + + GENERAL: Female who appears younger than her stated age. Examination of her gait reveals she walks without assistive devices. + +HEENT: Normocephalic and atraumatic. + +CHEST: Clear to auscultation. + +CARDIOVASCULAR: Regular rate and rhythm. + +ABDOMEN: Soft. + +EXTREMITIES: Grossly neurovascularly intact. + +HOSPITAL COURSE: + + The patient was taken to the operating room (OR) on 03/15/2007. She underwent right total knee arthroplasty. She tolerated this well. She was taken to the recovery room. After uneventful recovery room course, she was brought to regular surgical floor. Mechanical and chemical deep venous thrombosis (DVT) prophylaxis were initiated. Routine postoperative antibiotics were administered. Hemovac drain was discontinued on postoperative day #2. Physical therapy was initiated. Continuous passive motion (CPM) was also initiated. She was able to spontaneously void. She transferred to oral pain medication. Incision remained clean, dry, and intact during the hospital course. No pain with calf squeeze. She was felt to be ready for discharge home on 03/19/2007. + +DISPOSITION: + +Discharged to home. + +FOLLOW UP: + + Follow up with Dr. X in one week. Prescriptions were written for Percocet and Coumadin. + +INSTRUCTIONS: + + Home physical therapy and PT and INR to be drawn at home for adjustment of Coumadin dosing. + diff --git a/3914_Discharge Summary.txt b/3914_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..3611a2251f8cdb6565254b1438665a84b655e469 --- /dev/null +++ b/3914_Discharge Summary.txt @@ -0,0 +1,51 @@ +ADMISSION DIAGNOSES: + +1. Menometrorrhagia. + +2. Dysmenorrhea. + +3. Small uterine fibroids. + +DISCHARGE DIAGNOSES: + +1. Menorrhagia. + +2. Dysmenorrhea. + +3. Small uterine fibroids. + +OPERATION PERFORMED: + +Total vaginal hysterectomy. + +BRIEF HISTORY AND PHYSICAL: + +The patient is a 42 year-old white female, gravida 3, para 2, with two prior vaginal deliveries. She is having increasing menometrorrhagia and dysmenorrhea. Ultrasound shows a small uterine fibroid. She has failed oral contraceptives and surgical therapy is planned. + +PAST HISTORY: + + Significant for reflux. + +SURGICAL HISTORY: + +Tubal ligation. + +PHYSICAL EXAMINATION: + + A top normal sized uterus with normal adnexa. + +LABORATORY VALUES: + +Her discharge hemoglobin is 12.4. + +HOSPITAL COURSE: + + She was taken to the operating room on 11/05/07 where a total vaginal hysterectomy was performed under general anesthesia. Postoperatively, she has done well. Bowel and bladder function have returned normally. She is ambulating well, tolerating a regular diet. Routine postoperative instructions given and said follow up will be in four weeks in the office. + +DISCHARGE MEDICATIONS: + + Preoperative meds plus Vicodin for pain. + +DISCHARGE CONDITION: + + Good. \ No newline at end of file diff --git a/3915_Discharge Summary.txt b/3915_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..29aac1025b9dcb17e9caed6f9caf8c9db0d2edfb --- /dev/null +++ b/3915_Discharge Summary.txt @@ -0,0 +1,29 @@ +ADMISSION DIAGNOSES: + +Fracture of the right femoral neck, also history of Alzheimer's dementia, and hypothyroidism. + +DISCHARGE DIAGNOSES: + + Fracture of the right femoral neck, also history of Alzheimer's dementia, hypothyroidism, and status post hemiarthroplasty of the hip. + +PROCEDURE PERFORMED: + +Hemiarthroplasty, right hip. + +CONSULTATIONS: + +Medicine for management of multiple medical problems including Alzheimer's. + +HOSPITAL COURSE: + + The patient was admitted on 08/06/2007 after a fall with subsequent fracture of the right hip. The patient was admitted to Orthopedics and consulted Medicine. The patient was actually taken to the operating room, consent signed by durable power of attorney, taken on 08/06/2007, had right hip hemiarthroplasty, recovered without incidence. The patient had continued confusion and dementia, which is apparently his baseline secondary to his Alzheimer's. Brief elevation of white count following the surgery, which did subside. Studies, UA and blood culture were negative. The patient was stable and was discharged to Heartland. + +CONDITION ON DISCHARGE: + + Stable. + +DISCHARGE INSTRUCTIONS: + + Transfer to ABC for rehab and continued care. Diabetic diet. Activity, ambulate as tolerated with posterior hip precautions. Rehab potential fair. He will need nursing, Social Work, PT/OT + + and nutrition consults. Resume home meds, DVT prophylaxis, aspirin, and compression stockings. Follow up Dr. X in one to two weeks; call 123-4567 for an appointment. \ No newline at end of file diff --git a/3916_Discharge Summary.txt b/3916_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..9aa801bb4d122058355f5a50f6a9f26ff0d5182c --- /dev/null +++ b/3916_Discharge Summary.txt @@ -0,0 +1,87 @@ +CHIEF COMPLAINT: + + Decreased ability to perform daily living activity secondary to recent right hip surgery. + +HISTORY OF PRESENT ILLNESS: + +The patient is a 51-year-old white female who is status post right total hip replacement performed on 08/27/2007 at ABCD Hospital by Dr. A. The patient had an unremarkable postoperative course, except low-grade fever of 99 to 100 postoperatively. She was admitted to the Transitional Care Unit on 08/30/2007 at XYZ Services. Prior to her discharge from ABCD Hospital, she had received DVT prophylaxis utilizing Coumadin and Lovenox and the INR goal is 2.0 to 3.0. She presents reporting that her last bowel movement was on 08/26/2007 prior to surgery. Otherwise, she reports some intermittent right calf discomfort and some postoperative right hip pain. + +ALLERGIES: + + No known drug allergies. + +PAST MEDICAL HISTORY: + + Anxiety, depression, osteoarthritis, migraine headaches associated with menstrual cycle, history of sciatic pain in the distant past, history of herniated disc, and status post appendectomy. + +MEDICATIONS: + +Medications taken at home are Paxil, MOBIC + + and Klonopin. + +MEDICATIONS ON TRANSFER: + + Celebrex, Coumadin, Colace, Fiorinal, oxycodone, Klonopin, and Paxil. + +FAMILY HISTORY: + + Noncontributory. + +SOCIAL HISTORY: + + The patient is married. She lives with her husband and is employed as a school nurse for the School Department. She had quit smoking cigarettes some 25 years ago and is a nondrinker. + +REVIEW OF SYSTEMS: + + As mentioned above. She has a history of migraine headaches associated with her menstrual cycle. She wears glasses and has a history of floaters. She reports a low-grade temperature of 99 to 100 postoperatively, mild intermittent cough, scratchy throat, (the symptoms may be secondary to intubation during surgery) + + intermittent right calf pain, which was described as sharp, but momentary with a negative Homans sign. The patient denies any cardiopulmonary symptoms such as chest pain, palpitation, pain in the upper neck and down to her arm, difficulty breathing, shortness of breath, or hemoptysis. She denies any nausea, vomiting, or diarrhea, but reports as being constipated with the last bowel movement being on 08/26/2007 prior to surgery. She denies urinary symptoms such as dysuria, urinary frequency, incomplete bladder emptying or voiding difficulties. First day of her last menstrual cycle was 08/23/207 and she reports that she is most likely not pregnant since her husband had a vasectomy years ago. + +PHYSICAL EXAMINATION: + +VITAL SIGNS: At the time of admission, temperature 97.7, blood pressure 108/52, heart rate 94, respirations 18, and 95% O2 saturation on room air. + +GENERAL: No acute distress at the time of exam. + +HEENT: Normocephalic. Sclerae are nonicteric. EOMI. Dentition is in good repair. + +NECK: Trachea is at the midline. + +LUNGS: Clear to auscultation. + +HEART: Regular rate and rhythm. + +ABDOMEN: Bowel sounds are heard throughout. Soft and nontender. + +EXTREMITIES: Right hip incision is clean, intact, and no drainage is noted. There is diffuse edema, which extends distally. There is no calf tenderness per se bilaterally and Homans sign is negative. There is no pedal edema. + +MENTAL STATUS: Alert and oriented x3, pleasant and cooperative during the exam. + +LABORATORY DATA: + + Initial workup included chemistry panel, which was unremarkable with the exception of a fasting glucose of 122 and an anion gap that was slightly decreased at 6. The BUN was normal at 8, creatinine was 0.9, INR was 1.49. CBC + + had a white count of 5.7, hemoglobin was 9.2, hematocrit was 26.6, and platelets were 318,000. + +IMPRESSION: + +1. Status post right total hip replacement. The patient is admitted to the TCU at XYZ's Health Services and will be seen in consultation by Physical Therapy and Occupational Therapy. + +2. Postoperative anemia, Feosol 325 mg one q.d. + +3. Pain management. Oxycodone SR 20 mg b.i.d. + + and oxycodone IR 5 mg one to two tablets q.4h. + + p.r.n. pain. Additionally, she will utilize ice to help decrease edema. + +4. Depression and anxiety, Paxil 40 mg daily, Klonopin 1 mg q.h.s. + +5. Osteoarthritis, Celebrex 200 mg b.i.d. + +6. GI prophylaxis, Protonix 40 mg b.i.d. Dulcolax suppository and lactulose will be used as a p.r.n. basis and Colace 100 mg b.i.d. + +7. DVT prophylaxis will be maintained with Arixtra 2.5 mg subcutaneously daily until the INR is greater than 1.7 and Coumadin will be adjusted according to the INR. She will continue on 5 mg every day. + +8. Right leg muscle spasm/calf pain is stable at this time and we will reevaluate on a regular basis. Monitor for any possibility of DVT. \ No newline at end of file diff --git a/3917_Discharge Summary.txt b/3917_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..127ab4c829b455576dc83175755b0f4c026c9d5b --- /dev/null +++ b/3917_Discharge Summary.txt @@ -0,0 +1,45 @@ +ADMITTING DIAGNOSIS: + + Intrauterine pregnancy at term with previous cesarean. + +SECONDARY DIAGNOSIS: + + Desired sterilization. + +DISCHARGE DIAGNOSES + +1. Intrauterine pregnancy at term with previous cesarean. + +2. Desired sterilization. + +3. Status post repeat low transverse cesarean and bilateral tubal ligation. + +HISTORY: + + The patient is a 35-year-old gravida 2, para 1-0-0-1 with intrauterine pregnancy on 08/30/09. Pregnancy was uncomplicated. She opted for a scheduled elective C-section and sterilization without any trial of labor. All routine screening labs were normal and she underwent a high-resolution ultrasound during pregnancy. + +PAST MEDICAL HISTORY: + + Significant for postpartum depression after her last baby as well as a cesarean. + +ALLERGIES: + + SHE HAS SEASONAL ALLERGIES. + +MEDICATIONS: + + She is taking vitamins and iron. + +PHYSICAL EXAMINATION + +GENERAL: An alert gravid woman in no distress. + +ABDOMEN: Gravid, nontender, non-irritable, with an infant in the vertex presentation. Estimated fetal weight was greater than 10 pounds. + +HOSPITAL COURSE: + +On the first hospital day, the patient went to the operating room where repeat low transverse cesarean and tubal ligation were performed under spinal anesthesia with delivery of a viable female infant weighing 7 pounds 10 ounces and Apgars of 9 and 9. There was normal placenta, normal pelvic anatomy. There was 600 cc estimated blood loss. Patient recovered uneventfully from her anesthesia and surgery. She was able to ambulate and void. She tolerated regular diet. She passed flatus. She was breast-feeding. Postoperative hematocrit was 31. On the second postoperative day, the patient was discharged home in satisfactory condition. + +DISCHARGE MEDICATIONS: + + Motrin and Percocet for pain. Paxil for postpartum depression. She was instructed to do no lifting, straining, or driving, to put nothing in the vagina and to see me in two weeks or with signs of severe pain, heavy bleeding, fever, or other problems. \ No newline at end of file diff --git a/3918_Discharge Summary.txt b/3918_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..0da2c8e9cda8588c680c0b38758fe93af30b5abb --- /dev/null +++ b/3918_Discharge Summary.txt @@ -0,0 +1,81 @@ +CHIEF COMPLAINT: + + GI bleed. + +HISTORY OF PRESENT ILLNESS: + + The patient is an 80-year-old white female with history of atrial fibrillation, on Coumadin, who presented as outpatient, complaining of increasing fatigue. CBC revealed microcytic anemia with hemoglobin of 8.9. Stool dark brown, strongly OB positive. The patient denied any shortness of breath. No chest pain. No GI complaints. The patient was admitted to ABCD for further evaluation. + +PAST MEDICAL HISTORY: + +Significant for atrial fibrillation, hypertension, osteoarthritis of the knees, hypercholesterolemia, non-insulin-dependent diabetes mellitus, asthma, and hypothyroidism. + +PHYSICAL EXAMINATION: + +GENERAL: The patient is in no acute distress. + +VITAL SIGNS: Stable. + +HEENT: Benign. + +NECK: Supple. No adenopathy. + +LUNGS: Clear with good air movement. + +HEART: Irregularly regular. No gallops. + +ABDOMEN: Positive bowel sounds, soft, and nontender. No masses or organomegaly. + +EXTREMITIES: 1+ lower extremity edema bilaterally. + +HOSPITAL COURSE: + + The patient underwent upper endoscopy performed by Dr. A, which revealed erosive gastritis. Colonoscopy did reveal diverticulosis as well as polyp, which was resected. The patient tolerated the procedure well. She was transfused, and prior to discharge hemoglobin was stable at 10.7. The patient was without further GI complaints. Coumadin was held during hospital stay and recommendations were given by GI to hold Coumadin for an additional three days after discharge then resume. The patient was discharged with outpatient PMD + + GI + + and Cardiology followup. + +DISCHARGE DIAGNOSES: + +1. Upper gastrointestinal bleed. + +2. Anemia. + +3. Atrial fibrillation. + +4. Non-insulin-dependent diabetes mellitus. + +5. Hypertension. + +6. Hypothyroidism. + +7. Asthma. + +CONDITION UPON DISCHARGE: + + Stable. + +MEDICATIONS: + + Feosol 325 mg daily, multivitamins one daily, Protonix 40 mg b.i.d. + + KCl 20 mEq daily, Lasix 40 mg b.i.d. + + atenolol 50 mg daily, Synthroid 80 mcg daily, Actos 30 mg daily, Mevacor 40 mg daily, and lisinopril 20 mg daily. + +ALLERGIES: + + None. + +DIET: + + 1800-calorie ADA. + +ACTIVITY: + + As tolerated. + +FOLLOWUP: + + The patient to hold Coumadin through weekend. Followup CBC and INR were ordered. Outpatient followup as arranged. \ No newline at end of file diff --git a/3919_Discharge Summary.txt b/3919_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..5640dabf55193efe30c62930554b536d781e67c5 --- /dev/null +++ b/3919_Discharge Summary.txt @@ -0,0 +1,39 @@ +ADMISSION DIAGNOSES: + +1. Menorrhagia. + +2. Uterus enlargement. + +3. Pelvic pain. + +DISCHARGE DIAGNOSIS: + + Status post vaginal hysterectomy. + +COMPLICATIONS: + + None. + +BRIEF HISTORY OF PRESENT ILLNESS: + + This is a 36-year-old, gravida 3, para 3 female who presented initially to the office with abnormal menstrual bleeding and increase in flow during her period. She also had symptoms of back pain, dysmenorrhea, and dysuria. The symptoms had been worsening over time. The patient was noted also to have increasing pelvic pain over the past 8 months and she was noted to have uterine enlargement upon examination. + +PROCEDURE: + + The patient underwent a total vaginal hysterectomy. + +HOSPITAL COURSE: + +The patient was admitted on 09/04/2007 to undergo total vaginal hysterectomy. The procedure preceded as planned without complication. Uterus was sent for pathologic analysis. The patient was monitored in the hospital, 2 days postoperatively. She recovered quite well and vitals remained stable. + +Laboratory studies, H&H were followed and appeared stable on 09/05/2007 with hemoglobin of 11.2 and hematocrit of 31.8. + +The patient was ready for discharge on Monday morning of 09/06/2007. + +LABORATORY FINDINGS: + + Please see chart for full studies during admission. + +DISPOSITION: + +The patient was discharged to home in stable condition. She was instructed to follow up in the office postoperatively. \ No newline at end of file diff --git a/3920_Discharge Summary.txt b/3920_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..78fbe5be2b1ac90c42e9a4e47927c1c07d78170a --- /dev/null +++ b/3920_Discharge Summary.txt @@ -0,0 +1,23 @@ +DIAGNOSIS AT ADMISSION: + + Hypothermia. + +DIAGNOSES ON DISCHARGE + +1. Hypothermia. + +2. Rule out sepsis, was negative as blood cultures, sputum cultures, and urine cultures were negative. + +3. Organic brain syndrome. + +4. Seizure disorder. + +5. Adrenal insufficiency. + +6. Hypothyroidism. + +7. Anemia of chronic disease. + +HOSPITAL COURSE: + +The patient was admitted through the emergency room. He was admitted to the Intensive Care Unit. He was rewarmed and had blood, sputum, and urine cultures done. He was placed on IV Rocephin. His usual medications of Dilantin and Depakene were given. The patient's hypertension was treated with fluid boluses. The patient was empirically placed on Synthroid and hydrocortisone by Dr. X. Blood work consisted of a chemistry panel that was unremarkable, except for decreased proteins. H&H was stable at 33.3/10.9 and platelets of 80,000. White blood cell counts were normal, differential was normal. TSH was 3.41. Free T4 was 0.9. Dr. X felt this was consistent with secondary hypothyroidism and recommended Synthroid replacement. A cortisol level was obtained prior to administration of hydrocortisone. This was 10.9 and that was not a fasting level. Dr. X felt because of his hypothyroidism and his hypothermia that he had secondary adrenal insufficiency and recommended hydrocortisone and Florinef. The patient was eventually changed to prednisone 2.5 mg b.i.d. in addition to his Florinef 0.1 mg on Monday, Wednesday, and Friday. The patient was started back on his tube feeds. He tolerated these poorly with residuals. Reglan was increased to 10 mg q.6 h. and erythromycin is being added. The patient's temperature has been stable in the 94 to 95 range. Other vital signs have been stable. His urine output has been diminished. An external jugular line was placed in the Intensive Care Unit. The patient's legal guardian, Janet Sanchez in Albuquerque has requested he be transported there. As per several physicians in Albuquerque and Dr. Y, an internist, we will accept him once we have a nursing home available to him. He is being transported back to the nursing home today and discharge planners are working on getting him a nursing home in Albuquerque. His prognosis is poor. \ No newline at end of file diff --git a/3921_Discharge Summary.txt b/3921_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..06d0d98eb31267f7bde403c1ab7d6c3195a0d95d --- /dev/null +++ b/3921_Discharge Summary.txt @@ -0,0 +1,25 @@ +FINAL DIAGNOSES + +1. Morbid obesity, status post laparoscopic Roux-en-Y gastric bypass. + +2. Hypertension. + +3. Obstructive sleep apnea, on CPAP. + +OPERATION AND PROCEDURE: + + Laparoscopic Roux-en-Y gastric bypass. + +BRIEF HOSPITAL COURSE SUMMARY: + +This is a 30-year-old male, who presented recently to the Bariatric Center for evaluation and treatment of longstanding morbid obesity and associated comorbidities. Underwent standard bariatric evaluation, consults, diagnostics, and preop Medifast induced weight loss in anticipation of elective bariatric surgery. + +Taken to the OR via same day surgery process for elective gastric bypass, tolerated well, recovered in the PACU + + and sent to the floor for routine postoperative care. There, DVT prophylaxis was continued with subcu heparin, early and frequent mobilization, and SCDs. PCA was utilized for pain control, efficaciously, he utilized the CPAP + + was monitored, and had no new cardiopulmonary complaints. Postop day #1, labs within normal limits, able to clinically start bariatric clear liquids at 2 ounces per hour, this was tolerated well. He was ambulatory, had no cardiopulmonary complaints, no unusual fever or concerning symptoms. By the second postoperative day, was able to advance to four ounces per hour, tolerated this well, and is able to discharge in stable and improved condition today. He had his drains removed today as well. + +DISCHARGE INSTRUCTIONS: + + Include re-appointment in the office in the next week, call in the interim if any significant concerning complaints. Scripts left in the chart for omeprazole and Lortab. Med rec sheet completed (on no meds). He will maintain bariatric clear liquids at home, goal 64 ounces per day, maintain activity at home, but no heavy lifting or straining. Can shower starting tomorrow, drain site care and wound care reviewed. He will re-appoint in the office in the next week, certainly call in the interim if any significant concerning complaints. \ No newline at end of file diff --git a/3922_Discharge Summary.txt b/3922_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..70e18a10cacfa15ed16c6931f45281a180441035 --- /dev/null +++ b/3922_Discharge Summary.txt @@ -0,0 +1,29 @@ +ADMITTING DIAGNOSES + +1. Acute gastroenteritis. + +2. Nausea. + +3. Vomiting. + +4. Diarrhea. + +5. Gastrointestinal bleed. + +6. Dehydration. + +DISCHARGE DIAGNOSES + +1. Acute gastroenteritis, resolved. + +2. Gastrointestinal bleed and chronic inflammation of the mesentery of unknown etiology. + +BRIEF H&P AND HOSPITAL COURSE: + + This patient is a 56-year-old male, a patient of Dr. X with 25-pack-year history, also a history of diabetes type 2, dyslipidemia, hypertension, hemorrhoids, chronic obstructive pulmonary disease, and a left lower lobe calcified granuloma that apparently is stable at this time. This patient presented with periumbilical abdominal pain with nausea, vomiting, and diarrhea for the past 3 days and four to five watery bowel movements a day with symptoms progressively getting worse. The patient was admitted into the ER and had trop x1 done, which was negative and ECG showed to be of normal sinus rhythm. + +Lab findings initially presented with a hemoglobin of 13.1, hematocrit of 38.6 with no elevation of white count. Upon discharge, his hemoglobin and hematocrit stayed at 10.9 and 31.3 and he was still having stool guaiac positive blood, and a stool study was done which showed few white blood cells, negative for Clostridium difficile and moderate amount of occult blood and moderate amount of RBCs. The patient's nausea, vomiting, and diarrhea did resolve during his hospital course. Was placed on IV fluids initially and on hospital day #2 fluids were discontinued and was started on clear liquid diet and diet was advanced slowly, and the patient was able to tolerate p.o. well. The patient also denied any abdominal pain upon day of discharge. The patient was also started on prednisone as per GI recommendations. He was started on 60 mg p.o. Amylase and lipase were also done which were normal and LDH and CRP was also done which are also normal and LFTs were done which were also normal as well. + +PLAN: + + The plan is to discharge the patient home. He can resume his home medications of Prandin, Actos, Lipitor, Glucophage, Benicar, and Advair. We will also start him on a tapered dose of prednisone for 4 weeks. We will start him on 15 mg p.o. for seven days. Then, week #2, we will start him on 40 mg for 1 week. Then, week #3, we will start him on 30 mg for 1 week, and then, 20 mg for 1 week, and then finally we will stop. He was instructed to take tapered dose of prednisone for 4 weeks as per the GI recommendations. \ No newline at end of file diff --git a/3923_Discharge Summary.txt b/3923_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..cb1c85fa33dc2023d39ee2589447c8a1fc546290 --- /dev/null +++ b/3923_Discharge Summary.txt @@ -0,0 +1,59 @@ +ADMITTING DIAGNOSES + +1. Vomiting, probably secondary to gastroenteritis. + +2. Goldenhar syndrome. + +3. Severe gastroesophageal reflux. + +4. Past history of aspiration and aspiration pneumonia. + +DISCHARGE DIAGNOSES + +1. Gastroenteritis versus bowel obstruction. + +2. Gastroesophageal reflux. + +3. Goldenhar syndrome. + +4. Anemia, probably iron deficiency. + +HISTORY OF PRESENT ILLNESS: + + This is a 10-week-old female infant who has Goldenhar syndrome and has a gastrostomy tube in place and a J-tube in place. She was noted to have vomiting approximately 18 to 24 hours prior to admission and was seen in the emergency department and then admitted. + +Because of her Goldenhar syndrome and previous problems with aspiration, she is not fed my mouth, but does have a G-tube. However, she has not been tolerating feedings through this prior to admission. + +PHYSICAL EXAMINATION: + +GENERAL: At transfer to UNM on October 13, 2003 reveals a dysmorphic infant who is small and slightly cachectic. Her left side of the face is deformed with microglia present, micrognathia present, and a moderate amount of torticollis. + +VITAL SIGNS: Presently, her temperature is 98, pulse 152, respirations 36, weight is 3.98 kg, pulse oximetry on room air is 95%. + +HEENT: Head is with anterior fontanelle open. Eyes: Red reflex elicited bilaterally. Left ear is without an external ear canal and the right is not well visualized at this time. Nose is presently without any discharge, and throat is nonerythematous. NECK: Neck with torticollis exhibited. + +LUNGS: Presently are clear to auscultation. + +HEART: Regular rate without murmur, click or gallop present. ABDOMEN: Moderately distended, but soft. Bowel sounds are decreased, and there is a G-tube and a J-tube in place. The skin surrounding the G-tube is moderately erythematous, but without any discharges present. J-tube is with a dressing in place and well evaluated. + +EXTREMITIES: Grossly normal. Hip defects are not checked at this time. + +GENITALIA: Normal female. + +NEUROLOGIC: The infant does have a suck reflex, feeding grasp-reflex, and a feeding Moro reflex. + +SKIN: Warm and dry and there is a macular area to the left ___ that is approximately 1 cm in length. + +LABORATORY DATA: + + WBC count on October 12, 2003 is 12,600 with 16 segs, 6 bands, 54 lymphocytes, 13% of which are noted to be reactive. Hemoglobin is 10.4, hematocrit 30.8, and she has abnormal red blood cell morphology. RDW is 13.1 and MCV is 91. Sodium level is 138, potassium 5.4, chloride 103, CO2 23, BUN 7, creatinine 0.4, glucose 84, calcium 9.9, and at this dictation, the report on the abdominal flat plate is pending. + +HOSPITAL COURSE: + +The child was placed at bowel rest initially and then re-tried on full strength formula, but she did not tolerate. She was again placed on bowel rest and her medications, Pepcid and Reglan, were given in an attempt to increase bowel motility. Feedings were re-attempted with Pedialyte through the J-tube and these did not result in production of any stool and the child then began having vomiting again. The vomitus was noted to be bilious in nature and with particulate matter present. + +After consultation with Dr. X, it was determined the child probably needed further evaluation, and she had both of her drains placed to gravity and was kept n.p.o. Her fluids have been D5 and 0.25 normal saline with 20 mEq/L of potassium chloride, which has run at her maintenance of 16 mL/h. + +CONSULTATIONS: + + With Dr. X and Dr. Y and the child is now ready for transport for continued diagnosis and treatment. Her condition at discharge is stable. \ No newline at end of file diff --git a/3924_Discharge Summary.txt b/3924_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..3a26e4da529aa12a8dc5ed3e13ea762903e69a36 --- /dev/null +++ b/3924_Discharge Summary.txt @@ -0,0 +1,25 @@ +DIAGNOSIS ON ADMISSION: + + Gastrointestinal bleed. + +DIAGNOSES ON DISCHARGE + +1. Gastrointestinal bleed, source undetermined, but possibly due to internal hemorrhoids. + +2. Atherosclerotic cardiovascular disease. + +3. Hypothyroidism. + +PROCEDURE: + + Colonoscopy. + +FINDINGS: + + Poor prep with friable internal hemorrhoids, but no gross lesions, no source of bleed. + +HOSPITAL COURSE: + +The patient was admitted to the emergency room by Dr. X. He apparently had an NG tube placed in the emergency room with gastric aspirate revealing no blood. Dr. Y Miller saw him in consultation and recommended a colonoscopy. A bowel prep was done. H&Hs were stable. His most recent H&H was 38.6/13.2 that was this morning. His H&H at admission was 41/14.3. The patient had the bowel prep that revealed no significant bleeding. His vital signs are stable. He is continuing on his usual medications of Imdur, metoprolol, and Synthroid. His Plavix is discontinued. He is given IV Protonix. I am hesitant to use Prilosec or Protonix because of his history of pancreatitis associated with Prilosec. + +The patient's PT/INR was 1.03, PTT 25.8. Chemistry panel was unremarkable. The patient was given a regular diet after his colonoscopy today. He tolerated it well and is being discharged home. He will be followed closely as an outpatient. He will continue his Pepcid 40 mg at night, Imdur, Synthroid, and metoprolol as prior to admission. He will hold his Plavix for now. They will call me for further dark stools and will avoid Pepto-Bismol. They will follow up in the office on Thursday. \ No newline at end of file diff --git a/3925_Discharge Summary.txt b/3925_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..b558bdffb5a7a8df8393011aaea27e5aa140c47d --- /dev/null +++ b/3925_Discharge Summary.txt @@ -0,0 +1,76 @@ +ADMITTING DIAGNOSES: + + Solitary left kidney with obstruction, and hypertension, and chronic renal insufficiency. + +DISCHARGE DIAGNOSES: + + Solitary left kidney with obstruction and hypertension and chronic renal insufficiency, plus a Pseudomonas urinary tract infection. + +PROCEDURES: + + Cystoscopy under anesthesia, ureteroscopy, an attempted tube placement, stent removal with retrograde pyelography, percutaneous tube placement, and nephrostomy by Radiology. + +PERTINENT LABORATORIES: + + Creatinine of 1.4. During the hospitalization it was decreased to 0.8 and Pseudomonas urinary tract infection, positive culture sensitive to ceftazidime and ciprofloxacin. + +HISTORY OF PRESENT ILLNESS: + +The patient is a 3-1/2-year-old boy with a solitary kidney, had a ureteropelvic junction repair performed by Dr. Y, in the past, unfortunately, it was thought still be obstructed. A stent was placed approximately 6 weeks ago after urethroscopic placement with some difficulty. Plan was to remove the stent. At the time of removal, we were unable to place another tube within the collecting system, and the patient was admitted for percutaneous nephrostomy placement. He has had no recent cold or flu. He has problems with hypertension for which he is on enalapril at home in addition to his Macrodantin prophylaxis. + +PAST MEDICAL HISTORY: + + The patient has no known allergies. Multiple urinary tract infection, solitary kidney, and previous surgeries as mentioned above. + +REVIEW OF SYSTEMS: + + A 14-organ system review of systems is negative except for the history of present illness. He also has history of being a 34-week preemie twin. + +ALLERGIES: + + No known allergies. + +FAMILY HISTORY: + + Unremarkable without any bleeding or anesthetic problems. + +SOCIAL HISTORY: + + The patient lives at home with his parents, 2 brothers, and a sister. + +IMMUNIZATIONS: + + Up-to-date. + +MEDICATIONS: + + On admission was Macrodantin, hydralazine, and enalapril. + +PHYSICAL EXAMINATION: + +GENERAL: The patient is an active little boy. + +HEENT: The head and neck exam was grossly normal. He had no oral, ocular, or nasal discharge. + +LUNGS: Exam was normal without wheezing. + +HEART: Without murmur or gallops. + +ABDOMEN: Soft, without mass or tenderness with a well-healed flank incision. + +GU: Uncircumcised male with bilaterally descended testes. + +EXTREMITIES: He has full range of motion in all 4 extremities. + +SKIN: Warm, pink, and dry. + +NEUROLOGIC: Grossly intact. + +BACK: He has normal back. Normal gait. + +HOSPITAL COURSE: + + The patient was admitted to the hospital after inability to place a ureteral stent via ureteroscopy and cystoscopy. He was made NPO. He had a fever at first time with elevated creatinine. He was also evaluated and treated by Dr. X, for fluid management, hypertensive management, and gave him some hydralazine and Lasix to improve his urine output, in addition to manage his blood pressure. Once the percutaneous tube was placed, we found that his urine culture grew Pseudomonas, so he was kept on Fortaz, and was switched over to ciprofloxacin without difficulty. He, otherwise, did well with continuing decrease his creatinine at the time of discharge to home. + +The patient was discharged home in stable condition with ciprofloxacin, enalapril, and recommendation for followup in Urology in 1 to 2 weeks for the surgical correction in 2 to 3 weeks of repeat pyeloplasty or possible ureterocalicostomy. The patient had draining nephrostomy tube without difficulty. + diff --git a/3926_Discharge Summary.txt b/3926_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..8488aede1f5a5bb01be8222b4fff6acff48eb712 --- /dev/null +++ b/3926_Discharge Summary.txt @@ -0,0 +1,85 @@ +CHIEF COMPLAINT: + + Falls at home. + +HISTORY OF PRESENT ILLNESS: + + The patient is an 82-year-old female who fell at home and presented to the emergency room with increased anxiety. Family members who are present state that the patient had been increasingly anxious and freely admitted that she was depressed at home. They noted that she frequently came to the emergency room for "attention." The patient denied any chest pain or pressure and no change to exercise tolerance. The patient denied any loss of consciousness or incontinence. She denies any seizure activity. She states that she "tripped" at home. Family states she frequently takes Darvocet for her anxiety and that makes her feel better, but they are afraid she is self medicating. They stated that she has numerous medications at home, but they were not sure if she was taking them. The patient been getting along for a number of years and has been doing well, but recently has been noting some decline primarily with regards to her depression. The patient denied SI or HI. + +PHYSICAL EXAMINATION: + +GENERAL: The patient is pleasant 82-year-old female in no acute distress. + +VITAL SIGNS: Stable. + +HEENT: Negative. + +NECK: Supple. Carotid upstrokes are 2+. + +LUNGS: Clear. + +HEART: Normal S1 and S2. No gallops. Rate is regular. + +ABDOMEN: Soft. Positive bowel sounds. Nontender. + +EXTREMITIES: No edema. There is some ecchymosis noted to the left great toe. The area is tender; however, metatarsal is nontender. + +NEUROLOGICAL: Grossly nonfocal. + +HOSPITAL COURSE: + + A psychiatric evaluation was obtained due to the patient's increased depression and anxiety. Continue Paxil and Xanax use was recommended. The patient remained medically stable during her hospital stay and arrangements were made for discharge to a rehabilitation program given her recent falls. + +DISCHARGE DIAGNOSES: + +1. Falls + +2. Anxiety and depression. + +3. Hypertension. + +4. Hypercholesterolemia. + +5. Coronary artery disease. + +6. Osteoarthritis. + +7. Chronic obstructive pulmonary disease. + +8. Hypothyroidism. + +CONDITION UPON DISCHARGE: + + Stable. + +DISCHARGE MEDICATIONS: + + Tylenol 650 mg q.6h. p.r.n. + + Xanax 0.5 q.4h. p.r.n. + + Lasix 80 mg daily, Isordil 10 mg t.i.d. + + KCl 20 mEq b.i.d. + + lactulose 10 g daily, Cozaar 50 mg daily, Synthroid 75 mcg daily, Singulair 10 mg daily, Lumigan one drop both eyes at bed time, NitroQuick p.r.n. + + Pravachol 20 mg daily, Feldene 20 mg daily, Paxil 20 mg daily, Minipress 2 mg daily, Provera p.r.n. + + Advair 250/50 one puff b.i.d. + + Senokot one tablet b.i.d. + + Timoptic one drop OU daily, and verapamil 80 mg b.i.d. + +ALLERGIES: + + None. + +ACTIVITY: + + Per PT. + +FOLLOW-UP: + + The patient discharged to a skilled nursing facility for further rehabilitation. \ No newline at end of file diff --git a/3927_Discharge Summary.txt b/3927_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..e890efe5b7aadacc2f9b338abe46de901714f124 --- /dev/null +++ b/3927_Discharge Summary.txt @@ -0,0 +1,17 @@ +HISTORY OF PRESENT ILLNESS: + + This is the case of a 31-year-old white female admitted to the hospital with pelvic pain and vaginal bleeding. The patient had a positive hCG with a negative sonogram and hCG titer of about 18,000. + +HOSPITAL COURSE: + + The patient was admitted to the hospital with the diagnosis of a possible incomplete abortion, to rule out ectopic pregnancy or rupture of corpus luteal cyst. The patient was kept in observation for 24 hours. The sonogram stated there was no gestational sac, but there was a small mass within the uterus that could represent a gestational sac. The patient was admitted to the hospital. A repeat hCG titer done on the same day came back as 15,000, but then the following day, it came back as 18,000. The diagnosis of a possible ruptured ectopic pregnancy was established. The patient was taken to surgery and a laparotomy was performed with findings of a right ruptured ectopic pregnancy. The right salpingectomy was performed with no complications. The patient received 2 units of red packed cells. On admission, her hemoglobin was 12.9, then in the afternoon it dropped to 8.1, and the following morning, it was 7.9. Again, based on these findings, the severe abdominal pain, we made the diagnosis of ectopic and it was proved or confirmed at surgery. The hospital course was uneventful. There was no fever reported. The abdomen was soft. She had a normal bowel movement. The patient was dismissed on 09/09/2007 to be followed in my office in 4 days. + +FINAL DIAGNOSES: + +1. Right ruptured ectopic pregnancy with hemoperitoneum. + +2. Anemia secondary to blood loss. + +PLAN: + + The patient will be dismissed on pain medication and iron therapy. \ No newline at end of file diff --git a/3928_Discharge Summary.txt b/3928_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..68e6bc8e89b1ad7774ef32689bf4a0f46ddbd058 --- /dev/null +++ b/3928_Discharge Summary.txt @@ -0,0 +1,35 @@ +ADMITTING DIAGNOSES: + +1. Hematuria. + +2. Benign prostatic hyperplasia. + +3. Osteoarthritis. + +DISCHARGE DIAGNOSES: + +1. Hematuria, resolved. + +2. Benign prostatic hyperplasia. + +3. Complex renal cyst versus renal cell carcinoma or other tumor. + +4. Osteoarthritis. + +HOSPITAL COURSE: + + This is a 77-year-old African-American male who was previously well until he began having gross hematuria and clots passing through his urethra on the day of admission. He stated that he never had blood in his urine before, however, he does have a past history of BPH and he had a transurethral resection of prostate more than 10 years ago. He was admitted to a regular bed. Dr. G of Urology was consulted for evaluation of his hematuria. During the workup for this, he had a CT of the abdomen and pelvis with and without contrast with early and late-phase imaging for evaluation of the kidneys and collecting system. At that time, he was shown to have multiple bilateral renal cysts with one that did not meet classification as a simple cyst and ultrasound was recommended. + +He had an ultrasound done of the cyst which showed a 2.1 x 2.7 cm mass arising from the right kidney which, again, did not fit ultrasound criteria for a simple cyst and they recommended further evaluation by an MRI as this could be a hemorrhagic cyst or a solid mass or tumor, so an MRI was scheduled on the day of discharge for further evaluation of this. The report was not back at discharge. The patient had a cystoscopy and transurethral resection of prostate as well with entire resection of the prostate gland. Pathology on this specimen showed multiple portions of prostatic tissue which was primarily fibromuscular, and he was diagnosed with nonprostatic hyperplasia. His urine slowly cleared. He tolerated a regular diet with no difficulties in his activities of daily living, and his Foley was removed on the day of discharge. + +He was started on ciprofloxacin, Colace, and Lasix after the transurethral resection and continued these for a short course. He is asked to continue the Colace as an outpatient for stool softening for comfort. + +DISCHARGE MEDICATIONS: + + Colace 100 mg 1 b.i.d. + +DISCHARGE FOLLOWUP PLANNING: + + The patient is to follow up with his primary care physician at ABCD + + Dr. B or Dr. J, the patient is unsure of which, in the next couple weeks. He is to follow up with Dr. G of Urology in the next week by phone in regards to the patient's MRI and plans for a laparoscopic partial renal resection biopsy. This is scheduled for the week after discharge potentially by Dr. G, and the patient will discuss the exact time later this week. The patient is to return to the emergency room or to our clinic if he has worsening hematuria again or no urine output. \ No newline at end of file diff --git a/3929_Discharge Summary.txt b/3929_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..4b7c19f804bb26c602129f1fa03478a81591d993 --- /dev/null +++ b/3929_Discharge Summary.txt @@ -0,0 +1,93 @@ +CHIEF COMPLAINT: + + Chest pain and fever. + +HISTORY OF PRESENT ILLNESS: + + This 48-year-old white married female presents in the emergency room after two days of increasing fever with recent diagnosis of urinary tract infection on outpatient treatment with nitrofurantoin. The patient noted since she began to feel poorly earlier on the day of admission, had an episode of substernal chest discomfort that was associated with nausea, dizziness, and sweating. The patient does have a past medical history of diabetes and hypertension. In addition, the patient complained of some neck and head discomfort for which she underwent a lumbar puncture in the emergency room; this was normal, causes turned out to be normal as well. The patient denies nosebleed, visual changes, nausea, vomiting, diarrhea or changes in bowel habits. She has not had any musculoskeletal or neurological deficits. She denies any rashes or skin lesions. + +PAST MEDICAL HISTORY: + +Hypertension, diabetes, hyperlipidemia, particularly elevated triglycerides with a slightly elevated LDL at 81 with an new standard LDL of 74, diabetics with a bad family history for cardiovascular disease such as this patient does have, and postmenopausal hot flashes. + +PAST SURGICAL HISTORY: + +Cholecystectomy, appendectomy, oophorectomy. + +FAMILY HISTORY: + + Positive for coronary artery disease in her father and brother in their 40s. + +SOCIAL HISTORY: + + She is married and does not smoke or drink nor did she ever. + +PHYSICAL EXAMINATION: + + On admission, temperature 99.4 degrees F. + + blood pressure 137/60, pulse 90 and regular without ectopy, respiratory rate 20 without unusual respiratory effort. In general, she is well developed, well nourished, oriented, and alert and in no apparent distress. Head, ears, eyes, nose, and throat are unremarkable. Neck is supple. No neck vein distention is noted. No bruits are heard. Chest is clear to percussion and auscultation. Heart has a regular rhythm and rate without murmurs or rubs or gallops. Abdomen is soft, obese, and nontender. Musculoskeletal is intact without deformity. However, the patient did develop severe cramp behind her left knee during her treadmill testing. Neurologic: Cranial nerves are intact and she is nonfocal. Skin is warm and dry without rash or lesions noted. + +LABORATORY FINDINGS: + + Glucose 162, BUN 14, creatinine 1.0, sodium 137, potassium 3.6, chloride 103, bicarbonate 23, protein 4.2. Liver function panel is normal. CK was 82. MB fraction was 1.0. Troponin was less than 0.1 on three occasions. White count was 12,200 with a normal differential, hemoglobin was 12.1, platelet count 230,000. Urinalysis showed positive nitrites, positive leukocyte esterase, 5 to 10 white cells per high power field, and 1+ bacteria rods. Spinal fluid was clear with 11 red cells, glucose 75, protein 67, white count 0. EKG was normal. + +DIAGNOSES ON ADMISSION: + +1. Urinary tract infection. + +2. Chest pain of unclear etiology, rule out myocardial infarction. + +3. Neck and back pain of unclear etiology with a negative spinal tap. + +4. Hypertension. + +5. Diabetes type II + + not treated with insulin. + +6. Hyperlipidemia treated with TriCor but not statins. + +7. Arthritis. + +ADDITIONAL LABORATORY STUDIES: + + B-natriuretic peptide was 26. Urine smear and culture negative on 24 and 48 hours. Chest x-ray was negative. Lipid panel - triglycerides 249, VLDL 49, HDL 33, LDL 81. + +COURSE IN THE HOSPITAL: + + The patient was placed on home medications. This will be listed at the end of the discharge summary. She was put on rule out acute myocardial infarction routine, and she did in fact rule out. She had a stress test completed on the day of discharge which was normal, and she was discharged with a diagnoses of chest pain, acute myocardial infarction ruled out, urinary tract infection, fever secondary to UTI + + diabetes mellitus type 2 non-insulin treated, hyperlipidemia with elevated triglycerides and an LDL elevated to 81 with new normal being less than 70. She has a strong family history of early myocardial disease in the men in their 40s. + +DISCHARGE MEDICATIONS: + +1. Enteric-coated aspirin 81 mg one daily. This is new, as the patient was not taking aspirin at home. + +2. TriCor 48 mg one daily. + +3. Zantac 40 mg one daily. + +4. Lisinopril 20 mg one daily. + +5. Mobic 75 mg one daily for arthritis. + +6. Metformin 500 mg one daily. + +7. Macrodantin one two times a day for several more days. + +8. Zocor 20 mg one daily, which is a new addition. + +9. Effexor XR 37.5 mg one daily. + +DIET: + + ADA 1800-calorie diet. + +ACTIVITY: + + As tolerated. Continue water exercise five days a week. + +DISPOSITION: + + Recheck at Hospital with a regular physician there in 1 week. Consider Byetta as an adjunct to her diabetic treatment and efforts to weight control. \ No newline at end of file diff --git a/3930_Discharge Summary.txt b/3930_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..0550a06788c5e1a544f5f05c37028751b6375a59 --- /dev/null +++ b/3930_Discharge Summary.txt @@ -0,0 +1,63 @@ +ADMISSION DIAGNOSIS: + + End-stage renal disease (ESRD). + +DISCHARGE DIAGNOSIS: + + End-stage renal disease (ESRD). + +PROCEDURE: + + Cadaveric renal transplant. + +HISTORY OF PRESENT ILLNESS: + + This is a 46-year-old gentleman with end-stage renal disease (ESRD) secondary to diabetes and hypertension, who had been on hemodialysis since 1993 and is also status post cadaveric kidney transplant in 1996 with chronic rejection. + +PAST MEDICAL HISTORY: + +1. Diabetes mellitus diagnosed 12 years ago. + +2. Hypertension. + +3. Coronary artery disease with a myocardial infarct in September of 2006. + +4. End-stage renal disease. + +PAST SURGICAL HISTORY: + + Coronary artery bypass graft x5 in 1995 and cadaveric renal transplant in 1996. + +SOCIAL HISTORY: + +The patient denies tobacco or ethanol use. + +FAMILY HISTORY: + + Hypertension. + +PHYSICAL EXAMINATION: + +GENERAL: The patient was alert and oriented x3 in no acute distress, healthy-appearing male. + +VITAL SIGNS: Temperature 96.6, blood pressure 166/106, heart rate 83, respiratory rate 18, and saturations 96% on room air. + +CARDIOVASCULAR: Regular rate and rhythm. + +PULMONARY: Clear to auscultation bilaterally. + +ABDOMEN: Soft, nontender, and nondistended with positive bowel sounds. + +EXTREMITIES: No clubbing, cyanosis, or edema. + +PERTINENT LABORATORY DATA: + + White blood cell count 6.4, hematocrit 34.6, and platelet count 182. Sodium 137, potassium 5.4, BUN 41, creatinine 7.9, and glucose 295. Total protein 6.5, albumin 3.4, AST 51, ALT 51, alk phos 175, and total bilirubin 0.5. + +COURSE IN HOSPITAL: + + The patient was admitted postoperatively to the surgical intensive care unit. Initially, the patient had a decrease in hematocrit from 30 to 25. The patient's hematocrit stabilized at 25. During the patient's stay, the patient's creatinine progressively decreased from 8.1 to a creatinine at the time of discharge of 2.3. The patient was making excellent urine throughout his stay. The patient's Jackson-Pratt drain was removed on postoperative day #1 and he was moved to the floor. The patient was advanced in diet appropriately. The patient was started on Prograf by postoperative day #2. Initial Prograf levels came back high at 18. The patient's Prograf doses were changed accordingly and today, the patient is deemed stable to be discharged home. During the patient's stay, the patient received four total doses of Thymoglobulin. Today, he will complete his final dose of Thymoglobulin prior to being discharged. In addition, today, the patient has an elevated blood pressure of 198/96. The patient is being given an extra dose of metoprolol for this blood pressure. In addition, the patient has an elevated glucose of 393 and for this reason he has been given an extra dose of insulin. These labs will be rechecked later today and once his blood pressure has decreased to systolic blood pressure less than 116 and his glucose has come down to a more normal level, he will be discharged to home. + +DISCHARGE INSTRUCTIONS: + + The patient is discharged with instructions to seek medical attention in the event if he develops fevers, chills, nausea, vomiting, decreased urine output, or other concerns. He is discharged on a low-potassium diet with activity as tolerated. He is instructed that he may shower; however, he is to undergo no underwater soaking activities for approximately two weeks. The patient will be followed up in the Transplant Clinic at ABCD tomorrow, at which time, his labs will be rechecked. The patient's Prograf levels at the time of discharge are pending; however, given that his Prograf dose was decreased, he will be followed tomorrow at the Renal Transplant Clinic. \ No newline at end of file diff --git a/3931_Discharge Summary.txt b/3931_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..00558fa4249e1e12305c523ac94aab30d154e222 --- /dev/null +++ b/3931_Discharge Summary.txt @@ -0,0 +1,63 @@ +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. \ No newline at end of file diff --git a/3932_Discharge Summary.txt b/3932_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..c2ae46e680a89ca29003f081ba34656d587a7ee8 --- /dev/null +++ b/3932_Discharge Summary.txt @@ -0,0 +1,97 @@ +ADMITTING DIAGNOSIS: + + A nonhealing right below-knee amputation. + +DISCHARGE DIAGNOSIS: + + A nonhealing right below-knee amputation. + +SECONDARY DIAGNOSES: + + Include: + +1. Peripheral vascular disease, bilateral carotid artery stenosis status post bilateral carotid endarterectomies. + +2. Peripheral vascular disease status post aortobifemoral bypass and bilateral femoropopliteal bypass grafting. + +3. Hypertension. + +4. Diverticulosis. + +5. Hypothyroidism. + +6. Chronic renal insufficiency. + +7. Status post open incision and drainage of an intestinal abscess at an unknown point. + +DETERMINATION: + + Status post right below-knee amputation. + +OPERATIONS PERFORMED: + +1. Extensive debridement of right below-knee amputation with debridement of skin, subcutaneous tissue, muscle, and bone on July 17, 2008. + +2. Irrigation and debridement of right below-knee amputation wound on July 21, 2008, July 24, 2008, July 28, 2008, and August 1, 2008. + +HISTORY OF PRESENT ILLNESS: + + The patient is an 89-year-old gentleman with multiple medical conditions including coronary artery disease, hypothyroidism, and severe peripheral vascular disease status post multiple revascularizations, and a right below-knee amputation in June 2008 following a thrombosis of his right femoropopliteal bypass graft. Following his amputation, he had poor wound healing. He presented to the ED with pain in his right lower extremity on July 9, 2008. Due to concern for infection at that time, he was started on oral Keflex and instructed to follow up with the Vascular Clinic as scheduled. At his follow-up appointment, it was decided to re-admit The patient for debridement and revision of his stump wound. + +HOSPITAL COURSE: + + Briefly, The patient underwent extensive debridement of his right below-knee amputation wound on July 17, 2008. He underwent debridement of skin, subcutaneous tissue, muscle, and bone to remove the necrotic tissue from the stump. A wound VAC. was also placed to help accelerate wound healing. The patient's postoperative course was complicated initially by acute blood-loss anemia, requiring blood transfusion. He returned to the OR on Monday, July 21, 2008 for irrigation and debridement of his right below-knee amputation and a wound VAC change. Again, on July 24, 2008, and then again on July 28, 2008, The patient returned to the operating room for irrigation and debridement of his wound and wound VAC change. Following his procedure on July 28, 2008, The patient began having recurrent episodes of diarrhea, prompting stool cultures and C. difficile assay to be sent. He was also started on Flagyl, empirically. C. difficile assay returned positive and the decision was made to continue Flagyl for a full 14-day course. On July 31, 2008, the patient began experiencing shortness of breath and wheezing after standing to be weighed. His vital signs remained stable. However, his oxygen saturation dropped to 93% + + improving only to 97% after an addition of 2 liters by nasal cannula. A chest x-ray revealed bilateral pleural effusions and bibasilar atelectasis in addition to some pulmonary edema diffusely. The patient's IV fluids were decreased. He was given p.r.n. albuterol and infusion of Lasix, resulting in significant urine output. His symptoms of shortness of breath gradually improved. On August 1, 2008, he returned to the OR for final irrigation and debridement of his below-knee amputation. Again, a wound VAC was placed. Postoperatively, he did well. His Foley catheter was removed. His vital signs remained stable, and his respiratory status also remained stable. Arrangements were made for home health and wound VAC care upon discharge. + +DISCHARGE CONDITION: + + The patient is resting comfortably. He denies shortness of breath or chest pain. He has mild bibasilar wheezing, but breathing is otherwise nonlabored. All other exams normal. + +DISCHARGE MEDICATIONS: + +1. Acetaminophen 325 mg daily. + +2. Albuterol 2 puffs every six hours as needed. + +3. Vitamin C 500 mg one to two times daily. + +4. Aspirin 81 mg daily. + +5. Symbicort 1 puff every morning and 1 puff every evening. + +6. Tums p.r.n. + +7. Calcium 600 mg plus vitamin D daily. + +8. Plavix 75 mg daily. + +9. Clorazepate dipotassium 7.5 mg every six hours as needed. + +10. Lexapro 10 mg daily at bedtime. + +11. Hydrochlorothiazide 25 mg one-half tablet daily. + +12. Ibuprofen 200 mg three pills as needed. + +13. Imdur 30 mg daily. + +14. Levoxyl 112 mcg daily. + +15. Ativan 0.5 mg one-half tablet every six hours as needed. + +16. Lopressor 50 mg one-half tablet twice daily. + +17. Flagyl 500 mg every six hours for 10 days. + +18. Multivitamin daily. + +19. Nitrostat 0.4 mg to take as directed. + +20. Omeprazole 20 mg daily. + +21. Oxycodone-acetaminophen 5/325 mg every four to six hours as needed for pain. + +22. Lyrica 25 mg daily at bedtime. + +23. Zocor 40 mg one-half tablet daily at bedtime. \ No newline at end of file diff --git a/3933_Discharge Summary.txt b/3933_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..4742351084f420af0f90b22cb976fb4df5687587 --- /dev/null +++ b/3933_Discharge Summary.txt @@ -0,0 +1,51 @@ +DISCHARGE DIAGNOSIS: + +1. Respiratory failure improved. + +2. Hypotension resolved. + +3. Anemia of chronic disease stable. + +4. Anasarca improving. + +5. Protein malnourishment improving. + +6. End-stage liver disease. + +HISTORY AND HOSPITAL COURSE: + +The patient was admitted after undergoing a drawn out process with a small bowel obstruction. His bowel function started to improve. He was on TPN prior to coming to Hospital. He has remained on TPN throughout his time here, but his appetite and his p.o. intake have improved some. The patient had an episode while here where his blood pressure bottomed out requiring him to spend multiple days in the Intensive Care Unit on dopamine. At one point, we were unsuccessful at weaning him off the dopamine, but after approximately 11 days, he finally started to tolerate weaning parameters, was successfully removed from dopamine, and has maintained his blood pressure without difficulty. The patient also was requiring BiPAP to help with his oxygenation and it appeared that he developed a left-sided pneumonia. This has been treated successfully with Zyvox and Levaquin and Diflucan. He seems to be currently doing much better. He is only using BiPAP in the evening. As stated above, he is eating better. He had some evidence of redness and exquisite swelling around his genital and lower abdominal region. This may be mainly dependent edema versus anasarca. The patient has been diuresed aggressively over the last 4 to 5 days, and this seems to have made some improvement in his swelling. This morning, the patient denies any acute distress. He states he is feeling good and understands that he is being discharged to another facility for continued care and rehabilitation. He will be discharged to Garden Court skilled nursing facility. + +DISCHARGE MEDICATIONS/INSTRUCTIONS: + + He is going to be going with Protonix 40 mg daily, metoclopramide 10 mg every 6 hours, Zyvox 600 mg daily for 5 days, Diflucan 150 mg p.o. daily for 3 days, Bumex 2 mg p.o. daily, Megace 400 mg p.o. b.i.d. + + Ensure 1 can t.i.d. with meals, and MiraLax 17 gm p.o. daily. The patient is going to require physical therapy to help with assistance in strength training. He is also going to need respiratory care to work with his BiPAP. His initial settings are at a rate of 20, pressure support of 12, PEEP of 6, FIO2 of 40%. The patient will need a sleep study, which the nursing home will be able to set up. + +PHYSICAL EXAMINATION: + +VITAL SIGNS: On the day of discharge, heart rate 99, respiratory rate 20, blood pressure 102/59, temperature 98.2, O2 sat 97%. + +GENERAL: A well-developed white male who appears in no apparent distress. + +HEENT: Unremarkable. + +CARDIOVASCULAR: Positive S1, S2 without murmur, rubs, or gallops. + +LUNGS: Clear to auscultation bilaterally without wheezes or crackles. + +ABDOMEN: Positive for bowel sounds. Soft, nondistended. He does have some generalized redness around his abdominal region and groin. This does appear improved compared to presentation last week. The swelling in this area also appears improved. + +EXTREMITIES: Show no clubbing or cyanosis. He does have some lower extremity edema, 2+ distal pedal pulses are present. + +NEUROLOGIC: The patient is alert and oriented to person and place. He is alert and aware of surroundings. We have not had any difficulties with confusion here lately. + +MUSCULOSKELETAL: The patient moves all extremities without difficulty. He is just weak in general. + +LABORATORY DATA: + + Lab work done today shows the following: White count 4.2, hemoglobin 10.2, hematocrit 30.6, and platelet count 184,000. Electrolytes show sodium 139, potassium 4.1, chloride 98, CO2 26, glucose 79, BUN 56, and creatinine 1.4. Calcium 8.8, phosphorus is a little high at 5.5, magnesium 2.2, albumin 3.9. + +PLAN: + +Discharge this gentleman from Hospital and admit him to Garden Court SNF where they can continue with his rehab and conditioning. Hopefully, long-term planning will be discharge home. He has a history of end-stage liver disease with cirrhosis, which may make him a candidate for hospice upon discharge. The family initially wanted to bring the patient home, but he is too weak and requires too much assistance to adequately consider this option at this time. \ No newline at end of file diff --git a/3934_Discharge Summary.txt b/3934_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..4f24d7a6f3ead698e3eb067dfb63921150a50fff --- /dev/null +++ b/3934_Discharge Summary.txt @@ -0,0 +1,79 @@ +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. \ No newline at end of file diff --git a/3935_Discharge Summary.txt b/3935_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..8f14fab7ca30f9f2f3368ff93a1028a351180d01 --- /dev/null +++ b/3935_Discharge Summary.txt @@ -0,0 +1,53 @@ +ADMITTING DIAGNOSES: + + Left renal cell carcinoma, left renal cyst. + +DISCHARGE DIAGNOSIS: + + Left renal cell carcinoma, left renal cyst. + +SECONDARY DIAGNOSES: + +1. Chronic obstructive pulmonary disease. + +2. Coronary artery disease. + +PROCEDURES: + + Robotic-Assisted laparoscopic left renal cyst decortication and cystoscopy. + +HISTORY OF PRESENT ILLNESS: + + Mr. ABC is a 70-year-old male who has been diagnosed with a left renal cell carcinoma with multiple renal cysts. He has undergone MRI of the abdomen on June 18, 2008 revealing an enhancing mass of the upper pole of the left kidney consistent with his history of renal cell carcinoma. Of note, there are no other enhancing solid masses seen on this MRI. After discussion of multiple management strategies with the patient including: + +1. Left partial nephrectomy. + +2. Left radical nephrectomy. + +3. Left renal cyst decortication. The patient is likely to undergo the latter procedure. + +HOSPITAL COURSE: + +The patient was admitted to undergo left renal cyst decortication as well as a cystoscopy. Intraoperatively, approximately four enlarged renal cysts and six smaller renal cysts were initially removed. The contents were aspirated and careful dissection of the cyst wall was performed. Multiple specimens of the cyst wall were sent for pathology. Approximately one liter of cystic fluid was drained during the procedure. The renal bed was inspected for hemostasis, which appear to be adequate. There were no complications with the procedure. Single JP drain was left in place. Additionally, the patient underwent flexible cystoscopy, which revealed no gross strictures or any other abnormalities in the penile nor prostatic urethra. Furthermore, no gross lesions were encountered in the bladder. The patient left OR with transfer to the PACU and subsequently to the hospital floor. + +The patient's postoperative course was relatively uneventful. His diet and activity were gradually advanced without complication. On postoperative day #2, he was passing flatus and has had bowel movements. His Jackson-Pratt drain was discontinued on postoperative day #3 that being the day of discharge. His Foley catheter was removed on the morning of discharge and the patient subsequently passed the voiding trial without difficultly. At the time of discharge, he was afebrile. His vital signs indicated hemodynamic stability and he had no evidence of infection. The patient was instructed to follow up with Dr. XYZ on 8/12/2008 at 1:50 p.m. and was given prescription for pain medications as well as laxative. + +DISPOSITION: + + To home. + +DISCHARGE CONDITION: + + Good. + +MEDICATIONS: + +Please see attached medication list. + +INSTRUCTIONS: + + The patient was instructed to contact Dr. XYZ's office for fever greater than 101.5, intractable pain, nausea, vomiting, or any other concerns. + +FOLLOWUP: + + The patient will follow up with Dr. XYZ for a postoperative check on 08/12/2008 at 1:50 p.m. and he was made aware of this appointment. \ No newline at end of file diff --git a/3936_Discharge Summary.txt b/3936_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..6ac8a8d467cd80a651f4210265987f3ec46b15ea --- /dev/null +++ b/3936_Discharge Summary.txt @@ -0,0 +1,75 @@ +DISCHARGE DIAGNOSES: + +1. Central nervous system lymphoma. + +2. Gram-negative bacteremia. + +3. Pancytopenia. + +4. Hypertension. + +5. Perianal rash. + +6. Diabetes mellitus. + +7. Hypoxia. + +8. Seizure prophylaxis. + +9. Acute kidney injury. + +PROCEDURES DURING HOSPITALIZATION: + +1. Cycle five high-dose methotrexate. + +2. Rituxan weekly. + +3. Chest x-ray. + +4. Wound consult. + +HISTORY OF PRESENT ILLNESS: + + Ms. ABC is a pleasant 60-year-old Caucasian female who was diagnosed in April 2008 with diffuse large B-cell lymphoma after she developed visual saltation, changes, and confusion. Further staging revealed borderline mediastinal pretracheal lymphadenopathy but was otherwise unremarkable. She began high-dose methotrexate in mid May 2008; courses of methotrexate have been complicated by prolonged methotrexate levels, mental confusion, and mania. During cycle three, repeat MRI showed interval worsening of disease, and Rituxan was added to her regimen. Ms. ABC had a repeat MRI on July 24, 2008 prior to this admission, which showed significant improvement in her CNS disease. + +HOSPITAL COURSE: + + Ms. ABC was admitted to the Hematology B Service under attending Dr. Z. + +1. CNS lymphoma. Upon admission, she was started on her Rituxan, which she tolerated well. She was then hydrated with bicarbonate solution to a urine pH of 8. She received methotrexate 5 g/m2. 24-hour creatinine was 0.9, 48-hour methotrexate level was elevated at 2.08. This was likely secondary to the need to initiate treatment with antibiotics secondary to infection. Her leucovorin was increased to 100 mg/m2. 72-hour methotrexate level was 0.58. 96-hour methotrexate was 0.16, and 19-hour was 0.08. She continued additional four doses of oral leucovorin. Her creatinine improved. On day prior to discharge, she received her weekly dose of Rituxan. She will return for Rituxan next week and then return for an appointment with Dr. X on August 18, 2008 with plans for admission for next cycle of methotrexate. + +2. Gram-negative bacteremia. On the morning of June 27, 2008, Ms. ABC did spike a fever. She was started on empiric antibiotics with cefepime and vancomycin. Cultures were drawn peripherally and from the Port-A-Cath which both grew out Gram-negative rods within 12 hours. After being initiated on IV antibiotics, she remained afebrile for the remainder of the hospitalization. Both cultures eventually grew out Proteus mirabilis, which was pansensitive. She had three additional blood cultures, which were all negative. On the day prior to discharge, she was transitioned to oral Cipro and remained afebrile. We had intended to send her home with oral antibiotics; however, by day of discharge, she was pancytopenic and it was decided that she should be discharged to complete a 14-day course of IV antibiotics with cefepime. She will continue this with the assistance of home health services. She was advised to follow neutropenic precautions and labs will be followed closely as an outpatient. She understands if she develops a fever greater than 100.5, she should call to return immediately for admission. + +3. Pancytopenia. On the day of discharge, the patient was pancytopenic with white count of 0.7, ANC of 500, hemoglobin 8.5, hematocrit 24.8, and platelet count 38, 000. Her labs will be followed closely as an outpatient. During the admission, we did obtain a HIT antibody, which was negative. Heparin was held until this level was returned. She was placed on Arixtra for prophylaxis against thrombus. It is thought that her decreasing counts may be secondary to infection; however, if she continues to be pancytopenic, she will have a repeat bone marrow as an outpatient. + +4. Hypertension. Blood pressure remained stable throughout the admission. She will continue lisinopril daily. + +5. Perianal rash. Upon admission, she was found to have worsening of a candidal rash in the perianal region. A wound consult was obtained. They recommended Aloe Vesta foam and Silver gel to the area topically. She was also continued on Diflucan 200 mg daily. She will complete a 10-day course. + +6. Diabetes mellitus. At the time of admission, she was found to have hyperglycemia. She was started on sliding scale insulin and eventually started on long-acting Lantus insulin. She will be discharged with the regimen of Lantus 35 units at bedtime and continue the sliding scale as needed. + +7. Hypoxia. She did have evidence of decreased saturations. There was concern that she may have a pneumonia, which was treated with vancomycin for possible hospital acquired pneumonia; however, upon further review of the blood cultures improved, chest x-ray consistent with atelectasis and normal saturations that this was likely secondary to increased fluids associated with methotrexate and atelectasis from being confined to bed. + +8. Seizure prophylaxis. She will continue Keppra twice daily. + +9. Acute kidney injury. She did have a bump in the creatinine when methotrexate level was elevated. This resolved by the time of discharge. Creatinine on day of discharge is 0.9. This will be followed as an outpatient. + +DISPOSITION: + + To home in stable condition with home health services. + +DISCHARGE MEDICATIONS: + + See separate sheet attached. + +DIET: + + Neutropenic diabetic. + +ACTIVITY: + + Resume same activity. + +FOLLOWUP: + + With weekly lab work and plans for admission on August 18, 2008. Ms. ABC was advised if she has any problems or concerns in the interim and needs to be seen sooner, she should call. \ No newline at end of file diff --git a/3937_Discharge Summary.txt b/3937_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..b6152519fa3e7be8f2107b94f9038d3733a976f5 --- /dev/null +++ b/3937_Discharge Summary.txt @@ -0,0 +1,31 @@ +PRINCIPAL DIAGNOSIS: + + Mesothelioma. + +SECONDARY DIAGNOSES: + + Pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis. + +PROCEDURES + +1. On August 24, 2007, decortication of the lung with pleural biopsy and transpleural fluoroscopy. + +2. On August 20, 2007, thoracentesis. + +3. On August 31, 2007, Port-A-Cath placement. + +HISTORY AND PHYSICAL: + + The patient is a 41-year-old Vietnamese female with a nonproductive cough that started last week. She has had right-sided chest pain radiating to her back with fever starting yesterday. She has a history of pericarditis and pericardectomy in May 2006 and developed cough with right-sided chest pain, and went to an urgent care center. Chest x-ray revealed right-sided pleural effusion. + +PAST MEDICAL HISTORY + +1. Pericardectomy. + +2. Pericarditis. + +2. Atrial fibrillation. + +4. RNCA with intracranial thrombolytic treatment. + +5 \ No newline at end of file diff --git a/3938_Discharge Summary.txt b/3938_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..39f27b04d70d63c919c428099cd28258167c5d51 --- /dev/null +++ b/3938_Discharge Summary.txt @@ -0,0 +1,61 @@ +PROCEDURES: + +1. Chest x-ray on admission, no acute finding, no interval change. + +2. CT angiography, negative for pulmonary arterial embolism. + +3. Nuclear myocardial perfusion scan, abnormal. Reversible defect suggestive of ischemia, ejection fraction of 55%. + +DIAGNOSES ON DISCHARGE: + +1. Chronic obstructive pulmonary disease exacerbation improving, on steroids and bronchodilators. + +2. Coronary artery disease, abnormal nuclear scan, discussed with Cardiology Dr. X, who recommended to discharge the patient and follow up in the clinic. + +3. Diabetes mellitus type 2. + +4. Anemia, hemoglobin and hematocrit stable. + +5. Hypokalemia, replaced. + +6. History of coronary artery disease status post stent placement 2006-2008. + +7. Bronchitis. + +HOSPITAL COURSE: + +The patient is a 65-year-old American-native Indian male, past medical history of heavy tobacco use, history of diabetes mellitus type 2, chronic anemia, COPD + + coronary artery disease status post stent placement, who presented in the emergency room with increasing shortness of breath, cough productive for sputum, and orthopnea. The patient started on IV steroid, bronchodilator as well as antibiotics. + +He also complained of chest pain that appears to be more pleuritic with history of coronary artery disease and orthopnea. He was evaluated by Cardiology Dr. X, who proceeded with stress test. Stress test reported positive for reversible ischemia, but Cardiology decided to follow up the patient in the clinic. The patient's last cardiac cath was in 2008. + +The patient clinically significantly improved and wants to go home. His hemoglobin on admission was 8.8, and has remained stable. He is afebrile, hemodynamically stable. + +ALLERGIES: + + LISINOPRIL AND PENICILLIN. + +MEDICATIONS ON DISCHARGE: + +1. Prednisone tapering dose 40 mg p.o. daily for three days, then 30 mg p.o. daily for three days, then 20 mg p.o. daily for three days, then 10 mg p.o. daily for three days, and 5 mg p.o. daily for two days. + +2. Levaquin 750 mg p.o. daily for 5 more days. + +3. Protonix 40 mg p.o. daily. + +4. The patient can continue other current home medications at home. + +FOLLOWUP APPOINTMENTS: + +1. Recommend to follow up with Cardiology Dr. X's office in a week. + +2. The patient is recommended to see Hematology Dr. Y in the office for workup of anemia. + +3. Follow up with primary care physician's office tomorrow. + +SPECIAL INSTRUCTIONS: + +1. If increasing shortness of breath, chest pain, fever, any acute symptoms to return to emergency room. + +2. Discussed about discharge plan, instructions with the patient by bedside. He understands and agreed. Also discussed discharge plan instructions with the patient's nurse. \ No newline at end of file diff --git a/3939_Discharge Summary.txt b/3939_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..89ef63cc7c1b33e218cd19e98febe7dc14d7df1c --- /dev/null +++ b/3939_Discharge Summary.txt @@ -0,0 +1,24 @@ +DISCHARGE DIAGNOSES: + +1. End-stage renal disease, on hemodialysis. + +2. History of T9 vertebral fracture. + +3. Diskitis. + +4. Thrombocytopenia. + +5. Congestive heart failure with ejection fraction of approximately 30%. + +6. Diabetes, type 2. + +7. Protein malnourishment. + +8. History of anemia. + +HISTORY AND HOSPITAL COURSE: + + The patient is a 77-year-old white male who presented to Hospital of Bossier on April 14, 2008. The patient was found to have lumbar diskitis and was going to require extensive antibiotic therapy, which was the cause of need for continued hospitalization. He also needed to continue with dialysis and he needed to improve his rehabilitation. The patient tolerated his medication well and he was going through rehab fairly well without any significant troubles. He did have some bouts of issues with constipation on and off throughout his hospitalization, but this seemed to come under control with more aggressive management. The patient had remained afebrile. He did also have a bout with some episodic confusion problems, which appeared to be more of a sundowner-type of a problem, but this too cleared with his stay here at Promise. On the day of discharge, on May 9, 2008, the patient was in good spirits, was very clear and lucid. He denied any complaints of pain. He did have some trouble with sleep at night at times, but I think this was mainly tied into the fact that he sleeps a lot during the day. The patient has increased his appetite some and has been eating some. His vital signs remain stable. His blood pressure on discharge was 126/63, heart rate is 80, respiratory rate of 20 and temperature was 98.3. PPD was negative. An SMS form was filled out in plan for his discharge and he was sent with medications that he had been receiving while here at Promise. + +The patient and his family understood our plan and agreed with it. He thanked us for the care that he received at Promise and thought that they did a fantastic job taking care of him. He did not have any acute questions as to where he was going and what the next step of his care would be, but we did discuss this at length prior to date of discharge. + diff --git a/3940_Discharge Summary.txt b/3940_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..4f2b341734b5602b1c794fbf644d15e4a2df764a --- /dev/null +++ b/3940_Discharge Summary.txt @@ -0,0 +1,69 @@ +ADMITTING DIAGNOSIS: + + Intractable migraine with aura. + +DISCHARGE DIAGNOSIS: + + Migraine with aura. + +SECONDARY DIAGNOSES: + +1. Bipolar disorder. + +2. Iron deficiency anemia. + +3. Anxiety disorder. + +4. History of tubal ligation. + +PROCEDURES DURING THIS HOSPITALIZATION: + +1. CT of the head with and without contrast, which was negative. + +2. An MRA of the head and neck with and without contrast also negative. + +3. The CTA of the neck also read as negative. + +4. The patient also underwent a lumbar puncture in the Emergency Department, which was grossly unremarkable though an opening pressure was not obtained. + +HOME MEDICATIONS: + +1. Vicodin 5/500 p.r.n. + +2. Celexa 40 mg daily. + +3. Phenergan 25 mg p.o. p.r.n. + +4. Abilify 10 mg p.o. daily. + +5. Klonopin 0.5 mg p.o. b.i.d. + +6. Tramadol 30 mg p.r.n. + +7. Ranitidine 150 mg p.o. b.i.d. + +ALLERGIES: + + SULFA drugs. + +HISTORY OF PRESENT ILLNESS: + + The patient is a 25-year-old right-handed Caucasian female who presented to the emergency department with sudden onset of headache occurring at approximately 11 a.m. on the morning of the July 31, 2008. She described the headache as worse in her life and it was also accompanied by blurry vision and scotoma. The patient also perceived some swelling in her face. Once in the Emergency Department, the patient underwent a very thorough evaluation and examination. She was given the migraine cocktail. Also was given morphine a total of 8 mg while in the Emergency Department. For full details on the history of present illness, please see the previous history and physical. + +BRIEF SUMMARY OF HOSPITAL COURSE: + +The patient was admitted to the neurological service after her headache felt to be removed with the headache cocktail. The patient was brought up to 4 or more early in the a.m. on the August 1, 2008 and was given the dihydroergotamine IV + + which did allow some minimal resolution in her headache immediately. At the time of examination this morning, the patient was feeling better and desired going home. She states the headache had for the most part resolved though she continues to have some diffuse trigger point pain. + +PHYSICAL EXAMINATION AT THE TIME OF DISCHARGE: + + General physical exam was unremarkable. HEENT: Pupils were equal and respond to light and accommodation bilaterally. Extraocular movements were intact. Visual fields were intact to confrontation. Funduscopic exam revealed no disc pallor or edema. Retinal vasculature appeared normal. Face is symmetric. Facial sensation and strength are intact. Auditory acuities were grossly normal. Palate and uvula elevated symmetrically. Sternocleidomastoid and trapezius muscles are full strength bilaterally. Tongue protrudes in midline. Mental status exam: revealed the patient alert and oriented x 4. Speech was clear and language is normal. Fund of knowledge, memory, and attention are grossly intact. Neurologic exam: Vasomotor system revealed full power throughout. Normal muscle tone and bulk. No pronator drift was appreciated. Coordination was intact to finger-to-nose, heel-to-shin and rapid alternating movement. No tremor or dysmetria. Excellent sensory. Sensation is intact in all modalities throughout. The patient does have notable trigger points diffusely including the occiput, trapezius bilaterally, lumbar, back, and sacrum. Gait was assessed, the patient's routine and tandem gait were normal. The patient is able to balance on heels and toes. Romberg is negative. Reflexes are 2+ and symmetric throughout. Babinski reflexes are plantar. + +DISPOSITION: + + The patient is discharged home. + +INSTRUCTIONS FOR FOLLOWUP: + +The patient is to followup with her primary care physician as needed. \ No newline at end of file diff --git a/3941_Discharge Summary.txt b/3941_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..b569cbc2373739063aaf9bf5443273c31273869e --- /dev/null +++ b/3941_Discharge Summary.txt @@ -0,0 +1,43 @@ +ADMITTING DIAGNOSIS: + + Trauma/ATV accident resulting in left open humerus fracture. + +DISCHARGE DIAGNOSIS: + + Trauma/ATV accident resulting in left open humerus fracture. + +SECONDARY DIAGNOSIS: + + None. + +HISTORY OF PRESENT ILLNESS: + + For complete details, please see dictated history and physical by Dr. X dated July 23, 2008. Briefly, the patient is a 10-year-old male who presented to the Hospital Emergency Department following an ATV accident. He was an unhelmeted passenger on ATV when the driver lost control and the ATV rolled over throwing the passenger and the driver approximately 5 to 10 meters. The patient denies any loss of consciousness. He was not amnestic to the event. He was taken by family members to the Iredell County Hospital, where he was initially evaluated. Due to the extent of his injuries, he was immediately transferred to Hospital Emergency Department for further evaluation. + +HOSPITAL COURSE: + + Upon arrival in the Hospital Emergency Department, he was noted to have an open left humerus fracture. No other apparent injuries. This was confirmed with radiographic imaging showing that the chest and pelvis x-rays were negative for any acute injury and that the cervical spine x-ray was negative for fracture malalignment. The left upper extremity x-ray did demonstrate an open left distal humerus fracture. The orthopedic surgery team was then consulted and upon their evaluation, the patient was taken emergently to the operating room for surgical repair of his left humerus fracture. In the operating room, the patient was prepared for an irrigation and debridement of what was determined to be an open type 3 subcondylar left distal humerus fracture. In the operating room, his upper extremity was evaluated for neurovascular status and great care was taken to preserve these structures. Throughout the duration of the procedure, the patient had a palpable distal radial pulse. The orthopedic team then completed an open reduction and internal fixation of the left supracondylar humerus fracture. A wound VAC was then placed over the wound at the conclusion of the procedure. The patient tolerated this procedure well and was returned to the Pediatric Intensive Care Unit for postsurgical followup and monitoring. His diet was advanced and his pain was controlled with pain medication. The day following his surgery, the patient was evaluated for a potential for closed head injury given the nature of his accident and the fact that he was not wearing a helmet during his accident. A CT of the brain without contrast showed no acute intracranial abnormalities moreover his cervical spine was radiographically and clinically cleared and his C-collar was removed at that point. Once his C spine had been cleared and the absence of a closed head injury was confirmed. The patient was then transferred from the Intensive Care Unit to the General Floor bed. His clinical status continued to improve and on July 26, 2008, he was taken back to the operating room for removal of the wound VAC and closure of his left upper extremity wound. He again tolerated this procedure well on his return to the General Pediatrics Floor. Throughout his stay, there was concern for compartment syndrome due to the nature and extent of his injuries. However, frequent checks of his distal pulses indicated that he had strong peripheral pulses in the left upper extremity. Moreover, the patient had no complaints of paresthesia. There was no demonstration of pallor or pain on passive motion. There was good capillary refill to the digits of the left hand. By the date of the discharge, the patient was on a full pediatric select diet and was tolerating this well. He had no abdominal tenderness and there were no abdominal injuries on exam or radiographic studies. He was afebrile and his vital signs were stable and once cleared by Orthopedics, he was deemed appropriate for discharge. + +PROCEDURES DURING THIS HOSPITALIZATION: + +1. Irrigation and debridement of open type 3 subcondylar left distal humerus fracture (July 23, 2008). + +2. Open reduction and internal fixation of the left supracondylar humerus fracture (July 23, 2008). + +3. Negative pressure wound dressing (July 23, 2008). + +4. Irrigation and debridement of left elbow fracture (July 26, 2008). + +5. CT of the brain without contrast (July 24, 2008). + +DISPOSITION: + +Home with parents. + +INVASIVE LINES: + + None. + +DISCHARGE INSTRUCTIONS: + +The patient was instructed that he can return home with his regular diet and he was asked not to do any strenuous activities, move furniture, lift heavy objects, or use his left upper extremity. He was asked to followup with return appointment in one week to see Dr. Y in Orthopedics. Additionally, he was told to call his pediatrician, if he develops any fevers, pain, loss of sensation, loss of pulse, or discoloration of his fingers, or paleness to his hand. \ No newline at end of file diff --git a/3942_Discharge Summary.txt b/3942_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..a32ed7739c70f5f0badaa627897713773a39e531 --- /dev/null +++ b/3942_Discharge Summary.txt @@ -0,0 +1,35 @@ +ADMISSION DIAGNOSIS: + + Morbid obesity. BMI is 51. + +DISCHARGE DIAGNOSIS: + + Morbid obesity. BMI is 51. + +PROCEDURE: + + Laparoscopic gastric bypass. + +SERVICE: + + Surgery. + +CONSULT: + + Anesthesia and pain. + +HISTORY OF PRESENT ILLNESS: + + Ms. A is a 27-year-old woman, who suffered from morbid obesity for many years. She has made multiple attempts at nonsurgical weight loss without success. She underwent a preoperative workup and clearance for gastric bypass and was found to be an appropriate candidate. She underwent her procedure. + +HOSPITAL COURSE: + + Ms. A underwent her procedure. She tolerated without difficulty. She was admitted to the floor post procedure. Her postoperative course has been unremarkable. On postoperative day 1, she was hemodynamically stable, afebrile, normal labs, and she was started on a clear liquid diet, which she has tolerated without difficulty. She has ambulated and had no complaints. Today, on postoperative day 2, the patient continues to do well. Pain controlled with p.o. pain medicine, ambulating without difficulty, tolerating a liquid diet. At this point, it is felt that she is stable for discharge. Her drain was discontinued. + +DISCHARGE INSTRUCTIONS: + + Liquid diet x1 week, then advance to pureed and soft as tolerated. No heavy lifting, greater than 10 pounds x4 weeks. The patient is instructed to not engage in any strenuous activity, but maintain mobility. No driving for 1 to 2 weeks. She must be able to stop in an emergency and be off narcotic pain medicine. She may shower. She needs to keep her wounds clean and dry. She needs to follow up in my office in 1 week for postoperative evaluation. She is instructed to call for any problems of shortness of breath, chest pain, calf pain, temperature greater than 101.5, any redness, swelling, or foul smelling drainage from her wounds, intractable nausea, vomiting, and abdominal pain. She is instructed just to resume her discharge medications. + +DISCHARGE MEDICATIONS: + + She was given a scripts for Lortab Elixir, Flexeril, ursodiol, and Colace. \ No newline at end of file diff --git a/3944_Discharge Summary.txt b/3944_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..1c5d1a8aaf2144dcc8f1de138735a159618c52e0 --- /dev/null +++ b/3944_Discharge Summary.txt @@ -0,0 +1,65 @@ +ADMITTING DIAGNOSIS: + + Posttraumatic AV in right femoral head. + +DISCHARGE DIAGNOSIS: + + Posttraumatic AV in right femoral head. + +SECONDARY DIAGNOSES PRIOR TO HOSPITALIZATION: + +1. Opioid use. + +2. Right hip surgery. + +3. Appendectomy. + +4. Gastroesophageal reflux disease. + +5. Hepatitis diagnosed by liver biopsy. + +6. Blood transfusion. + +6. Smoker. + +7. Trauma with multiple orthopedic procedures. + +8. Hip arthroscopy. + +POSTOP COMORBIDITIES: + + Postop acute blood loss anemia requiring transfusion and postop pain. + +PROCEDURES DURING THIS HOSPITALIZATION: + + Right total hip arthroplasty and removal of hardware. + +CONSULTS: + + Acute pain team consult. + +DISPOSITION: + + Home. + +HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE: + + For details, please refer to clinic notes and OP notes. In brief, the patient is a 47-year-old female with a posttraumatic AV in the right femoral head. She came in consult with Dr. X who after reviewing the clinical and radiological findings recommended she undergo a right total hip arthroplasty and removal of old hardware. After being explained the risks, benefits, alternative options, and possible outcomes of surgery, she was agreeable and consented to proceed and therefore on the day of her admission, she was sent to the operating room where she underwent a right total hip arthroplasty and removal of hardware without any complications. She was then transferred to PACU for recovery and postop orthopedic floor for convalescence, physical therapy, and discharge planning. DVT prophylaxis was initiated with Lovenox. Postop pain was adequately managed with the aid of Acute Pain team. Postop acute blood loss anemia was treated with blood transfusions to an adequate level of hemoglobin. Physical therapy and occupational therapy were initiated and continued to work with her towards discharge clearance on the day of her discharge. + +DISPOSITION: + + Home. On the day of her discharge, she was afebrile, vital signs were stable. She was in no acute distress. Her right hip incision was clean, dry, and intact. Extremity was warm and well perfused. Compartments were soft. Capillary refill less than two seconds. Distal pulses were present. + +PREDISCHARGE LABORATORY FINDINGS: + + White count of 10.9, hemoglobin of 9.5, and BMP is pending. + +DISCHARGE INSTRUCTIONS: + + Continue diet as before. + +ACTIVITY: + + Weightbearing as tolerated in the right lower extremity as instructed. Do not lift, drive, move furniture, do strenuous activity for six weeks. Call Dr. X if there is increased temperature greater than 101.5, increased redness, swelling, drainage, increased pain that is not relieved by current pain regimen as per postop orthopedic discharge instruction sheet. + +FOLLOW-UP APPOINTMENT: Follow up with Dr. X in two weeks. \ No newline at end of file diff --git a/3945_Discharge Summary.txt b/3945_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..19b2411149c19a9325d1f62754bd84815b4327d3 --- /dev/null +++ b/3945_Discharge Summary.txt @@ -0,0 +1,43 @@ +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. \ No newline at end of file diff --git a/3946_Discharge Summary.txt b/3946_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..e9e6b19624fea81a1f14b0e941709d237711e221 --- /dev/null +++ b/3946_Discharge Summary.txt @@ -0,0 +1,37 @@ +ADMISSION DIAGNOSIS: + + Symptomatic cholelithiasis. + +DISCHARGE DIAGNOSIS: + + Symptomatic cholelithiasis. + +SERVICE: + + Surgery. + +CONSULTS: + + None. + +HISTORY OF PRESENT ILLNESS: + + Ms. ABC is a 27-year-old woman who apparently presented with complaint of symptomatic cholelithiasis. She was afebrile. She was taken by Dr. X to the operating room. + +HOSPITAL COURSE: + + The patient underwent a procedure. She tolerated without difficulty. She had her pain controlled with p.o. pain medicine. She was afebrile. She is tolerating liquid diet. It was felt that the patient is stable for discharge. She did complain of bladder spasms when she urinated and she did say that she has a history of chronic UTIs. We will check a UA and urine culture prior to discharge. I will give her prescription for ciprofloxacin that she can take for 3 days presumptively and I have discharged her home with omeprazole and Colace to take over-the-counter for constipation and we will send her home with Percocet for pain. Her labs were within normal limits. She did have an elevated white blood cell count, but I believe this is just leukemoid reaction, but she is afebrile, and if she does have UTI + + may also be related. Her labs in terms of her bilirubin were within normal limits. Her LFTs were slightly elevated, I do believe this is related to the cautery used on the liver bed. They were 51 and 83 for the AST and ALT respectively. I feel that she looks good for discharge. + +DISCHARGE INSTRUCTIONS: + + Clear liquid diet x48 hours and she can return to her Medifast, she may shower. She needs to keep her wound clean and dry. She is not to engage in any heavy lifting greater than 10 pounds x2 weeks. No driving for 1 to 2 weeks. She must be able to stop in an emergency and be off narcotic meds, no strenuous activity, but she needs to maintain mobility. She can resume her medications per med rec sheets. + +DISCHARGE MEDICATIONS: + + As previously mentioned. + +FOLLOWUP: + + We will follow up on both urinalysis and cultures. She is instructed to follow up with Dr. X in 2 weeks. She needs to call for any shortness of breath, temperature greater than 101.5, chest pain, intractable nausea, vomiting, and abdominal pain, any redness, swelling or foul smelling drainage from her wounds. \ No newline at end of file diff --git a/3947_Discharge Summary.txt b/3947_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..dbcda6afa50a5a916ce4d1ba020e3dfb0a1c49be --- /dev/null +++ b/3947_Discharge Summary.txt @@ -0,0 +1,37 @@ +DISCHARGE DIAGNOSES: + +1. Gram-negative rod bacteremia, final identification and susceptibilities still pending. + +2. History of congenital genitourinary abnormalities with multiple surgeries before the 5th grade. + +3. History of urinary tract infections of pyelonephritis. + +OPERATIONS PERFORMED: + + Chest x-ray July 24, 2007, that was normal. Transesophageal echocardiogram July 27, 2007, that was normal. No evidence of vegetations. CT scan of the abdomen and pelvis July 27, 2007, that revealed multiple small cysts in the liver, the largest measuring 9 mm. There were 2-3 additional tiny cysts in the right lobe. The remainder of the CT scan was normal. + +HISTORY OF PRESENT ILLNESS: + + Briefly, the patient is a 26-year-old white female with a history of fevers. For further details of the admission, please see the previously dictated history and physical. + +HOSPITAL COURSE: + + Gram-negative rod bacteremia. The patient was admitted to the hospital with suspicion of endocarditis given the fact that she had fever, septicemia, and Osler nodes on her fingers. The patient had a transthoracic echocardiogram as an outpatient, which was equivocal, but a transesophageal echocardiogram here in the hospital was normal with no evidence of vegetations. The microbiology laboratory stated that the Gram-negative rod appeared to be anaerobic, thus raising the possibility of organisms like bacteroides. The patient does have a history of congenital genitourinary abnormalities which were surgically corrected before the fifth grade. We did a CT scan of the abdomen and pelvis, which only showed some benign appearing cysts in the liver. There was nothing remarkable as far as her kidneys, ureters, or bladder were concerned. I spoke with Dr. XYZ of infectious diseases, and Dr. XYZ asked me to talk to the patient about any contact with animals, given the fact that we have had a recent outbreak of tularemia here in Utah. Much to my surprise, the patient told me that she had multiple pet rats at home, which she was constantly in contact with. I ordered tularemia and leptospirosis serologies on the advice of Dr. XYZ + + and as of the day after discharge, the results of the microbiology still are not back yet. The patient, however, appeared to be responding well to levofloxacin. I gave her a 2-week course of 750 mg a day of levofloxacin, and I have instructed her to follow up with Dr. XYZ in the meantime. Hopefully by then we will have a final identification and susceptibility on the organism and the tularemia and leptospirosis serologies will return. A thought of ours was to add doxycycline, but again the patient clinically appeared to be responding to the levofloxacin. In addition, I told the patient that it would be my recommendation to get rid of the rats. I told her that if indeed the rats were carriers of infection and she received a zoonotic infection from exposure to the rats, that she could be in ongoing continuing danger and her children could also potentially be exposed to a potentially lethal infection. I told her very clearly that she should, indeed, get rid of the animals. The patient seemed reluctant to do so at first, but I believe with some coercion from her family, that she finally came to the realization that this was a recommendation worth following. + + + +DISPOSITION + +DISCHARGE INSTRUCTIONS: + + Activity is as tolerated. Diet is as tolerated. + +MEDICATIONS: + + Levaquin 750 mg daily x14 days. + +Followup is with Dr. XYZ of infectious diseases. I gave the patient the phone number to call on Monday for an appointment. Additional followup is also with Dr. XYZ + + her primary care physician. Please note that 40 minutes was spent in the discharge. \ No newline at end of file diff --git a/3948_Discharge Summary.txt b/3948_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..a884ea6830cb2d0004038f62602a6fb7507b1882 --- /dev/null +++ b/3948_Discharge Summary.txt @@ -0,0 +1,41 @@ +DISCHARGE DIAGNOSES: + +1. Bilateral lower extremity cellulitis secondary to bilateral tinea pedis. + +2. Prostatic hypertrophy with bladder outlet obstruction. + +3. Cerebral palsy. + +DISCHARGE INSTRUCTIONS: + + The patient would be discharged on his usual Valium 10-20 mg at bedtime for spasticity, Flomax 0.4 mg daily, cefazolin 500 mg q.i.d. + + and Lotrimin cream between toes b.i.d. for an additional two weeks. He will be followed in the office. + +HISTORY OF PRESENT ILLNESS: + + This is a pleasant 62-year-old male with cerebral palsy. The patient was recently admitted to Hospital with lower extremity cellulitis. This resolved, however, recurred in both legs. Examination at the time of this admission demonstrated peeling of the skin and excoriation between all of his toes on both feet consistent with tinea pedis. + +PAST MEDICAL/FAMILY/SOCIAL HISTORY: + + As per the admission record. + +REVIEW OF SYSTEMS: + + As per the admission record. + +PHYSICAL EXAMINATION: + +As per the admission record. + +LABORATORY STUDIES: + + At the time of admission, his white blood cell count was 8200 with a normal differential, hemoglobin 13.6, hematocrit 40.6 with normal indices, and platelet count was 250,000. Comprehensive metabolic profile was unremarkable, except for a nonfasting blood sugar of 137, lactic acid was 0.8. Urine demonstrated 4-9 red blood cells per high-powered field with 2+ bacteria. Blood culture and wound cultures were unremarkable. Chest x-ray was unremarkable. + +HOSPITAL COURSE: + + The patient was admitted to the General Medical floor and treated with intravenous ceftriaxone and topical Lotrimin. On this regimen, his lower extremity edema and erythema resolved quite rapidly. + +Because of urinary frequency, a bladder scan was done suggesting about 600 cc of residual urine. A Foley catheter was inserted and was productive of approximately 500 cc of urine. The patient was prescribed Flomax 0.4 mg daily. 24 hours later, the Foley catheter was removed and a bladder scan demonstrated 60 cc of residual urine after approximately eight hours. + +At the time of this dictation, the patient was ambulating minimally, however, not sufficiently to resume independent living. \ No newline at end of file diff --git a/3949_Discharge Summary.txt b/3949_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..97a885ff054363d2a14299af2ff84ea9fca9afe8 --- /dev/null +++ b/3949_Discharge Summary.txt @@ -0,0 +1,67 @@ +DISCHARGE DIAGNOSIS: + +1. Epigastric pain. Questionable gastritis, questionable underlying myocardial ischemia. + +2. Congestive heart failure exacerbation. + +3. Small pericardial effusion with no tamponade. + +4. Hypothyroidism. + +5. Questionable subacute infarct versus neoplasm in the pons. + +6. History of coronary artery disease, status post angioplasty and stent. + +7. Hypokalemia. + +CLINICAL RESUME: + + This 83 year-old woman who presented to the ER with complaints of nausea, vomiting, and epigastric discomfort, ongoing for about 4 to 5 months. She has had extensive work up and had her gallbladder removed on April 22, 2007, and had an endoscopy, which had demonstrative gastric ulcer disease apparently about a year ago. She has had abdominal CAT scan and gastric emptying studies which was normal. + +A CT scan of the abdomen done on her May 9, 2007, which showed bilateral peripelvic renal cysts and a redundant sigmoid colon. Otherwise unremarkable. The patient follows with Dr. XYZ as an outpatient. The patient had some worsening of her symptoms over the last few days and then came to the ER. She was admitted. Please refer to Dr. XYZ initial H&P for complete details. + +HOSPITAL COURSE: + +1. Epigastric pain, nausea, and vomiting. The patient was restituted with antiemetics and her symptoms improved. It was not clear whether her nausea and abdominal pain were due to gastritis, peptic ulcer disease/gastric ischemia, or cardiac origin. A brain MRI was also done which basically showed a tiny focus of abnormal enhancement in the pons, which could be subacute like infarct. However, brain neoplasm could not be excluded. Other workup including a CT angio did not show any evidence of acute pulmonary emboli. It showed some moderate cardiomegaly with bilateral pleural effusions, and a small pericardial effusion. The patient underwent Cardiolite stress test but finished only the resting studies, which was inconclusive. She refused to complete the stress test. She was seen by Dr. XYZ in consultation who recommended that the patient should have a small bowel follow through and eventually angiogram as an outpatient. + +2. Congestive heart failure exacerbation. The patient was treated with ACE inhibitors, diuretics, Aldactone, and Lasix, and improved. An echocardiogram done showed an ejection fraction of about 30% to 35% + + mild water decrease in LV systolic function, with multiple segmental wall motion abnormalities, a small anterior pericardial effusion, but no electrocardiographic signs of cardiac tamponade. There was some pseudo normal pattern of filling, mild MR and global hypokinesis of the LV. + +3. Small pericardial effusion. The patient did not have any clinical or echocardiographic evidence of tamponade. + +4. Hypothyroidism. TSH was quite elevated at 19. + +5. Questionable subacute infarct versus neoplasm in the pons on an MRI of the head. + +6. History of coronary artery disease/angioplasty and stents. + +7. Hyperkalemia. + +8. Patient was doing well. She was back to her baseline and was refusing further workup and the patient was stable and it was felt she could be safely discharged home to have further testing done as an outpatient. + +MEDICATIONS AND ADVICE ON DISCHARGE: + +1. She is to continue taking Coreg 12.5 mg p.o. b.i.d. + +2. Cozaar 50 mg p.o. daily. + +3. Aldactone 25 mg p.o. daily. + +4. Synthroid 0.075 mg p.o. daily. + +5. Carafate 1 gram p.o. 4 times a day. + +6. Claritin 10 mg p.o. daily. + +7. Lasix 20 mg p.o. daily. + +8. K-Dur 20 mEq p.o. daily. + +9. Prilosec 40 mg p.o. daily. + +10. Zofran 4 mg p.o. q.4-6 hourly p.r.n. + +She is to follow up with her primary care physician, Dr. XYZ in 2 to 3 days' time. She is to follow up with Dr. XYZ her cardiologist in 1 to 2 days' time. She is to follow up with Dr. XYZ from GI as scheduled. The patient was advised that she will need a small bowel follow through with angiogram which can be arranged by her gastroenterologist as an outpatient. She was also advised that she would need a repeat MRI of her head in 2 to 3 months' time. She will also need repeat echocardiogram done in one month for a pericardial effusion. This can be arranged by her primary care physician. Repeat TSH to be done in 6 weeks' time. + +Over 35 minutes were spent in the patient discharged. \ No newline at end of file diff --git a/3950_Discharge Summary.txt b/3950_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..068ae6ced9e37217898e87bd7e31151fc5194e76 --- /dev/null +++ b/3950_Discharge Summary.txt @@ -0,0 +1,55 @@ +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. \ No newline at end of file diff --git a/3951_Discharge Summary.txt b/3951_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..a73369d3fefd41ad7468819532e1d19fcf7b280b --- /dev/null +++ b/3951_Discharge Summary.txt @@ -0,0 +1,77 @@ +ADMISSION DIAGNOSES: + +1. Atypical chest pain. + +2. Nausea. + +3. Vomiting. + +4. Diabetes. + +5. Hypokalemia. + +6. Diarrhea. + +7. Panic and depression. + +8. Hypertension. + +DISCHARGE DIAGNOSES: + +1. Serotonin syndrome secondary to high doses of Prozac. + +2. Atypical chest pain with myocardial infarction ruled out. + +3. Diabetes mellitus. + +4. Hypertension. + +5. Diarrhea resolved. + +ADMISSION SUMMARY: + + The patient is a 53-year-old woman with history of hypertension, diabetes, and depression. Unfortunately her husband left her 10 days prior to admission and she developed severe anxiety and depression. She was having chest pains along with significant vomiting and diarrhea. Of note, she had a nuclear stress test performed in February of this year, which was normal. She was readmitted to the hospital to rule out myocardial infarction and for further evaluation. + +ADMISSION PHYSICAL: + + Significant for her being afebrile. Apparently there was one temperature registered mildly high at 100. Her blood pressure was 140/82, heart rate 83, oxygen saturation was 100%. She was tearful. HEART: Heart sounds were regular. LUNGS: Clear. ABDOMEN: Soft. Apparently there were some level of restlessness and acathexia. She was also pacing. + +ADMISSION LABS: + +Showed CBC with a white count of 16.9, hematocrit of 46.9, platelets 318,000. She had 80% neutrophils, no bands. UA on 05/02 came out negative. Chemistry panel shows sodium 138, potassium 3.5, creatinine 0.6, calcium 8.3, lactate 0.9, ALT was 39, AST 38, total bilirubin 0.6. Her initial CK came out at 922. CK-MB was low. Troponin was 0.04. She had a normal amylase and lipase. Previous TSH few days prior was normal. Chest x-ray was negative. + +HOSPITAL COURSE: + +1. Serotonin syndrome. After reevaluation of the patient including evaluation of the lab abnormalities it was felt that she likely had serotonin syndrome with obvious restlessness, increased bowel activity, agitation, and elevated white count and CPK. She did not have fever, tremor or hyperreflexia. Her CPK improved with IV fluids. She dramatically improved with this discontinuation of her Prozac. Her white count came back down towards normal. At time of discharge, she was really feeling back to normal. + +2. Depression and anxiety with history of panic attacks exacerbated by her husband leaving her 2 weeks ago. We discussed this. Also, discussed the situation with a psychiatrist who is available on Friday and I discussed the situation with the patient. In regards to her medications, we are discontinuing the Prozac and she is being reevaluated by Dr. X on Monday or Tuesday. Cymbalta has been recommended as a good alternative medication for her. The patient does have a counselor. It is going to be difficult for her to go home alone. I discussed the resources with her. She has a daughter who will be coming to town in a couple of weeks, but she does have a friend that she can call and stay the next few days with. + +3. Hypertension. She will continue on her usual medications. + +4. Diabetes mellitus. She will continue on her usual medications. + +5. Diarrhea resolved. Her electrolyte abnormalities resolved. She had received fluid rehydration. + +DISPOSITION: + + She is being discharged to home. She will stay with a friend for a couple of days. She will be following up with Dr. X on Monday or Tuesday. Apparently Dr. Y has already discussed the situation and the plan with her. She will continue on her usual medications except for discontinuing the Prozac. + +DISCHARGE MEDICATIONS: + + Include,1. Omeprazole 20 mg daily. + +2. Temazepam 15 mg at night. + +3. Ativan 1 mg one-half to one three times a day as needed. + +4. Cozaar 50 daily. + +5. Prandin 1 mg before meals. + +6. Aspirin 81 mg. + +7. Multivitamin daily. + +8. Lantus 60 units at bedtime. + +9. Percocet 10/325 one to two at night for chronic pain. She is running out of that, so we are calling a prescription for #10 of those. \ No newline at end of file diff --git a/3952_Discharge Summary.txt b/3952_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..dac23204b0cec9906fe501e59a5641917957b47a --- /dev/null +++ b/3952_Discharge Summary.txt @@ -0,0 +1,27 @@ +DISCHARGE DIAGNOSES: + +1. Chronic obstructive pulmonary disease with acute hypercapnic respiratory failure. + +2. Chronic atrial fibrillation with prior ablation done on Coumadin treatment. + +3. Mitral stenosis. + +4. Remote history of lung cancer with prior resection of the left upper lobe. + +5. Anxiety and depression. + +HISTORY OF PRESENT ILLNESS: + + Details are present in the dictated report. + +BRIEF HOSPITAL COURSE: + + The patient is a 71-year-old lady who came in with increased shortness of breath of one day duration. She denied history of chest pain or fevers or cough with purulent sputum at that time. She was empirically treated with a course of antibiotics of Avelox for ten days. She also received steroids, prednisolone 60 mg, and breathing treatments with albuterol, Ipratropium and her bronchodilator therapy was also optimized with theophylline. She continued to receive Coumadin for her chronic atrial fibrillation. Her heart rate was controlled and was maintained in the 60s-70s. On the third day of admission she developed worsening respiratory failure with fatigue, and hence was required to be intubated and ventilated. She was put on mechanical ventilation from 1/29 to 2/6/06. She was extubated on 2/6 and put on BI-PAP. The pressures were gradually increased from 10 and 5 to 15 of BI-PAP and 5 of E-PAP with FIO2 of 35% at the time of transfer to Kindred. Her bronchospasm also responded to the aggressive bronchodilation and steroid therapy. + +DISCHARGE MEDICATIONS: + + Prednisolone 60 mg orally once daily, albuterol 2.5 mg nebulized every 4 hours, Atrovent Respules to be nebulized every 6 hours, Pulmicort 500 micrograms nebulized twice every 8 hours, Coumadin 5 mg orally once daily, magnesium oxide 200 mg orally once daily. + +TRANSFER INSTRUCTIONS: + + The patient is to be strictly kept on bi-level PAP of 15 I-PAP/E-PAP of 5 cm and FIO2 of 35% for most of the times during the day. She may be put on nasal cannula 2 to 3 liters per minute with an O2 saturation of 90-92% at meal times only, and that is to be limited to 1-2 hours every meal. On admission her potassium had risen slightly to 5.5, and hence her ACE inhibitor had to be discontinued. We may restart it again at a later date once her blood pressure control is better if required. \ No newline at end of file diff --git a/3953_Discharge Summary.txt b/3953_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..80b0e7a878bf13576bc8bb29fea1e7735079b436 --- /dev/null +++ b/3953_Discharge Summary.txt @@ -0,0 +1,71 @@ +ADMISSION DIAGNOSIS (ES): + +1. Chronic obstructive pulmonary disease. + +2. Pneumonia. + +3. Congestive heart failure. + +4. Diabetes mellitus. + +5. Neuropathy. + +6. Anxiety. + +7. Hypothyroidism. + +8. Depression. + +9. Hypertension. + +DISCHARGE DIAGNOSIS (ES): + +1. Severe chronic obstructive pulmonary disease. + +2. Diabetes mellitus. + +3. Hypothyroidism. + +4. Altered mental status, less somnolent, likely secondary to medications, resolved. + +5. Lower gastrointestinal bleed. + +6. Status post episode of atrial fibrillation. + +7. Status post diverticular bleed. + +DISCHARGE MEDICATIONS: + +1. Albuterol inhaler q.i.d. + +2. Xanax 1 mg t.i.d. + +3. Cardizem CD 120 mg daily. + +4. Colace 100 mg b.i.d. + +5. Iron sulfate 325 mg b.i.d. + +6. NPH 10 units subcutaneous b.i.d. + +7. Atrovent inhaler q.i.d. + +8. Statin oral suspension p.o. q.i.d. + + swish and spit. + +9. Paxil 10 mg daily. + +10. Prednisone 20 mg daily. + +11. Darvocet Darvocet-N 100, one q.4h PRN pain. + +12. Metamucil one pack b.i.d. + +13. Synthroid 50 mcg daily. + +14. Nexium 40 mg daily. + +HOSPITAL COURSE: + + The patient was a 66-year-old who presented with complaints of shortness of breath and was found to have acute COPD exacerbation. She had previously been at outlying hospital and had left AMA after 10 sets of BiPAP use. Here she was able to be kept off BiPAP later and slowly improved her exacerbation of COPD with the assistance of pulmonary. She was thought to have bronchitis as well and was treated with antibiotics. During hospitalization she developed acute lower GI bleed and was transferred to intensive care unit and transfused packed red blood cells. GI was consulted, performed endoscopy, revealing diverticular disease of the sigmoid colon, with this being the suspected cause of hemorrhage. Plavix is being held for at least 10 days. Lovenox held as well. No further signs of bleeding. The patient's respiratory status did slowly improve to baseline. She is discharged and given the above noted medications. Followup with Dr. Pesce, of diagnostic pulmonary, in the outpatient setting. She will also followup with Dr. Pesce, in the outpatient setting. \ No newline at end of file diff --git a/3955_Discharge Summary.txt b/3955_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..824798a14ee416ea60aeef080b3bb25d443340f1 --- /dev/null +++ b/3955_Discharge Summary.txt @@ -0,0 +1,41 @@ +FINAL DIAGNOSIS/REASON FOR ADMISSION: + +1. Acute right lobar pneumonia. + +2. Hypoxemia and hypotension secondary to acute right lobar pneumonia. + +3. Electrolyte abnormality with hyponatremia and hypokalemia - corrected. + +4. Elevated liver function tests, etiology undetermined. + +5. The patient has a history of moderate-to-severe dementia, Alzheimer's type. + +6. Anemia secondary to current illness and possible iron deficiency. + +7. Darkened mole on the scalp, status post skin biopsy, pending pathology report. + +OPERATION AND PROCEDURE: + + The patient underwent a scalp skin biopsy with pathology specimen obtained on 6/11/2009. Dr. X performed the procedure, thoracentesis on 6/12/2009 both diagnostic and therapeutic. Dr. Y's results pending. + +DISPOSITION: + + The patient discharged to long-term acute facility under the care of Dr. Z. + +CONDITION ON DISCHARGE: + + Clinically improved, however, requiring acute care. + +CURRENT MEDICATIONS: + +Include those on admission combined with IV Flagyl 500 mg every 8 hours and Levaquin 500 mg daily. + +HOSPITAL SUMMARY: + + This is one of several admissions for this 68-year-old female who over the initial 48 hours preceding admission had a complaint of low-grade fever, confusion, dizziness, and a nonproductive cough. Her symptoms progressed and she presented to the emergency room at Brighton Gardens where a chest x-ray revealed evolving right lobar infiltrate. She was started on antibiotics. Infectious Disease was consulted. She was initially begun on vancomycin. Blood, sputum, and urine cultures were obtained; the results of which were negative for infection. She was switched to IV Levaquin and received IV Flagyl for possible C. diff colitis as well as possible cholecystitis. During her hospital stay, she initially was extremely relatively hypotensive with mild symptoms and she became dizzy with upright positioning. Her systolic blood pressure was 60-70 mmHg despite rather aggressive IV fluid management up to 250 mL an hour. She was seen in consultation by Dr. Y who monitored her fluid and pulmonary treatment. Due to some elevated liver function tests, she was seen in consultation by Dr. X. An ultrasound was negative; however, she did undergo CT scan of the chest and abdomen and there was a suspicion of fluid circling the gallbladder. A HIDA scan was performed and revealed no evidence of gallbladder dysfunction. Liver functions were monitored throughout her stay and while elevated, did reduce to approximately 1.5 times normal value. She also was seen in consultation by Infectious Disease who followed her for several days and agreed with current management of antibiotics. Over her week-stay, the patient was moderately hypoxemic with room air pulse oximetry of 90%. She was placed on incentive spirometry and over the succeeding days, she did have improved pulmonary function. + +LABORATORY TESTS: + + Initially revealed a white count of 13,000, however, approximately 24 hours following admission her white count stabilized and in fact remained normal throughout her stay. Blood cultures were negative at 5 days. Sputum culture was negative. Urine culture was negative and thoracentesis culture negative at 24 hours. The patient did receive 2 units of packed red cells with the hemoglobin drop to 9 for cardiovascular support, as no evidence of GI bleeding was obtained. Her most recent blood work on 6/14/2009 revealed a white count of 7000 and hemoglobin of 12.1 with a hematocrit of 36.8. Her PT and PTT were normal. Occult blood studies were negative for occult blood. Hepatitis B antigen was negative. Hepatitis A antibody IgM was negative. Hepatitis B core IgM negative, and hepatitis C core antibody was negative. At the time of discharge on 6/14/2009, sodium was 135, potassium was 3.7, calcium was 8.0, her ALT was 109, AST was 70, direct bilirubin was 0.2, LDH was 219, serum iron was 7, total iron unbound 183, and ferritin level was 267. + +At the time of discharge, the patient had improved. She complained of some back discomfort and lumbosacral back x-ray did reveal some evidence of mild degenerative disk disease with no obvious compression fracture acute noted and she will be followed by Dr. Z. \ No newline at end of file diff --git a/3956_Discharge Summary.txt b/3956_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..fa721fe6469c1e4cbaa7d9769c89a2447f7218ba --- /dev/null +++ b/3956_Discharge Summary.txt @@ -0,0 +1,43 @@ +DATE OF ADMISSION: + + MM/DD/YYYY. + +DATE OF DISCHARGE: + + MM/DD/YYYY. + +REFERRING PHYSICIAN: + + AB CD + + M.D. + +ATTENDING PHYSICIAN AT DISCHARGE: + + X Y, M.D. + +ADMITTING DIAGNOSES: + +1. Ewing sarcoma. + +2. Anemia. + +3. Hypertension. + +4. Hyperkalemia. + +PROCEDURES DURING HOSPITALIZATION: + +Cycle seven Ifosfamide, mesna, and VP-16 chemotherapy. + +HISTORY OF PRESENT ILLNESS: + + Ms. XXX is a pleasant 37-year-old African-American female with the past medical history of Ewing sarcoma, iron deficiency anemia, hypertension, and obesity. She presented initially with a left frontal orbital swelling to Dr. XYZ on MM/DD/YYYY. A biopsy revealed small round cells and repeat biopsy on MM/DD/YYYY also showed round cells consistent with Ewing sarcoma, genetic analysis indicated a T1122 translocation. MRI on MM/DD/YYYY showed a 4 cm soft tissue mass without bony destruction. CT showed similar result. The patient received her first cycle of chemotherapy on MM/DD/YYYY. On MM/DD/YYYY + + she was admitted to the ED with nausea and vomitting and was admitted to the Hematology and Oncology A Service following her first course of chemotherapy. She had her last course of chemotherapy on MM/DD/YYYY followed by radiation treatment to the ethmoid sinuses on MM/DD/YYYY. + +HOSPITAL COURSE: + +1. Ewing sarcoma, she presented for cycle seven of VP-16, ifosfamide, and mesna infusions, which she tolerated well throughout the admission. + +2. She was followed for hemorrhagic cystitis with urine dipsticks and only showed trace amounts of blood in the urine throughout the admission. \ No newline at end of file diff --git a/3957_Discharge Summary.txt b/3957_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..bd279208d4538844ca96abc02ad7bd2eb6138c39 --- /dev/null +++ b/3957_Discharge Summary.txt @@ -0,0 +1,75 @@ +DATE OF ADMISSION: + + MM/DD/YYYY. + +DATE OF DISCHARGE: + + MM/DD/YYYY. + +ADMITTING DIAGNOSIS: + + Peritoneal carcinomatosis from appendiceal primary. + +DISCHARGE DIAGNOSIS: + + Peritoneal carcinomatosis from appendiceal primary. + +SECONDARY DIAGNOSIS: + + Diarrhea. + +ATTENDING PHYSICIAN: + + AB CD + + M.D. + +SERVICE: + + General surgery C, Surgery Oncology. + +CONSULTING SERVICES: + + Urology. + +PROCEDURES DURING THIS HOSPITALIZATION: + + On MM/DD/YYYY + + + +1. Cystoscopy, bilaterally retrograde pyelograms, insertion of bilateral externalized ureteral stents. + +2. Exploratory laparotomy, right hemicolectomy, cholecystectomy, splenectomy, omentectomy, IPHC with mitomycin-C. + +HOSPITAL COURSE: + + The patient is a pleasant 56-year-old gentleman with no significant past medical history who after an extensive workup for peritoneal carcinomatosis from appendiceal primary was admitted on MM/DD/YYYY. He was admitted to General Surgery C Service for a routine preoperative evaluation including baseline labs, bowel prep, urology consult for ureteral stent placement. The patient was taken to the operative suite on MM/DD/YYYY and was first seen by Urology for a cystoscopy with bilateral ureteral stent placement. Dr. XYZ performed an exploratory laparotomy, right hemicolectomy, cholecystectomy, splenectomy, omentectomy, and IPHC with mitomycin-C. The procedure was without complications. The patient was observed closely in the ICU for one day postoperatively for persistent tachycardia after extubation. He was then transferred to the floor where he has done exceptionally well. + +On postoperative day #2, the patient passed flatus and we were able to start a clear liquid diet. We advanced him as tolerated to a regular health select diet by postoperative day #4. His pain was well controlled throughout this hospitalization, initially with a PCA pump, which he very seldomly used. He was then switched over to p.o. pain medicines and has required very little for adequate pain control. By postoperative date #2, the patient had been out of bed and ambulating in the hallways. The patient's only problem was with some mild diarrhea on postoperative days #3 and 4. This was thought to be a result of his right hemicolectomy. A C. diff toxin was sent and came back negative and he was started on Imodium to manage his diarrhea. His post-splenectomy vaccines including pneumococcal, HiB, and meningococcal vaccines were administered during his hospitalization. + +On the day of discharge, the patient was resting comfortably in the bed without complaints. He had been afebrile throughout his hospitalization and his vital signs were stable. Pertinent physical exam findings include that his abdomen was soft, nondistended and nontender with bowel sounds present throughout. His midline incision is clean, dry, and intact and staples are in place. He is just six days postop, he will go home with his staples in place and they will be removed on his follow-up appointment. + +CONDITION AT DISCHARGE: + +The patient was discharged in good and stable condition. + +DISCHARGE MEDICATIONS: + +1. Multivitamins daily. + +2. Lovenox 40 mg in 0.4 mL solution inject subcutaneously once daily for 14 days. + +3. Vicodin 5/500 mg and take one tablet by mouth every four hours as needed for pain. + +4. Phenergan 12.5 mg tablets, take one tablet by mouth every six hours p.r.n. for nausea. + +5. Imodium A-D tablets take one tablet by mouth b.i.d. as needed for diarrhea. + +DISCHARGE INSTRUCTIONS: + + The patient was instructed to contact us with any questions or concerns that may arise. In addition, he was instructed to contact us, if he would have fevers greater than 101.4, chills, nausea or vomitting, continuing diarrhea, redness, drainage, or warmth around his incision site. He will be seen in about one week's time in Dr. XYZ's clinic and his staples will be removed at that time. + +FOLLOW-UP APPOINTMENT: + + The patient will be seen by Dr. XYZ in clinic in one week's time. \ No newline at end of file diff --git a/3958_Discharge Summary.txt b/3958_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..28f8dfa61c655b7b8777c3d6a736da9dfc6eddfe --- /dev/null +++ b/3958_Discharge Summary.txt @@ -0,0 +1,59 @@ +CURRENT HISTORY: + + A 94-year-old female from the nursing home with several days of lethargy and anorexia. She was found to have evidence of UTI. She also has renal insufficiency and digitalis toxicity. She is admitted for further treatment. + +Past medical history, social history, family history, physical examination can be seen on the admission H&P. + +LABORATORIES ON ADMISSION: + + White count 11,700, hemoglobin 12.8, hematocrit 37.2, BUN 91, creatinine 2.2, sodium 131, potassium 5.1. Digoxin level of 4.1. + +HOSPITAL COURSE: + + The patient was admitted and intravenous fluids and antibiotics were administered. Blood cultures were negative. Urine cultures were nondiagnostic. Renal function improved with creatinine down to 1 at the time of discharge. Digoxin was restarted at a lower dose. Her condition improved and she is stabilized and transferred back to assisted living in good condition. + +PRIMARY DIAGNOSES: + +1. Urinary tract infection. + +2. Volume depletion. + +3. Renal insufficiency. + +4. Digitalis toxicity. + +SECONDARY DIAGNOSES: + +1. Aortic valve stenosis. + +2. Congestive heart failure. + +3. Hypertension. + +4. Chronic anemia. + +5. Degenerative joint disease. + +6. Gastroesophageal reflux disease. + +PROCEDURES: + + None. + +COMPLICATIONS: + + None. + +DISCHARGE CONDITION: + + Improved and stable. + +DISCHARGE PLAN: + +Physical activity: With assistance. + +Diet: No restriction. + +Medications: Lasix 40 mg daily, lisinopril 5 mg daily, digoxin 0.125 mg daily, Augmentin 875 mg 1 tablet twice a day for 1 week, Nexium 40 mg daily, Elavil 10 mg at bedtime, Detrol 2 mg twice a day, potassium 10 mEq daily and diclofenac 50 mg twice a day. + +Follow up: She will see Dr. X in the office as scheduled. \ No newline at end of file diff --git a/3959_Discharge Summary.txt b/3959_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..c558e4ddc7b32980149213f04149eb4df0dab819 --- /dev/null +++ b/3959_Discharge Summary.txt @@ -0,0 +1,39 @@ +FINAL DIAGNOSES: + +1. Gastroenteritis. + +2. Autism. + +DIET ON DISCHARGE: + + Regular for age. + +MEDICATIONS ON DISCHARGE: + + Adderall and clonidine for attention deficit hyperactivity disorder. + +ACTIVITY ON DISCHARGE: + + As tolerated. + +DISPOSITION ON DISCHARGE: + + Follow up with Dr. X in ABC Office in 1 to 2 weeks. + +HISTORY OF PRESENT ILLNESS: + + This 10-and-4/12-year-old Caucasian female has autism and is enrolled at ABC School, and she takes Adderall and clonidine for her hyperactivity. She developed constipation one week prior to admission and mother gave her MiraLax and her constipation improved. She developed vomiting 3 days prior to admission, but did not have diarrhea. She voided on the day of admission. When she presented to the office, her weight was 124 pounds, which was approximately 10 pounds below previous weights and even had a weight of 151.5 pounds, 05/30/2007 and weight of 137.5 pounds, 09/11/2007 with mother giving no good explanation as to why she had lost all this weight. She was admitted because of the persistent vomiting, but there was concern about the weight loss. + +Physical examination on admission was unremarkable except for the obvious signs autistic spectrum disorder. + +LABORATORY DATA: + +Laboratory data included sedimentation rate of 12, magnesium level of 2.2, TSH of 2.63 with normal being 0.34 to 5.60, free T4 of 1.68 with normal being 0.58 to 1.64. Chest x-ray and abdominal films were unremarkable. Hemoglobin 14.5, hematocrit 43.5, platelet count 400,000, white blood count 11,800. Urinalysis was negative for ketones. Specific gravity 1.023, and negative for protein. Sodium 137, potassium 3.4, chloride 103, CO2 20, BUN 21, creatinine 0.9, and anion gap 14, glucose 90, total protein 8.1, albumin 4.5, calcium 8.8, bilirubin 1.5, AST 26, ALT 16, alkaline phosphatase 118. Thyroid peroxidase antibody studies are pending. + +HOSPITAL COURSE: + +The child was observed on IV fluids and advanced to clear liquids and then regular diet as tolerated. On the second hospital day, mother was comfortable taking her to home. Mother did not have a good explanation for the weight loss. In the hospital, her weight was 124 pounds, her height 58 inches, temperature 98.0 degree F. + + pulse 123, respirations 18, blood pressure 148/94. Follow up blood pressure were some of them were in the 125 to 70 range making us think her hypertension as labile and perhaps related to the excitement of the admission. + +She seem quite happy and in no distress at the time of discharge. We will follow up in the office and try to further evaluate her for the unexplained weight loss. She has been taking the Adderall for at least a year, and the mother does not think the Adderall is the cause of the weight loss. The free T4 is borderline high and probably bears repeating along with further studies for Graves disease as an outpatient. \ No newline at end of file diff --git a/3962_Discharge Summary.txt b/3962_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..7954972cb37ba88464d15eefa7bd7c8109915040 --- /dev/null +++ b/3962_Discharge Summary.txt @@ -0,0 +1,21 @@ +FINAL DIAGNOSES: + +1. Cardiac arrest. + +2. Severe congestive heart failure. + +3. Acute on chronic respiratory failure. + +4. Osteoporosis. + +5. Depression. + +HISTORY OF PRESENT ILLNESS: + + This 92-year-old lady with history of depression and chronic low back pain, osteoporosis, and congestive heart failure, was diagnosed having pneumonia approximately for at least 10 days prior to admission. In the ER + + she was given oral antibiotics. She also saw me few days before admission coming for a followup. She was doing fairly well. She was thought to have congestive heart failure and she was advised to continue with her diuretics. For the last few days, the patient started to have anorexia, she did not eat well, and she did not drink well. Her family could not take care of her. So, she was brought to the emergency room, where she was found to have rapid heart rate with a sinus tachycardia around 112 to 130s. The ________ was found to be dry. She was given 1 L of IV fluids and she was subsequently admitted in the hospital for further management. + +COURSE IN THE HOSPITAL: + + The patient stayed in the telemetry. The patient had significant shortness of breath secondary to congestive heart failure with bilateral basilar crackles. She was continued on IV antibiotics and general IV hydration was started initially because of low blood pressure and low perfusion status. On subsequently improved and stopped and Lasix was started; Dr. X, cardiologist was also placed. The patient's family wanted her to be a DNR and DNI. They were allowing us to treat her aggressively medically for pneumonia and congestive heart failure. However, the patient became extremely weak, mostly unresponsive. At this time, the patient's family wanted a Hospice consult, which was requested. By the time the Hospice could evaluate her, the patient's condition got deteriorated, she went into more bradycardiac and hypertension and subsequently expired. Please see the hospital notes for complete details. \ No newline at end of file diff --git a/3963_Discharge Summary.txt b/3963_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..af884019030b27843354f6359f9f5b83ae3ab82f --- /dev/null +++ b/3963_Discharge Summary.txt @@ -0,0 +1,39 @@ +HISTORY OF PRESENT ILLNESS: + + The patient is a 60-year-old female patient who off and on for the past 10 to 12 months has had almost daily diarrhea, nausea, inability to eat. She had an EGD and colonoscopy with Dr. ABC a few days prior to this admission. Colonoscopy did reveal diverticulosis and EGD showed retained bile and possible gastritis. Biopsies were done. The patient presented to our emergency room for worsening abdominal pain as well as swelling of the right lower leg. + +PAST MEDICAL HISTORY: + + Extensive and well documented in prior charts. + +PHYSICAL EXAMINATION: + + Abdomen was diffusely tender. Lungs clear. Blood pressure 129/69 on admission. At the time of admission, she had just a trace of bilateral lower edema. + +LABORATORY STUDIES: + + White count 6.7, hemoglobin 13, hematocrit 39.3. Potassium of 3.2 on 08/15/2007. + +HOSPITAL COURSE: + + Dr. ABC apparently could not advance the scope into the cecum and therefore warranted a barium enema. This was done and did not really show what the cecum on the barium enema. There was some retained stool in that area and the patient had a somewhat prolonged hospital course on the remaining barium from the colon. She did have some enemas. She had persistent nausea, headache, neck pain throughout this hospitalization. Finally, she did improve enough to the point where she could be discharged home. + +DISCHARGE DIAGNOSIS: + + Nausea and abdominal pain of uncertain etiology. + +SECONDARY DIAGNOSIS: + +Migraine headache. + +COMPLICATIONS: + +None. + +DISCHARGE CONDITION: + + Guarded. + +DISCHARGE PLAN: + +Follow up with me in the office in 5 to 7 days to resume all pre-admission medications. Diet and activity as tolerated. \ No newline at end of file diff --git a/3964_Discharge Summary.txt b/3964_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..b1a6f5490f784ba08e4e478c81ebab1323a18bc8 --- /dev/null +++ b/3964_Discharge Summary.txt @@ -0,0 +1,31 @@ +DISCHARGE DIAGNOSES: + +1. Advanced non-small cell lung carcinoma with left malignant pleural effusion status post chest tube insertion status post chemical pleurodesis. + +2. Respiratory failure secondary to above. + +3. Likely postobstructive pneumonia. + +4. Gastrointestinal bleed. + +5. Thrombocytopenia. + +6. Acute renal failure. + +7. Hyponatremia. + +8. Hypercalcemia, likely secondary to paraneoplastic syndrome from the non-small cell lung CA + + possible metastases to the bones. + +9. Leukemoid reaction, likely secondary to malignancy. + +10. Elevated liver function tests. + +HOSPITAL COURSE: + + This is a 53-year-old African American male patient of Dr. X who was admitted through the emergency room. He has been having some right hip pain and cough. The patient had a CT scan of the chest, which revealed a left pleural effusion, extensive mediastinal mass, left hilar adenopathy, causing complete obstruction of the left lower lobe and the lingula and the left pulmonary vein, and the multiple nodules on the right side of his chest. These were all consistent with metastatic disease. He was thus also a suspicion for osseous metastatic disease involving the right scapula with a left large pleural effusion. The patient had severe shortness of breath, chest pain, a left-sided chest tube was inserted, and pleural effusion was positive for malignant cells. The history of right hip pain could be secondary to metastatic disease. The patient underwent bronchoscopy, which is positive for non-small cell lung CA. The patient was seen by various consultants. The patient underwent respiratory failure, requiring intubation, mechanical ventilatory support. He was extubated, but had to be re-intubated because of respiratory failure. Had a long discussion with the patient's wife and other family members. The patient was seen by Dr. Y. The patient was not in a condition to undergo any kind of chemotherapy, being on the ventilator. The patient progressively got deteriorated. The patient's family requested for DNR + + withdrawal of the life support. The patient was extubated, and he was pronounced expired on 08/21/08 at 01:40 hours. + +I appreciate all consultants' input. \ No newline at end of file diff --git a/3966_Discharge Summary.txt b/3966_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..ba91a38567b41cffa30af41a6cf3d0ebe3a57a4b --- /dev/null +++ b/3966_Discharge Summary.txt @@ -0,0 +1,35 @@ +ADMITTING DIAGNOSES: + + Hiatal hernia, gastroesophageal reflux disease reflux. + +DISCHARGE DIAGNOSES: + + Hiatal hernia, gastroesophageal reflux disease reflux. + +SECONDARY DIAGNOSIS: + + Postoperative ileus. + +PROCEDURES DONE: + + Hiatal hernia repair and Nissen fundoplication revision. + +BRIEF HISTORY: + + The patient is an 18-year-old male who has had a history of a Nissen fundoplication performed six years ago for gastric reflux. Approximately one year ago, he was involved in a motor vehicle accident and CT scan at that time showed that he had a hiatal hernia. Over the past year, this has caused him an increasing number of problems, including chest pain when he eats, and shortness of breath after large meals. He is also having reflux symptoms again. He presents to us for repair of the hiatal hernia and revision of the Nissen fundoplication. + +HOSPITAL COURSE: + + Mr. A was admitted to the adolescent floor by Brenner Children's Hospital after his procedure. He was stable at that time. He did complain of some nausea. However, he did not have any vomiting at that time. He had an NG tube in and was n.p.o. He also had a PCA for pain management as well as Toradol. On postoperative day #1, he complained of not being able to urinate, so a Foley catheter was placed. Over the next several days, his hospital course proceeded as follows. He continued to complain of some nausea; however, he did not ever have any vomiting. Eventually, the Foley catheter was discontinued and he had excellent urine output without any complications. He ambulated frequently. He remained n.p.o. for three days. He also had the NG tube in during that time. On postoperative day #4, he began to have some flatus, and the NG tube was discontinued. He was advanced to a liquid diet and tolerated this without any complications. At this time, he was still using the PCA for pain control. However, he was using it much less frequently than on days #1 and #2 postoperatively. After tolerating the full liquid diet without any complications, he was advanced to a soft diet and his pain medications were transitioned to p.o. medications rather than the PCA. The PCA was discontinued. He tolerated the soft diet without any complications and continued to have flatus frequently. On postoperative day #6, it was determined that he was stable for discharge to home as he was taking p.o. without any complications. His pain was well controlled with p.o. pain medications. He was passing gas frequently, had excellent urine output, and was ambulating frequently without any issues. + +DISCHARGE CONDITION: + + Stable. + +DISPOSITION: + + Discharged to home. + +DISCHARGE INSTRUCTIONS: + + The patient was discharged to home with instructions for maintaining a soft diet. It was also recommended that he does not drink any soda postoperatively. He is instructed to keep his incision site clean and dry and it was also recommended that he avoid any heavy lifting. He will be able to attend school when it starts in a few weeks. However, he is not going to be able to play football in the near future. He was given prescription for pain medication upon discharge. He is instructed to contact Pediatric Surgery if he has any fevers, any nausea and vomiting, any chest pain, any constipation, or any other concerns. \ No newline at end of file diff --git a/3967_Discharge Summary.txt b/3967_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..548850d69f51fd8315c31440fdbff9add41c7813 --- /dev/null +++ b/3967_Discharge Summary.txt @@ -0,0 +1,31 @@ +DIAGNOSES ON ADMISSION + +1. Cerebrovascular accident (CVA) with right arm weakness. + +2. Bronchitis. + +3. Atherosclerotic cardiovascular disease. + +4. Hyperlipidemia. + +5. Thrombocytopenia. + +DIAGNOSES ON DISCHARGE + +1. Cerebrovascular accident with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect. + +2. Old coronary infarct, anterior aspect of the right external capsule. + +3. Acute bronchitis with reactive airway disease. + +4. Thrombocytopenia most likely due to old coronary infarct, anterior aspect of the right external capsule. + +5. Atherosclerotic cardiovascular disease. + +6. Hyperlipidemia. + +HOSPITAL COURSE: + + The patient was admitted to the emergency room. Plavix was started in addition to baby aspirin. He was kept on oral Zithromax for his cough. He was given Xopenex treatment, because of his respiratory distress. Carotid ultrasound was reviewed and revealed a 50 to 69% obstruction of left internal carotid. Dr. X saw him in consultation and recommended CT angiogram. This showed no significant obstructive lesion other than what was known on the ultrasound. Head MRI was done and revealed the above findings. The patient was begun on PT and improved. By discharge, he had much improved strength in his right arm. He had no further progressions. His cough improved with oral Zithromax and nebulizer treatments. His platelets also improved as well. By discharge, his platelets was up to 107,000. His H&H was stable at 41.7 and 14.6 and his white count was 4300 with a normal differential. Chest x-ray revealed a mild elevated right hemidiaphragm, but no infiltrate. Last chemistry panel on December 5, 2003, sodium 137, potassium 4.0, chloride 106, CO2 23, glucose 88, BUN 17, creatinine 0.7, calcium was 9.1. PT/INR on admission was 1.03, PTT 34.7. At the time of discharge, the patient's cough was much improved. His right arm weakness has much improved. His lung examination has just occasional rhonchi. He was changed to a metered dose inhaler with albuterol. He is being discharged home. An echocardiogram revealed mild concentric LVH with normal left ventricular function with an EF of 57% + + moderate left atrial enlargement and diastolic dysfunction with mild mitral regurgitation. He will follow up in my office in 1 week. He is to start PT and OT as an outpatient. He is to avoid driving his car. He is to notify, if further symptoms. He has 2 more doses of Zithromax at home, he will complete. His prognosis is good. \ No newline at end of file diff --git a/3968_Discharge Summary.txt b/3968_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..3071796bebd87570d06eb3e08b0ebed46fba186f --- /dev/null +++ b/3968_Discharge Summary.txt @@ -0,0 +1,87 @@ +DISCHARGE DIAGNOSES: + +1. Acute cerebrovascular accident/left basal ganglia and deep white matter of the left parietal lobe. + +2. Hypertension. + +3. Urinary tract infection. + +4. Hypercholesterolemia. + +PROCEDURES: + +1. On 3/26/2006, portable chest, single view. Impression: atherosclerotic change in the aortic knob. + +2. On 3/26/2006, chest, portable, single view. Impression: Mild tortuosity of the thoracic aorta, maybe secondary to hypertension; right lateral costophrenic angle is not evaluated due to positioning of the patient. + +3. On March 27, 2006, swallowing study: Normal swallowing study with minimal penetration with thin liquids. + +4. On March 26, 2006, head CT without contrast: 1) Air-fluid level in the right maxillary sinus suggestive of acute sinusitis; 2) A 1.8-cm oval, low density mass in the dependent portion of the left maxillary sinus is consistent with a retention cyst; 3) Mucoparietal cell thickening in the right maxillary sinus and ethmoid sinuses. + +4. IV contrast CT scan of the head is unremarkable. + +5. On 3/26/2006, MRI/MRA of the neck and brain, with and without contrast: 1) Changes consistent with an infarct involving the right basal ganglia and deep white matter of the left parietal lobe, as described above; 2) Diffuse smooth narrowing of the left middle cerebral artery that may be a congenital abnormality. Clinical correlation is necessary. + +6. On March 27th, echocardiogram with bubble study. Impression: Normal left ventricular systolic function with estimated left ventricular ejection fraction of 55%. There is mild concentric left ventricular hypertrophy. The left atrial size is normal with a negative bubble study. + +7. On March 27, 2006, carotid duplex ultrasound showed: 1) Grade 1 carotid stenosis on the right; 2) No evidence of carotid stenosis on the left. + +HISTORY AND PHYSICAL: + +This is a 56-year-old white male with a history of hypertension for 15 years, untreated. The patient woke up at 7: 15 a.m. on March 26 with the sudden onset of right-sided weakness of his arm, hand, leg and foot and also with a right facial droop, right hand numbness on the dorsal side, left face numbness and slurred speech. The patient was brought by EMS to emergency room. The patient was normal before he went to bed the prior night. He was given aspirin in the ER. The CT of the brain without contrast did not show any changes. He could not have a CT with contrast because the machine was broken. He went ahead and had the MRI/MRA of the brain and neck, which showed infarct involving the right basal ganglia and deep white matter of the left parietal lobe. Also, there is diffuse smooth narrowing of the left middle cerebral artery. + +The patient was admitted to the MICU. + +HOSPITAL COURSE PER PROBLEM LIST: + +1. Acute cerebrovascular accident: The patient was not a candidate for tissue plasminogen activator. A neurology consult was obtained from Dr. S. She agrees with our treatment for this patient. The patient was on aspirin 325 mg and also on Zocor 20 mg once a day. We also ordered fasting blood lipids, which showed cholesterol of 165, triglycerides 180, HDL cholesterol 22, LDL cholesterol 107. Dr. Farber agreed to treat the risk factors, to not treat blood pressure for the first two weeks of the stroke. We put the patient on p.r.n. labetalol only for systolic blood pressure greater than 200, diastolic blood pressure greater than 120. The patient's blood pressure has been stable and he did not need any blood pressure medications. His right leg kept improving with increased muscle strength and it was 4-5/5, however, his right upper extremity did not improve much and was 0-1/5. His slurred speech has been improved a little bit. The patient started PT + + OT and speech therapy on the second day of hospitalization. The patient was transferred out to a regular floor on the same day of admission based on his stable neurologic exam. Also, we added Aggrenox for secondary stroke prevention, suggested by Dr. F. Echocardiogram was ordered and showed normal left ventricular function with bubble study that was negative. Carotid ultrasound only showed mild stenosis on the right side. EKG did not show any changes, so the patient will be transferred to Siskin Rehabilitation Hospital today on Aggrenox for secondary stroke prevention. He will not need blood pressure treatment unless systolic is greater than 220, diastolic greater than 120, for the first week of his stroke. On discharge, on his neurologic exam, he has a right facial palsy from the eye below, he has right upper extremity weakness with 0-1/5 muscle strength, right leg is 4-5/5, improved slurred speech. + +2. Hypertension: As I mentioned in item #1, see above, his blood pressure has been stable. This did not need any treatment. + +3. Urinary tract infection: The patient had urinalysis on March 26th, which showed a large amount of leukocyte esterase, small amount of blood with red blood cells 34, white blood cells 41, moderate amount of bacteria. The patient was started on Cipro 250 mg p.o. b.i.d. on March 26th. He needs to finish seven days of antibiotic treatment for his UTI. Urine culture and sensitivity were negative. + +4. Hypercholesterolemia: The patient was put on Zocor 20 mg p.o. daily. The goal LDL for this patient will be less than 70. His LDL currently is 107, HDL is 22, triglycerides 180, cholesterol is 165. + +CONDITION ON DISCHARGE: + + Stable. + +ACTIVITY: + +As tolerated. + +DIET: + + Low-fat, low-salt, cardiac diet. + +DISCHARGE INSTRUCTIONS: + +1. Take medications regularly. + +2. PT + + OT + + speech therapist to evaluate and treat at Siskin Rehab Hospital. + +3. Continue Cipro for an additional two days for his UTI. + +DISCHARGE MEDICATIONS: + +1. Cipro 250 mg, one tablet p.o. b.i.d. for an additional two days. + +2. Aggrenox, one tablet p.o. b.i.d. + +3. Docusate sodium 100 mg, one cap p.o. b.i.d. + +4. Zocor 20 mg, one tablet p.o. at bedtime. + +5. Prevacid 30 mg p.o. once a day. + +FOLLOW UP: + +1. The patient needs to follow up with Rehabilitation Hospital after he is discharged from there. + +2. The patient can call the Clinic if he needs a follow up appointment with us, or the patient can find a primary care physician since he has insurance. \ No newline at end of file diff --git a/3969_Discharge Summary.txt b/3969_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..d4312bc6d23a64462dd10fc58632a5b2823cd085 --- /dev/null +++ b/3969_Discharge Summary.txt @@ -0,0 +1,29 @@ +CAUSE OF DEATH: + +1. Acute respiratory failure. + +2. Chronic obstructive pulmonary disease exacerbation. + +SECONDARY DIAGNOSES: + +1. Acute respiratory failure, probably worsened by aspiration. + +2. Acute on chronic renal failure. + +3. Non-Q wave myocardial infarction. + +4. Bilateral lung masses. + +5. Occlusive carotid disease. + +6. Hypertension. + +7. Peripheral vascular disease. + +HOSPITAL COURSE: + +This 80-year-old patient with a history of COPD had had recurrent admissions over the past few months. The patient was admitted again on 12/15/08, after he had been discharged the previous day. Came in with acute on chronic respiratory failure, with CO2 of 57. The patient was in rapid atrial fibrillation. RVR with a rapid ventricular response of 160 beats per minute. The patient was on COPD exacerbation and CHF due to rapid atrial fibrillation. The patient's heart rate was controlled with IV Cardizem. Troponin was consistent with non-Q wave MI. The patient was treated medically transfer to catheterize the patient to evaluate her coronary artery disease. Echocardiogram showed normal ejection fraction, normal left and right side, but stage 3 restrictive physiology. There was also prosthetic aortic valve. The patient was admitted to Intensive Care Unit and was intubated. Pulmonary was managed by Critical Care, Dr. X. + +The patient was successfully extubated. Was tapered from IV steroids and put on p.o. steroids. The patient's renal function has stabilized with a creatinine of between 2.1 and 2.3. There was contemplation as to whether left heart catheterization should proceed since Nephrology was concerned about the patient's renal status. Wife decided catheterization should be canceled and the patient managed conservatively. The patient was transferred to the telemetry floor. While in telemetry floor, the patient's renal function started deteriorating, went up from 2.08 to 2.67 in two days. The patient had nausea and vomiting. Was unable to tolerate p.o. Was put on cautious hydration. The patient went into acute respiratory distress. Intubation showed the patient had aspirated. He was in acute respiratory failure with bronchospasms and exacerbation of COPD. X-ray of chest did not show any infiltrate, but showed dilatation of the stomach. The patient was transferred to the Intensive Care Unit because of acute respiratory failure, was intubated by Critical Care, Dr. X. The patient was put on the vent. Overnight, the patient's condition did not improve. Continued to be severely hypoxic. + +The patient expired on the morning of 12/24/08 from acute respiratory failure. \ No newline at end of file diff --git a/3970_Discharge Summary.txt b/3970_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..4197fb301fbfd34106ff012799db5caff006605b --- /dev/null +++ b/3970_Discharge Summary.txt @@ -0,0 +1,11 @@ +DIAGNOSIS: + + Cognitive linguistic impairment secondary to stroke. + +NUMBER OF SESSIONS COMPLETED: + + 5,HOSPITAL COURSE: + +The patient is a 73-year-old female who was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits. Based on the initial evaluation completed 12/29/08, the patient had mild difficulty with generative naming and auditory comprehension and recall. The patient's skilled speech therapy was recommended for three times a week for 8 weeks to improve her overall cognitive linguistic abilities. At this time, the patient has accomplished all 5 of her short-term therapy goals. She is able to complete functional mass tasks with 100% accuracy independently. She is able to listen to a narrative and recall the main idea plus at least five details after a 10 minute delay independently. + +She is able to read a newspaper article and recall the main idea plus five details after a 15 minute delay independently. She is able to state 15 items in a broad category within a minute and a half independently. The patient is also able to complete deductive reasoning tasks to promote her mental flexibility with 100% accuracy independently. The patient also met her long-term therapy goal of functional cognitive linguistic abilities to return to teaching and improve her independence and safety at home. The patient is no longer in need of skilled speech therapy and is discharged from my services. She did quite well in therapy and also agreed with this discharge. \ No newline at end of file diff --git a/3971_Discharge Summary.txt b/3971_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..9d1219a6b6f9614182d3f02176896946e968c000 --- /dev/null +++ b/3971_Discharge Summary.txt @@ -0,0 +1,55 @@ +DISCHARGE DIAGNOSES: + +1. Acute respiratory failure, resolved. + +2. Severe bronchitis leading to acute respiratory failure, improving. + +3. Acute on chronic renal failure, improved. + +4. Severe hypertension, improved. + +5. Diastolic dysfunction. + +X-ray on discharge did not show any congestion and pro-BNP is normal. + +SECONDARY DIAGNOSES: + +1. Hyperlipidemia. + +2. Recent evaluation and treatment, including cardiac catheterization, which did not show any coronary artery disease. + +3. Remote history of carcinoma of the breast. + +4. Remote history of right nephrectomy. + +5. Allergic rhinitis. + +HOSPITAL COURSE: + + This 83-year-old patient had some cold symptoms, was treated as bronchitis with antibiotics. Not long after the patient returned from Mexico, the patient started having progressive shortness of breath, came to the emergency room with severe bilateral wheezing and crepitations. X-rays however did not show any congestion or infiltrates and pro-BNP was within normal limits. The patient however was hypoxic and required 4L nasal cannula. She was admitted to the Intensive Care Unit. The patient improved remarkably over the night on IV steroids and empirical IV Lasix. Initial swab was positive for MRSA colonization. + + + +Discussed with infectious disease, Dr. X and it was decided no treatment was required for de-colonization. The patient's breathing has improved. There is no wheezing or crepitations and O2 saturation is 91% on room air. The patient is yet to go for exercise oximetry. Her main complaint is nasal congestion and she is now on steroid nasal spray. The patient was seen by Cardiology, Dr. Z, who advised continuation of beta blockers for diastolic dysfunction. The patient has been weaned off IV steroids and is currently on oral steroids, which she will be on for seven days. + +DISPOSITION: + + The patient has been discharged home. + +DISCHARGE MEDICATIONS: + +1. Metoprolol 25 mg p.o. b.i.d. + +2. Simvastatin 20 mg p.o. daily. + +NEW MEDICATIONS: + +1. Prednisone 20 mg p.o. daily for seven days. + +2. Flonase nasal spray daily for 30 days. + +Results for oximetry pending to evaluate the patient for need for home oxygen. + +FOLLOW UP: + + The patient will follow up with Pulmonology, Dr. Y in one week's time and with cardiologist, Dr. X in two to three weeks' time. \ No newline at end of file diff --git a/3972_Discharge Summary.txt b/3972_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..a7953daef58a71ef2b99c9111bee96ae7930f37c --- /dev/null +++ b/3972_Discharge Summary.txt @@ -0,0 +1,23 @@ +FINAL DIAGNOSES: + + Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress. + +PROCEDURE: + + Included primary low transverse cesarean section. + +SUMMARY: + + This 32-year-old gravida 2 was induced for cholestasis of pregnancy at 38-1/2 weeks. The patient underwent a 2-day induction. On the second day, the patient continued to progress all the way to the point of 9.5 cm at which point, she failed to progress. During the hour or two of evaluation at 9.5 cm, the patient was also noted to have some fetal tachycardia and an occasional late deceleration. Secondary to these factors, the patient was brought to the operative suite for primary low transverse cesarean section, which she underwent without significant complication. There was a slightly enlarged blood loss at approximately 1200 mL, and postoperatively, the patient was noted to have a very mild tachycardia coupled with 100.3 degrees Fahrenheit temperature right at delivery. It was felt that this was a sign of very early chorioamnionitis and therapeutic antibiotics were given throughout her stay. The patient received 72 hours of antibiotics with there never being a temperature above 100.3 degrees Fahrenheit. The maternal tachycardia resolved within a day. The patient did well throughout the 3-day stay progressing to full diet, regular bowel movements, normal urination patterns. The patient did receive 2 units of packed red cells on Sunday when attended to by my partner secondary to a hematocrit of 20%. It should be noted, however, that this was actually an expected result with the initial hematocrit of 32% preoperatively. Therefore, there was anemia but not an unexplained anemia. + +PHYSICAL EXAMINATION ON DISCHARGE: + + Includes the stable vital signs, afebrile state. An alert and oriented patient who is desirous at discharge. Full range of motion, all extremities; fully ambulatory. Pulse is regular and strong. Lungs are clear and the abdomen is soft and nontender with minimal tympany and a nontender fundus. The incision is beautiful and soft and nontender. There is scant lochia and there is minimal edema. + +LABORATORY STUDIES: + + Include hematocrit of 27% and the last liver function tests was within normal limits 48 hours prior to discharge. + +FOLLOWUP: + + For the patient includes pelvic rest, regular diet. Follow up with me in 1 to 2 weeks. Motrin 800 mg p.o. q.8h. p.r.n. cramps, Tylenol No. 3 one p.o. q.4h. p.r.n. pain, prenatal vitamin one p.o. daily, and topical triple antibiotic to incision b.i.d. to q.i.d. \ No newline at end of file diff --git a/3973_Discharge Summary.txt b/3973_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..e39122401399ee734d733885f99c74f81f93d1ed --- /dev/null +++ b/3973_Discharge Summary.txt @@ -0,0 +1,25 @@ +REASON FOR ADMISSION: + + Cholecystitis with choledocholithiasis. + +DISCHARGE DIAGNOSES: + + Cholecystitis, choledocholithiasis. + +ADDITIONAL DIAGNOSES + +1. Status post roux-en-y gastric bypass converted to an open procedure in 01/07. + +2. Laparoscopic paraventral hernia in 11/07. + +3. History of sleep apnea with reversal after 100-pound weight loss. + +4. Morbid obesity with bmi of 39.4. + +PRINCIPAL PROCEDURE: + + Laparoscopic cholecystectomy with laparoscopy converted to open common bile duct exploration and stone extraction. + +HOSPITAL COURSE: + + The patient is a 33-year-old female admitted with elevated bilirubin and probable common bile duct stone. She was admitted through the emergency room with abdominal pain, elevated bilirubin, and gallstones on ultrasound with a dilated common bile duct. She subsequently went for a HIDA scan to rule out cholecystitis. Gallbladder was filled but was unable to empty into the small bowel consistent with the common bile duct blockage. She was taken to the operating room that night for laparoscopic cholecystectomy. We proceeded with laparoscopic cholecystectomy and during the cholangiogram there was no contrast. It was able to be extravasated into the duodenum with the filling defect consistent with the distal common bile duct stone. The patient had undergone a Roux-en-Y gastric bypass but could not receive an ERCP and stone extraction, therefore, common bile duct exploration was performed and a stone was extracted. This necessitated conversion to an open operation. She was transferred to the medical surgical unit postoperatively. She had a significant amount of incisional pain following morning, but no nausea. A Jackson-Pratt drain, which was left in place in two places showed serosanguineous fluid. White blood cell count was down to 7500 and bilirubin decreased to 2.1. Next morning she was started on a liquid diet. Foley catheter was discontinued. There was no evidence of bile leak from the drains. She was advanced to a regular diet on postoperative day #3, which was 12/09/07. The following morning she was tolerating regular diet. Her bowels had begun to function, and she was afebrile with her pain control with oral pain medications. Jackson-Pratt drain was discontinued from the wound. The remaining Jackson-Pratt drain was left adjacent to her cystic duct. Following morning, her laboratory studies were better. Her bilirubin was down to normal and white blood cell count was normal with an H&H of 9 and 26.3. Jackson-Pratt drain was discontinued, and she was discharged home. Followup was in 3 days for staple removal. She was given iron 325 mg p.o. t.i.d. and Lortab elixir 15 cc p.o. q.4 h. p.r.n. for pain. \ No newline at end of file diff --git a/3974_Discharge Summary.txt b/3974_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..3325cde4c103ec6f1796de6d364f64322c83f3cd --- /dev/null +++ b/3974_Discharge Summary.txt @@ -0,0 +1,35 @@ +HISTORY OF PRESENT ILLNESS: + +A 67-year-old male with COPD and history of bronchospasm, who presents with a 3-day history of increased cough, respiratory secretions, wheezings, and shortness of breath. He was seen by me in the office on the day of admission and noted to be dyspneic with audible wheezing and he was admitted for acute asthmatic bronchitis, superimposed upon longstanding COPD. Unfortunately over the past few months he has returned to pipe smoking. At the time of admission, he denied fever, diaphoresis, nausea, chest pain or other systemic symptoms. + +PAST MEDICAL HISTORY: + + Status post artificial aortic valve implantation in summer of 2002 and is on chronic Coumadin therapy. COPD as described above, history of hypertension, and history of elevated cholesterol. + +PHYSICAL EXAMINATION: + + Heart tones regular with an easily audible mechanical click. Breath sounds are greatly diminished with rales and rhonchi over all lung fields. + +LABORATORY STUDIES: + +Sodium 139, potassium 4.5, BUN 42, and creatinine 1.7. Hemoglobin 10.7 and hematocrit 31.7. + +HOSPITAL COURSE: + + He was started on intravenous antibiotics, vigorous respiratory therapy, intravenous Solu-Medrol. The patient improved on this regimen. Chest x-ray did not show any CHF. The cortisone was tapered. The patient's oxygenation improved and he was able to be discharged home. + +DISCHARGE DIAGNOSES: + +Chronic obstructive pulmonary disease and acute asthmatic bronchitis. + +COMPLICATIONS: + + None. + +DISCHARGE CONDITION: + + Guarded. + +DISCHARGE PLAN: + + Prednisone 20 mg 3 times a day for 2 days, 2 times a day for 5 days and then one daily, Keflex 500 mg 3 times a day and to resume his other preadmission medication, can be given a pneumococcal vaccination before discharge. To follow up with me in the office in 4-5 days. \ No newline at end of file diff --git a/3975_Discharge Summary.txt b/3975_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..3efdb025fb5a3c13b2821b93ea94cb57da29b9a5 --- /dev/null +++ b/3975_Discharge Summary.txt @@ -0,0 +1,51 @@ +ADMISSION DIAGNOSES: + +1. Severe menometrorrhagia unresponsive to medical therapy. + +2. Severe anemia. + +3. Fibroid uterus. + +DISCHARGE DIAGNOSES: + +1. Severe menometrorrhagia unresponsive to medical therapy. + +2. Severe anemia. + +3. Fibroid uterus. + +OPERATIONS PERFORMED: + +1. Hysteroscopy. + +2. Dilatation and curettage (D&C). + +3. Myomectomy. + +COMPLICATIONS: + + Large endometrial cavity fibroid requiring careful dissection and excision. + +BLOOD TRANSFUSIONS: + + Two units of packed red blood cells. + +INFECTION: + + None. + +SIGNIFICANT LAB AND X-RAY: + + Posttransfusion of the 2nd unit showed her hematocrit of 25, hemoglobin of 8.3. + +HOSPITAL COURSE AND TREATMENT: + + The patient was admitted to the surgical suite and taken to the operating room where a dilatation and curettage (D&C) was performed. Hysteroscopy revealed a large endometrial cavity fibroid. Careful shaving and excision of this fibroid was performed with removal of the fibroid. Hemostasis was noted completely at the end of this procedure. Postoperatively, the patient has done well. The patient was given a 2nd unit of packed red blood cells because of intraoperative blood loss. The patient is now ambulating without difficulty and tolerating her diet. The patient desires to go home. The patient is discharged to home. + +DISCHARGE CONDITION: + + Stable. + +DISCHARGE INSTRUCTIONS: + +Regular diet, bedrest for 1 week with slow return to normal activities over the ensuing 2 to 3 weeks, pelvic rest for 6 weeks. Vicodin tablets 1 tablet p.o. q.4-6 h. p.r.n. pain, multiple vitamin 1 tab p.o. daily, ferrous sulfate tablets 1 tablet p.o. daily. Ambulate with assistance at home only. The patient is to return to see Dr. X p.r.n. plus Tuesday, 6/16/2009 for further followup care. The patient was given full and complete postop and discharge instructions. All her questions were answered. \ No newline at end of file diff --git a/3976_Discharge Summary.txt b/3976_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..934117f837cb4fa9e7d26d44394926b176df0640 --- /dev/null +++ b/3976_Discharge Summary.txt @@ -0,0 +1,37 @@ +DIAGNOSIS AT ADMISSION: + + Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis. + +DIAGNOSES AT DISCHARGE + +1. Chronic obstructive pulmonary disease exacerbation and acute bronchitis. + +2. Congestive heart failure. + +3. Atherosclerotic cardiovascular disease. + +4. Mild senile-type dementia. + +5. Hypothyroidism. + +6. Chronic oxygen dependent. + +7. Do not resuscitate/do not intubate. + +HOSPITAL COURSE: + + The patient was admitted from the office by Dr. X. She was placed on the usual medications that included Synthroid 0.05 mg a day, enalapril 5 mg a day, Imdur 30 mg a day, Lanoxin 0.125 mg a day, aspirin 81 mg a day, albuterol and Atrovent nebulizers q.4 h. + + potassium chloride 10 mEq 2 tablets per day, Lasix 40 mg a day, Humibid L.A. 600 mg b.i.d. She was placed on oral Levaquin after a load of 500 mg and 250 mg a day. She was given oxygen, encouraged to eat, and suctioned as needed. + +Laboratory data included a urinalysis that had 0-2 WBCs per high power field and urine culture was negative, blood cultures x2 were negative, TSH was 1.7, and chem-7, sodium 134, potassium 4.4, chloride 93, CO2 34, glucose 105, BUN 17, creatinine 0.9, and calcium 9.1. Digoxin was 1.3. White blood cell count was 6100 with a normal differential, H&H 37.4/12.1, platelets 335,000. Chest x-ray was thought to have prominent interstitial lung changes without acute infiltrate. There is a question if there is mild fluid overload. + +The patient improved with the above regimen. By discharge, her lungs fell back to her baseline. She had no significant shortness of breath. Her O2 saturations were stable. Her vital signs were stable. + +She is discharged home to follow up with me in a week and a half. + +Her daughter has been spoken to by phone and she will notify me if she worsens or has problems. + +PROGNOSIS: + +Guarded. \ No newline at end of file diff --git a/3977_Discharge Summary.txt b/3977_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..dc40a49cc43e8fdf659096d9f5f1f6fe7df43b78 --- /dev/null +++ b/3977_Discharge Summary.txt @@ -0,0 +1,41 @@ +DIAGNOSIS AT ADMISSION: + + Congestive heart failure (CHF) with left pleural effusion. + +DIAGNOSES AT DISCHARGE + +1. Congestive heart failure (CHF) with pleural effusion. + +2. Hypertension. + +3. Prostate cancer. + +4. Leukocytosis. + +5. Anemia of chronic disease. + +HOSPITAL COURSE: + +The patient was admitted to the emergency room by Dr. X. He has diuresed with IV Lasix. He was placed on Prinivil, aspirin, oxybutynin, docusate, and Klor-Con. Chest x-rays were followed. He did have free flowing fluid in his left chest. Radiology consultation was obtained for thoracentesis. The patient was seen by Dr. Y. An echocardiogram was done. This revealed an ejection fraction of 60% with diastolic dysfunction and periaortic stenosis with an opening of 1 cm3. An adenosine sestamibi was done in March 2000, with a small fixed apical defect, but no ischemia. Cardiac enzymes were negative. Dr. Y recommended a beta-blocker with an ACE inhibitor; therefore, the lisinopril was discontinued. The patient felt much better after the thoracentesis. I do not have the details of this, i.e. + + the volumes. No fluid was sent for routine studies. + +LABORATORY AT DISCHARGE: + + Sodium 134, potassium 4.2, chloride 99, CO2 26, glucose 182, BUN 17, and creatinine 1.0. Glucose was elevated because of several doses of Solu-Medrol given to him because of bronchospams. Magnesium was 1.8, calcium was 8.1. Liver enzymes were unremarkable. Cardiac enzymes were normal as mentioned. PT/INR is 1.02, PTT 31.3, white blood cell count 15, 000 with a left shift. This was presumed due to the corticosteroids. H&H was 32.3/11.3 and platelets 352,000, and MCV was 99. The patient's O2 saturations on room air were normal. + +Vital signs were stable. + +DISCHARGE MEDICATIONS: + + He is being discharged home on Lasix 40 mg daily, potassium chloride 10 mEq daily, atenolol 25 mg daily, aspirin 5 grains daily, Ditropan 5 mg b.i.d. + + and Colace 100 mg b.i.d. + +FOLLOWUP: + + He will be followed in my office in 1 week. He is to notify if recurrent fever or chills. + +PROGNOSIS: + +Guarded. \ No newline at end of file diff --git a/3978_Discharge Summary.txt b/3978_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..ea3f369e6df7285aaa6ad467cce91a1617d23e2f --- /dev/null +++ b/3978_Discharge Summary.txt @@ -0,0 +1,31 @@ +DISCHARGE DIAGNOSES + +1. Multiple extensive subcutaneous abscesses, right thigh. + +2. Massive open wound, right thigh, status post right excision of multiple subcutaneous abscesses, right thigh. + +PROCEDURES PERFORMED + +1. On 03/05/08, by Dr. X, was massive debridement of soft tissue, right lateral thigh and hip. + +2. Soft tissue debridement on 03/16/08 of right thigh and hip by Dr. X. + +3. Split thickness skin graft to right thigh and right hip massive open wound on 04/01/08 by Dr. Y. + +REASON FOR ADMISSION: + + The patient is a 62-year-old male with a history of drug use. He had a history of injection of heroin into his bilateral thighs. Unfortunately, he developed chronic abscesses, open wounds on his bilateral thighs, much worse on his right than his left. Decision was made to do a radical excision and then it is followed by reconstruction. + +HOSPITAL COURSE: + +The patient was admitted on 03/05/08 by Dr. X. He was taken to the operating room. He underwent a massive resection of multiple subcutaneous abscesses, heroin remnants, which left massive huge open wounds to his right thigh and hip. This led to a prolonged hospital course. The patient initially was treated with local wound care. He was treated with broad spectrum antibiotics. He ended up growing out different species of Clostridium. Infectious Disease consult was obtained from Dr. Z. He assisted in further antibiotic coverage throughout the rest of his hospitalization. The patient also had significant hypoalbuminemia, decreased nutrition. Given his large wounds, he did end up getting a feeding tube placement, and prior to grafting, he received significant feeding tube supplementation to help achieve adequate nutrition for healing. The patient had this superior area what appeared to be further necrotic, infected soft tissue. He went back to the OR on 03/16/08 and further resection done by Dr. X. After this, his wound appeared to be free of infection. He is treated with a wound VAC. He slowly, but progressively had significant progress in his wound. I went from a very poor-looking wound to a red granulated wound throughout its majority. He was thought ready for skin grafting. Note that the patient had serial ultrasounds given his high risk of DVT from this massive wound and need for decreased activity. These were negative. He was treated with SCDs to help decrease his risk. On 04/01/08, the patient was taken to the operating room, was thought to have an adequate ________ grafting. He underwent skin grafting to his right thigh and hip massive open wound. Donor sites were truncated. Postoperatively, the patient ended up with a vast majority of skin graft taking. To unable to take, he was kept on IV antibiotics, strict bed rest, and limited range of motion of his hip. He is continued on VAC dressing. Graft progressively improved with this therapy. Had another ultrasound, which was negative for DVT. The patient was mobilized up out of his bed. Infectious Disease recommendations were obtained. Plan was to complete additional 10 days of antibiotics at discharge. This will be oral antibiotics. I would monitor his left side, which has significantly decreased inflammation and irritation or infection given the antibiotic coverage. So, decision was not made to excise this, but instead monitor. By 04/11/08, his graft looked good. It was pink and filling in. He looked stable for discharge. The patient was discharged to home. + +DISCHARGE INSTRUCTIONS: + + Discharge to home. + +CONDITION: + + Stable. + +Antibiotic Augmentin XR script was written. He is okay to shower. Donor site and graft site dressing instruction orders were given for Home Health and the patient. His followup was arranged with Dr. X and myself. \ No newline at end of file diff --git a/3979_Discharge Summary.txt b/3979_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..9fd8ba2b9b56da7f73733a0a7ad9b3021ef9e2a7 --- /dev/null +++ b/3979_Discharge Summary.txt @@ -0,0 +1,57 @@ +ADMISSION DIAGNOSIS: + +1. Respiratory arrest. + +2 . End-stage chronic obstructive pulmonary disease. + +3. Coronary artery disease. + +4. History of hypertension. + +DISCHARGE DIAGNOSIS: + +1. Status post-respiratory arrest. + +2. Chronic obstructive pulmonary disease. + +3. Congestive heart failure. + +4. History of coronary artery disease. + +5. History of hypertension. + +SUMMARY: + + The patient is a 49-year-old man who was admitted to the hospital in respiratory distress, and had to be intubated shortly after admission to the emergency room. The patient’s past history is notable for a history of coronary artery disease with prior myocardial infarctions in 1995 and 1999. The patient has recently been admitted to the hospital with pneumonia and respiratory failure. The patient has been smoking up until three to four months previously. On the day of admission, the patient had the sudden onset of severe dyspnea and called an ambulance. The patient denied any gradual increase in wheezing, any increase in cough, any increase in chest pain, any increase in sputum prior to the onset of his sudden dyspnea. + +ADMISSION PHYSICAL EXAMINATION: + +GENERAL: Showed a well-developed, slightly obese man who was in extremis. + +NECK: Supple, with no jugular venous distension. + +HEART: Showed tachycardia without murmurs or gallops. + +PULMONARY: Status showed decreased breath sounds, but no clear-cut rales or wheezes. + +EXTREMITIES: Free of edema. + +HOSPITAL COURSE: + + The patient was admitted to the Special Care Unit and intubated. He received intravenous antibiotic therapy with Levaquin. He received intravenous diuretic therapy. He received hand-held bronchodilator therapy. The patient also was given intravenous steroid therapy with Solu-Medrol. The patient’s course was one of gradual improvement, and after approximately three days, the patient was extubated. He continued to be quite dyspneic, with wheezes as well as basilar rales. After pulmonary consultation was obtained, the pulmonary consultant felt that the patient’s overall clinical picture suggested that he had a,significant element of congestive heart failure. With this, the patient was placed on increased doses of Lisinopril and Digoxin, with improvement of his respiratory status. On the day of discharge, the patient had minimal basilar rales; his chest also showed minimal expiratory wheezes; he had no edema; his heart rate was regular; his abdomen was soft; and his neck veins were not distended. It was, therefore, felt that the patient was stable for further management on an outpatient basis. + +DIAGNOSTIC DATA: + + The patient’s admission laboratory data was notable for his initial blood gas, which showed a pH of 7.02 with a pCO2 of 118 and a pO2 of 103. The patient’s electrocardiogram showed nonspecific ST-T wave changes. The patent’s CBC showed a white count of 24,000, with 56% neutrophils and 3% bands. + +DISPOSITION: + + The patient was discharged home. + +DISCHARGE INSTRUCTIONS: + + His diet was to be a 2 grams sodium, 1800 calorie ADA diet. His medications were to be Prednisone 20 mg twice per day, Theo-24 400 mg per day, Furosemide 40 mg 1-1/2 tabs p.o. per day; Acetazolamide 250 mg one p.o. per day, Lisinopril 20 mg. one p.o. twice per day, Digoxin 0.125 mg one p.o. q.d. + + nitroglycerin paste 1 inch h.s. + + K-Dur 60 mEq p.o. b.i.d. He was also to use a Ventolin inhaler every four hours as needed, and Azmacort four puffs twice per day. He was asked to return for follow-up with Dr. X in one to two weeks. Arrangements have been made for the patient to have an echocardiogram for further evaluation of his congestive heart failure later on the day of discharge. \ No newline at end of file diff --git a/3981_Discharge Summary.txt b/3981_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..43c53b98458cd800197fe82b3c5f5f1519dacfbd --- /dev/null +++ b/3981_Discharge Summary.txt @@ -0,0 +1,23 @@ +ADMISSION DIAGNOSIS: + + Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy. + +SECONDARY DIAGNOSIS: + + Chronic pain syndrome. + +PRINCIPAL PROCEDURE: + + L5 Gill procedure with interbody and posterolateral (360 degrees circumferential) arthrodesis using cages, bone graft, recombinant bone morphogenic protein, and pedicle fixation. This was performed by Dr. X on 01/08/08. + +BRIEF HISTORY OF HOSPITAL COURSE: + + The patient is a man with a history of longstanding back, buttock, and bilateral leg pain. He was evaluated and found to have bilateral pars defects at L5-S1 with spondylolysis and instability. He was admitted and underwent an uncomplicated surgical procedure as noted above. In the postoperative period, he was up and ambulatory. He was taking p.o. fluids and diet well. He was afebrile. His wounds were healing well. Subsequently, the patient was discharged home. + +DISCHARGE MEDICATIONS: + + Discharge medications included his usual preoperative pain medication as well as other medications. + +FOLLOWUP: + +At this time, the patient will follow up with me in the office in six weeks' time. The patient understands discharge plans and is in agreement with the discharge plan. He will follow up as noted \ No newline at end of file diff --git a/3982_Discharge Summary.txt b/3982_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..15ebb8e6818ebf91ec6c30dad855bf445ed33049 --- /dev/null +++ b/3982_Discharge Summary.txt @@ -0,0 +1,29 @@ +We discovered new T-wave abnormalities on her EKG. There was of course a four-vessel bypass surgery in 2001. We did a coronary angiogram. This demonstrated patent vein grafts and patent internal mammary vessel and so there was no obvious new disease. + +She may continue in the future to have angina and she will have nitroglycerin available for that if needed. + +Her blood pressure has been elevated and so instead of metoprolol, we have started her on Coreg 6.25 mg b.i.d. This should be increased up to 25 mg b.i.d. as preferred antihypertensive in this lady's case. She also is on an ACE inhibitor. + +So her discharge meds are as follows: + +1. Coreg 6.25 mg b.i.d. + +2. Simvastatin 40 mg nightly. + +3. Lisinopril 5 mg b.i.d. + +4. Protonix 40 mg a.m. + +5. Aspirin 160 mg a day. + +6. Lasix 20 mg b.i.d. + +7. Spiriva puff daily. + +8. Albuterol p.r.n. q.i.d. + +9. Advair 500/50 puff b.i.d. + +10. Xopenex q.i.d. and p.r.n. + +I will see her in a month to six weeks. She is to follow up with Dr. X before that. \ No newline at end of file diff --git a/3983_Discharge Summary.txt b/3983_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..b0d4b063060b6d51bf8981c9831a52e4d81e110b --- /dev/null +++ b/3983_Discharge Summary.txt @@ -0,0 +1,48 @@ +DIAGNOSES: + +1. Bronchiolitis, respiratory syncytial virus positive; improved and stable. + +2. Innocent heart murmur, stable. + +HOSPITAL COURSE: + + The patient was admitted for an acute onset of congestion. She was checked for RSV + + which was positive and admitted to the hospital for acute bronchiolitis. She has always been stable on room air; however, because of her age and her early diagnosis, she was admitted for observation as RSV bronchiolitis typically worsens the third and fourth day of illness. She was treated per pathway orders. However, on the second day of admission, the patient was not quite eating well and parents live far away and she did have a little bit of trouble on first night of admission. There was a heart murmur that was heard that sounded innocent, but yet there was no chest x-ray that was obtained. We did obtain a chest x-ray, which did show a slight perihilar infiltrate in the right upper lobe. However, the rest of the lungs were normal and the heart was also normal. There were no complications during her hospitalization and she continued to be stable and eating better. On day 2 of the admission, it was decided she was okay to go home. Mother was advised regarding signs and symptoms of increased respiratory distress, which includes tachypnea, increased retractions, grunting, nasal flaring etc. and she was very comfortable looking for this. During her hospitalization, albuterol MDI was given to the patient and more for mom to learn outpatient care. The patient did receive a couple of doses, but she did not have any significant respiratory distress and she was discharged in improved condition. + +DISCHARGE PHYSICAL EXAMINATION: + +VITAL SIGNS: She is afebrile. Vital signs were stable within normal limits on room air. + +GENERAL: She is sleeping and in no acute distress. + +HEENT: Her anterior fontanelle was soft and flat. She does have some upper airway congestion. + +CARDIOVASCULAR: Regular rate and rhythm with a 2-3/6 systolic murmur that radiates to bilateral axilla and the back. + +EXTREMITIES: Her femoral pulses were 2+ and her extremities were warm and well perfused with good capillary refill. + +LUNGS: Her lungs did show some slight coarseness, but good air movement with equal breath sounds. She does not have any wheezes at this time, but she does have a few scattered crackles at bilateral bases. She did not have any respiratory distress while she was asleep. + +ABDOMEN: Normal bowel sounds. Soft and nondistended. + +GENITOURINARY: She is Tanner I female. + +DISCHARGE WEIGHT: + + Her weight at discharge 3.346 kg, which is up 6 grams from admission. + +DISCHARGE INSTRUCTIONS: + + + +ACTIVITY: No one should smoke near The patient. She should also avoid all other exposures to smoke such as from fireplaces and barbecues. She is to avoid contact with other infants since she is sick and they are to limit travel. There should be frequent hand washings. + +DIET: Regular diet. Continue breast-feeding as much as possible and encourage oral intake. + +MEDICATIONS: She will be sent home on albuterol MDI to be used as needed for cough, wheezes or dyspnea. + +ADDITIONAL INSTRUCTIONS: + + Mom is quite comfortable with bulb suctioning the nose with saline and they know that they are to return immediately if she starts having difficulty breathing, if she stops breathing or she decides that she does not want to eat. + diff --git a/3984_Discharge Summary.txt b/3984_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..c5fd910b3ad3d221ea2298921969b59d786b57d2 --- /dev/null +++ b/3984_Discharge Summary.txt @@ -0,0 +1,35 @@ +DISCHARGE DIAGNOSES: + + BRCA-2 mutation. + +HISTORY OF PRESENT ILLNESS: + +The patient is a 59-year-old with a BRCA-2 mutation. Her sister died of breast cancer at age 32 and her daughter had breast cancer at age 27. + +PHYSICAL EXAMINATION: + +The chest was clear. The abdomen was nontender. Pelvic examination shows no masses. No heart murmur. + +HOSPITAL COURSE: + +The patient underwent surgery on the day of admission. In the postoperative course she was afebrile and unremarkable. The patient regained bowel function and was discharged on the morning of the fourth postoperative day. + +OPERATIONS AND PROCEDURES: + + Total abdominal hysterectomy/bilateral salpingo-oophorectomy with resection of ovarian fossa peritoneum en bloc on July 25, 2006. + +PATHOLOGY: + + A 105-gram uterus without dysplasia or cancer. + +CONDITION ON DISCHARGE: + + Stable. + +PLAN: + +The patient will remain at rest initially with progressive ambulation after. She will avoid lifting, driving or intercourse. She will call me if any fevers, drainage, bleeding, or pain. Follow up in my office in four weeks. Family history, social history, psychosocial needs per the social worker. + +DISCHARGE MEDICATIONS: + + Percocet 5 #40 one every 3 hours p.r.n. pain. \ No newline at end of file diff --git a/3985_Discharge Summary.txt b/3985_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..5f1d3209fd52306ad2c761259668096950e19b0c --- /dev/null +++ b/3985_Discharge Summary.txt @@ -0,0 +1,83 @@ +CHIEF COMPLAINT: + + Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain. + +HISTORY OF PRESENT ILLNESS: + + The patient is a 45-year-old white male who was admitted with acute back pain. The patient reports that he had chronic problem with back pain for approximately 20 years, but it has gotten progressively worse over the last 3 years. On 08/29/2007, the patient had awoken and started his day as he normally does, but midday, he reports that he was in such severe back pain and he was unable to walk or stand upright. He was seen at ABCD Hospital Emergency Room, was evaluated and admitted. He was treated with IV analgesics as well as Decadron, after being evaluated by Dr. A. It was decided that the patient could benefit from physical therapy, since he was unable to perform ADLs, and was transferred to TCU at St. Joseph Health Services on 08/30/2007. He had been transferred with diagnosis of a back pain secondary to intravertebral lumbar disk disease, secondary to degenerative changes. The patient reports that he has had a " bulging disk" for approximately 1 year. He reports that he has history of testicular cancer in the distant past and the most recent bone scan was negative. The bone scan was done at XYZ Hospital, ordered by Dr. B, the patient's oncologist. + +ALLERGIES: + + PENICILLIN + + AMOXICILLIN + + CEPHALOSPORIN + + DOXYCYCLINE + + IVP DYE + + IODINE + + and SULFA + + all cause HIVES. + +Additionally, the patient reports that he has HIVES when he comes in contact with SAP FROM THE MANGO TREE + + and therefore, he avoids any mango product at all. + +PAST MEDICAL HISTORY: + + Status post right orchiectomy secondary to his testicular cancer 18 years ago approximately 1989, GERD + + irritable bowel syndrome, seasonal asthma (fall and spring) triggered by postnasal drip, history of bilateral carpal tunnel syndrome, and status post excision of abdominal teratoma and incisional hernia. + +FAMILY HISTORY: + + Noncontributory. + +SOCIAL HISTORY: + + The patient is employed in the finance department. He is a nonsmoker. He does consume alcohol on the weekend as much as 3 to 4 alcoholic beverages per day on the weekends. He denies any IV drug use or abuse. + +REVIEW OF SYSTEMS: + + No chills, fever, shakes or tremors. Denies chest pain palpitations, hemoptysis, shortness of breath, nausea, vomiting, diarrhea, constipation or hematemesis. The patient reports that his last bowel movement was on 08/30/2007. No urological symptoms such as dysuria, frequency, incomplete bladder emptying or voiding difficulties. The patient does report that he has occasional intermittent "numbness and tingling" of his hands bilaterally as he has a history of bilateral carpal tunnel syndrome. He denies any history of seizure disorders, but he did report that he had some momentary dizziness earlier, but that has since resolved. + +PHYSICAL EXAMINATION: + +VITAL SIGNS: At the time of admission, temperature 98, blood pressure 176/97, pulse 86, respirations 20, and 95% O2 saturation on room air. The patient weighs 260 pounds and is 5 feet and 10 inches tall by his report. + +GENERAL: The patient appears to be comfortable, in no acute distress. + +HEENT: Normocephalic. Sclerae are nonicteric. EOMI. Tongue is at midline and no evidence of thrush. + +NECK: Trachea is at the midline. + +LYMPHATICS: No cervical or axillary nodes palpable. + +LUNGS: Clear to auscultation bilaterally. + +HEART: Regular rate and rhythm. Normal S1 and S2. + +ABDOMEN: Obese, softly protuberant, and nontender. + +EXTREMITIES: There is no clubbing, cyanosis or edema. There is no calf tenderness bilaterally. Bilateral strength is 5/5 for the upper extremities bilaterally and he has 5/5 of left lower extremity. The right lower extremity is 4-5/5. + +MENTAL STATUS: He is alert and oriented. He was pleasant and cooperative during the examination. + +ASSESSMENT: + +1. Acute on chronic back pain. The patient is admitted to the TCU at St. Joseph Health Services for rehabilitation therapy. He will be seen in consultation by Physical Therapy and Occupational Therapy. He will continue a tapering dose of Decadron over the next 10 to 14 days and a tapering schedule has been provided, also Percocet 5/325 mg 1 to 2 tablets q.i.d. p.r.n. for pain. + +2. Status post right orchiectomy secondary to testicular cancer, stable at this time. We will attempt to obtain copy of the most recent bone scan performed at XYZ Hospital ordered by Dr. B. + +3. Gastroesophageal reflux disease, irritable bowel syndrome, and gastrointestinal prophylaxis. Colace 100 mg b.i.d. + + lactulose will be used on a p.r.n. basis, and Protonix 40 mg daily. + +4. Deep vein thrombosis prophylaxis will be maintained by the patient, continue to engage in his therapies including ambulating in the halls and doing leg exercises as well. + +5. Obesity. As mentioned above, the patient's weighs 260 pounds with a height of 5 feet and 10 inches, and we had discussed possible weight loss plan, which he is interested in pursuing and a dietary consult has been requested. \ No newline at end of file diff --git a/3986_Discharge Summary.txt b/3986_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..5add603fed7a423fa89399d43a3414242458fc9c --- /dev/null +++ b/3986_Discharge Summary.txt @@ -0,0 +1,65 @@ +REASON FOR TRANSFER: + + Need for cardiac catheterization done at ABCD. + +TRANSFER DIAGNOSES: + +1. Coronary artery disease. + +2. Chest pain. + +3. History of diabetes. + +4. History of hypertension. + +5. History of obesity. + +6. A 1.1 cm lesion in the medial aspect of the right parietal lobe. + +7. Deconditioning. + +CONSULTATIONS: + + Cardiology. + +PROCEDURES: + +1. Echocardiogram. + +2. MRI of the brain. + +3. Lower extremity Duplex ultrasound. + +HOSPITAL COURSE: + + Please refer to my H&P for full details. In brief, the patient is a 64-year-old male with history of diabetes, who presented with 6 hours of chest pressure. He was brought in by a friend. The friend states that the patient deteriorated over the last few weeks to the point that he is very short of breath with exertion. He apparently underwent a cardiac workup 6 months ago that the patient states he barely passed. His vital signs were stable on admission. He was ruled out for myocardial infarction with troponin x2. An echocardiogram showed concentric LVH with an EF of 62%. I had Cardiology come to see the patient, who reviewed the records from Fountain Valley. Based on his stress test in the past, Dr. X felt the patient needed to undergo a cardiac cath during his inpatient stay. + +The patient on initial presentation complained of, what sounded like, amaurosis fugax. I performed an MRI + + which showed a 1 cm lesion in the right parietal lobe. I was going to call Neurology at XYZ for evaluation. However, secondary to his indication for transfer, this could be followed up at ABCD with Dr. Y. + +The patient is now stable for transfer for cardiac cath. + +Discharged to ABCD. + +DISCHARGE CONDITION: + + Stable. + +DISCHARGE MEDICATIONS: + +1. Aspirin 325 mg p.o. daily. + +2. Lovenox 40 mg p.o. daily. + +3. Regular Insulin sliding scale. + +4. Novolin 70/30, 15 units b.i.d. + +5. Metformin 500 mg p.o. daily. + +6. Protonix 40 mg p.o. daily. + +DISCHARGE FOLLOWUP: + + Followup to be arranged at ABCD after cardiac cath. \ No newline at end of file diff --git a/3991_Discharge Summary.txt b/3991_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..7ab68ac3f040b95cbeb10815fb1c2161e8ff11d0 --- /dev/null +++ b/3991_Discharge Summary.txt @@ -0,0 +1,19 @@ +FINAL DIAGNOSES: + +1. Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy. + +2. Moderate stenosis C5-6. + +OPERATION: + + On 06/25/07, anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray. + +This is a 60-year-old white male who was in the office on 05/01/07 because of neck pain with left radiculopathy and "tension headaches." In the last year or so, he has had more and more difficulty and more recently has developed tingling and numbness into the fingers of the left hand greater than right. He has some neck pain at times and has seen Dr. X for an epidural steroid injection, which was very helpful. More recently he saw Dr. Y and went through some physical therapy without much relief. + +Cervical MRI scan was obtained and revealed a large right-sided disc herniation at C4-5 with significant midline herniations at C5-6 and a large left HNP at C6-7. In view of the multiple levels of pathology, I was not confident that anything short of surgical intervention would give him significant relief. The procedure and its risk were fully discussed and he decided to proceed with the operation. + +HOSPITAL COURSE: + + Following admission, the procedure was carried out without difficulty. Blood loss was about 125 cc. Postop x-ray showed good alignment and positioning of the cages, plate, and screws. After surgery, he was able to slowly increase his activity level with assistance from physical therapy. He had some muscle spasm and soreness between the shoulder blades and into the back part of his neck. He also had some nausea with the PCA. He had a low-grade fever to 100.2 and was started on incentive spirometry. Over the next 12 hours, his fever resolved and he was able to start getting up and around much more easily. + +By 06/27/07, he was ready to go home. He has been counseled regarding wound care and has received a neck sheet for instruction. He will be seen in two weeks for wound check and for a followup evaluation/x-rays in about six weeks. He has prescriptions for Lortab 7.5 mg and Robaxin 750 mg. He is to call if there are any problems. \ No newline at end of file diff --git a/3994_Discharge Summary.txt b/3994_Discharge Summary.txt new file mode 100644 index 0000000000000000000000000000000000000000..073b960d3596c2c8ccbe342db60e92f1a3f1af23 --- /dev/null +++ b/3994_Discharge Summary.txt @@ -0,0 +1,43 @@ +ADMITTING DIAGNOSIS: + + Abscess with cellulitis, left foot. + +DISCHARGE DIAGNOSIS: + + Status post I&D, left foot. + +PROCEDURES: + + Incision and drainage, first metatarsal head, left foot with culture and sensitivity. + +HISTORY OF PRESENT ILLNESS: + + The patient presented to Dr. X's office on 06/14/07 complaining of a painful left foot. The patient had been treated conservatively in office for approximately 5 days, but symptoms progressed with the need of incision and drainage being decided. + +MEDICATIONS: + + Ancef IV. + +ALLERGIES: + + ACCUTANE. + +SOCIAL HISTORY: + + Denies smoking or drinking. + +PHYSICAL EXAMINATION: + + Palpable pedal pulses noted bilaterally. Capillary refill time less than 3 seconds, digits 1 through 5 bilateral. Skin supple and intact with positive hair growth. Epicritic sensation intact bilateral. Muscle strength +5/5, dorsiflexors, plantar flexors, invertors, evertors. Left foot with erythema, edema, positive tenderness noted, left forefoot area. + +LABORATORY: + + White blood cell count never was abnormal. The remaining within normal limits. X-ray is negative for osteomyelitis. On 06/14/07, the patient was taken to the OR for incision and drainage of left foot abscess. The patient tolerated the procedure well and was admitted and placed on vancomycin 1 g q.12h after surgery and later changed Ancef 2 g IV every 8 hours. Postop wound care consists of Aquacel Ag and dry dressing to the surgical site everyday and the patient remains nonweightbearing on the left foot. The patient progressively improved with IV antibiotics and local wound care and was discharged from the hospital on 06/19/07 in excellent condition. + +DISCHARGE MEDICATIONS: + + Lorcet 10/650 mg, dispense 24 tablets, one tablet to be taken by mouth q.6h as needed for pain. The patient was continued on Ancef 2 g IV via PICC line and home health administration of IV antibiotics. + +DISCHARGE INSTRUCTIONS: + + Included keeping the foot elevated with long periods of rest. The patient is to wear surgical shoe at all times for ambulation and to avoid excessive ambulation. The patient to keep dressing dry and intact, left foot. The patient to contact Dr. X for all followup care, if any problems arise. The patient was given written and oral instruction about wound care before discharge. Prior to discharge, the patient was noted to be afebrile. All vitals were stable. The patient's questions were answered and the patient was discharged in apparent satisfactory condition. Followup care was given via Dr. X' office. \ No newline at end of file