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PREOPERATIVE DIAGNOSIS:, Iron deficiency anemia.,POSTOPERATIVE DIAGNOSIS:, Diverticulosis.,PROCEDURE:, Colonoscopy.,MEDICATIONS: , MAC.,PROCEDURE: , The Olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve and th... | 14 Gastroenterology |
CLINICAL INDICATION: ,Normal stress test.,PROCEDURES PERFORMED:,1. Left heart cath.,2. Selective coronary angiography.,3. LV gram.,4. Right femoral arteriogram.,5. Mynx closure device.,PROCEDURE IN DETAIL: , The patient was explained about all the risks, benefits, and alternatives of this procedure. The patient ... | 38 Surgery |
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 poste... | 33 Radiology |
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 ... | 38 Surgery |
REASON FOR VISIT: ,Elevated PSA with nocturia and occasional daytime frequency.,HISTORY: , A 68-year-old male with a history of frequency and some outlet obstructive issues along with irritative issues. The patient has had history of an elevated PSA and PSA in 2004 was 5.5. In 2003, he had undergone a biopsy by Dr. ... | 35 SOAP / Chart / Progress Notes |
XYZ, O.D.,RE: ABC,DOB: MM/DD/YYYY,Dear Dr. XYZ:,Thank you for your kind referral for patient ABC. Mr. ABC is being referred for evaluation of glaucoma. The patient states he has no visual complaints.,On examination, the patient's visual acuity is 20/20 bilaterally. The patient's visual fields are full to confronta... | 20 Letters |
PREOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at 30 and 4/7th weeks.,2. Previous cesarean section x2.,3. Multiparity.,4. Request for permanent sterilization.,POSTOPERATIVE DIAGNOSIS:,1. Intrauterine pregnancy at 30 and 4/7th weeks.,2. Previous cesarean section x2.,3. Multiparity.,4. Request for permanent st... | 38 Surgery |
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 effu... | 33 Radiology |
CLINICAL HISTORY: , Patient is a 37-year-old female with a history of colectomy for adenoma. During her preop evaluation it was noted that she had a lesion on her chest x-ray. CT scan of the chest confirmed a left lower mass.,SPECIMEN: , Lung, left lower lobe resection.,IMMUNOHISTOCHEMICAL STUDIES:, Tumor cells show... | 19 Lab Medicine - Pathology |
INDICATION: , Iron deficiency anemia.,PROCEDURE: ,Colonoscopy with terminal ileum examination.,POSTOPERATIVE DIAGNOSIS:, Normal examination.,WITHDRAWAL TIME: , 15 minutes.,SCOPE: , CF-H180AL.,MEDICATIONS: , Fentanyl 100 mcg and versed 10 mg.,PROCEDURE DETAIL: ,Following the preprocedure patient assessment the proced... | 38 Surgery |
PREOPERATIVE DIAGNOSIS: , Vitreous hemorrhage and retinal detachment, right eye.,POSTOPERATIVE DIAGNOSIS:, Vitreous hemorrhage and retinal detachment, right eye.,NAME OF PROCEDURE: , Combined closed vitrectomy with membrane peeling, fluid-air exchange, and endolaser, right eye.,ANESTHESIA: , Local with standby.,PROCED... | 38 Surgery |
REASON FOR CONSULT:, Depression.,HPI:, The patient is an 87-year-old white female admitted for low back pain status post hip fracture sustained a few days before Thanksgiving in 2006. The patient was diagnosed and treated for a T9 compression fraction with vertebroplasty. Soon after discharge, the patient was readm... | 5 Consult - History and Phy. |
PREOPERATIVE DIAGNOSIS: , Bunion, left foot.,POSTOPERATIVE DIAGNOSIS: ,Bunion, left foot.,PROCEDURE PERFORMED:,1. Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation.,2. Akin osteotomy with internal wire fixation of left foot.,HISTORY: , This 19-year-old Caucasian female presents... | 31 Podiatry |
PREOPERATIVE DIAGNOSES:,1. Partial rotator cuff tear with impingement syndrome.,2. Degenerative osteoarthritis of acromioclavicular joint, left shoulder, rule out slap lesion.,POSTOPERATIVE DIAGNOSES:,1. Partial rotator cuff tear with impingement syndrome.,2. Degenerative osteoarthritis of acromioclavicular joint, ... | 38 Surgery |
SUBJECTIVE:, | 15 General Medicine |
S -, A 44-year-old, 250-pound male presents with extreme pain in his left heel. This is his chief complaint. He says that he has had this pain for about two weeks. He works on concrete floors. He says that in the mornings when he gets up or after sitting, he has extreme pain and great difficulty in walking. He als... | 38 Surgery |
IDENTIFICATION OF PATIENT: , The patient is a 34-year-old Caucasian female.,CHIEF COMPLAINT:, Depression.,HISTORY OF PRESENT ILLNESS:, The patient's depression began in her teenage years. Sleep has been poor, for multiple reasons. She has obstructive sleep apnea, and has difficulties with a child who has insomnia r... | 32 Psychiatry / Psychology |
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 ... | 3 Cardiovascular / Pulmonary |
CHIEF COMPLAINT: , "Bloody bump on penis.",HISTORY OF PRESENT ILLNESS: , This is a 29-year-old African-American male who presents to the Emergency Department today with complaint of a bleeding bump on his penis. The patient states that he has had a large bump on the end of his penis for approximately a year and a half... | 39 Urology |
PROCEDURE IN DETAIL:, After appropriate operative consent was obtained, the patient was brought supine to the operating room and placed on the operating room table. After intravenous sedation was administered a retrobulbar block consisting of 2% Xylocaine with 0.75% Marcaine and Wydase was administered to the right e... | 26 Ophthalmology |
PREOPERATIVE DIAGNOSES,1. Neck pain with bilateral upper extremity radiculopathy.,2. Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 with probable instability.,POSTOPERATIVE DIAGNOSES,1. Neck pain with bilateral upper extremity radiculopathy.,2. Residual stenosis, C3-C4, C4-C5, C5-C6, and C6-C7 secondary to facet... | 38 Surgery |
DIAGNOSIS:, Synovitis/anterior cruciate ligament tear of the left knee.,HISTORY: , The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The patient states that on 10/02/08, the patient fell in a grocery store. He reports slipping on a grape that was on the floor. The... | 30 Physical Medicine - Rehab |
PREOPERATIVE DIAGNOSIS: ,Carcinoma of the left upper lobe.,PROCEDURES PERFORMED:,1. Bronchoscopy with aspiration.,2. Left upper lobectomy.,PROCEDURE DETAILS: ,With patient in supine position under general anesthesia with endotracheal tube in place, the flexible bronchoscope was then placed down through the endotrac... | 38 Surgery |
She has an extensive past medical history of rheumatoid arthritis, fibromyalgia, hypertension, hypercholesterolemia, and irritable bowel syndrome. She has also had bilateral carpal tunnel release.,On examination, normal range of movement of C-spine. She has full strength in upper and lower extremities. Normal straig... | 30 Physical Medicine - Rehab |
SUBJECTIVE:, The patient's assistant brings in her food diary sheets. The patient says she stays active by walking at the mall.,OBJECTIVE:, Weight today is 201 pounds, which is down 3 pounds in the past month. She has lost a total of 24 pounds. I praised this and encouraged her to continue. I went over her food d... | 35 SOAP / Chart / Progress Notes |
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 ... | 14 Gastroenterology |
PREOPERATIVE DIAGNOSIS: ,Bilateral carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Bilateral carpal tunnel syndrome.,PROCEDURES:,1. Right open carpal tunnel release.,2. Cortisone injection, left carpal tunnel.,ANESTHESIA: , General LMA.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS:, None.,INDICATIONS:, This p... | 38 Surgery |
PREOPERATIVE DIAGNOSIS: , Left hip degenerative arthritis.,POSTOPERATIVE DIAGNOSIS: , Left hip degenerative arthritis.,PROCEDURE PERFORMED: ,Total hip arthroplasty on the left.,ANESTHESIA: ,General.,BLOOD LOSS: , 800 cc.,The patient was positioned with the left hip exposed on the beanbag.,IMPLANT SPECIFICATION: , A 5... | 38 Surgery |
PREOPERATIVE DIAGNOSIS:, Bilateral inguinal hernia. ,POSTOPERATIVE DIAGNOSIS: , Bilateral inguinal hernia. ,PROCEDURE: , Bilateral direct inguinal hernia repair utilizing PHS system and placement of On-Q pain pump. ,ANESTHESIA: , General with endotracheal intubation. ,PROCEDURE IN DETAIL: , The patient was taken to th... | 38 Surgery |
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 cou... | 5 Consult - History and Phy. |
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 ni... | 15 General Medicine |
REASON FOR THE CONSULT:, Nonhealing right ankle stasis ulcer.,HISTORY OF PRESENT ILLNESS: , This is a 52-year-old native American-Indian man with hypertension, chronic intermittent bipedal edema, and recurrent leg venous ulcers, who was admitted on 01/27/09 for scheduled vascular surgery per Dr. X. I was consulted for... | 15 General Medicine |
ADMITTING DIAGNOSIS: , Encephalopathy related to normal-pressure hydrocephalus.,CHIEF COMPLAINT:, Diminished function secondary to above.,HISTORY: ,This pleasant gentleman was recently admitted to ABCD Medical Center and followed by the neurosurgical staff, including Dr. X, where normal-pressure hydrocephalus was dia... | 22 Neurology |
PREOPERATIVE DIAGNOSIS:, Prostate cancer.,POSTOPERATIVE DIAGNOSIS:, Prostate cancer.,OPERATIONS: , Brachytherapy, iodine-125 seed implantation, and cystoscopy.,ANESTHESIA:, LMA.,ESTIMATED BLOOD LOSS: , Minimal.,Total number of seeds placed, 63. Needles, 24.,BRIEF HISTORY OF THE PATIENT: , This is a 57-year-old male... | 38 Surgery |
MANNER OF DEATH: , Homicide.,CAUSE OF DEATH:, | 1 Autopsy |
PREOPERATIVE DIAGNOSES:,1. Senile nuclear cataract, left eye.,2. Senile cortical cataract, left eye., ,POSTOPERATIVE DIAGNOSES:,1. Senile nuclear cataract, left eye.,2. Senile cortical cataract, left eye., ,PROCEDURES: , Phacoemulsification of cataract, extraocular lens implant in left eye., ,LENS IMPLANT USED:, A... | 38 Surgery |
EXAM:,MRI RIGHT ANKLE,CLINICAL:,This is a 51 year old female who first came into the office 3/4/05 with right ankle pain. She stepped on ice the evening prior and twisted her ankle. PF's showed no frank fracture, dislocation, or subluxations.,FINDINGS:,Received for interpretation is an MRI examination performed on 4/28... | 27 Orthopedic |
HISTORY OF PRESENT ILLNESS:, Briefly, this is a 17-year-old male, who has had problems with dysphagia to solids and recently had food impacted in the lower esophagus. He is now having upper endoscopy to evaluate the esophagus after edema and inflammation from the food impaction has resolved, to look for any stricture... | 14 Gastroenterology |
PREOPERATIVE DIAGNOSIS: ,Right trigger thumb.,POSTOPERATIVE DIAGNOSIS:, Right trigger thumb.,OPERATIONS PERFORMED:, Trigger thumb release.,ANESTHESIA:, Monitored anesthesia care with regional anesthesia applied by surgeon with local.,COMPLICATIONS:, | 27 Orthopedic |
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: , ... | 27 Orthopedic |
SUBJECTIVE:, This is a 62-year-old female who comes for dietary consultation for carbohydrate counting for type I diabetes. The patient reports that she was hospitalized over the weekend for DKA. She indicates that her blood sugar on Friday night was 187 at bedtime and that when she woke up in the morning her blood ... | 5 Consult - History and Phy. |
INDICATION: , Bradycardia and dizziness.,COMMENTS:,1. The patient was monitored for 24 hours.,2. The predominant rhythm was normal sinus rhythm with a minimum heart rate of 56 beats per minute and the maximum heart rate of 114 beats per minute and a mean heart rate of 86 beats per minute.,3. There were occasional pr... | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSIS:, Right mesothelioma.,POSTOPERATIVE DIAGNOSIS: , Right lung mass invading diaphragm and liver.,FINDINGS: , Right lower lobe lung mass invading diaphragm and liver.,PROCEDURES:,1. Right thoracotomy.,2. Right lower lobectomy with en bloc resection of diaphragm and portion of liver.,SPECIMENS: , ... | 16 Hematology - Oncology |
NAME OF PROCEDURE,1. Left heart catheterization with left ventriculography and selective coronary angiography.,2. Percutaneous transluminal coronary angioplasty and stent placement of the right coronary artery.,HISTORY: , This is a 58-year-old male who presented with atypical chest discomfort. The patient had elevat... | 38 Surgery |
HISTORY:, I had the pleasure of meeting and evaluating the patient referred today for evaluation and treatment of chronic sinusitis. As you are well aware, she is a pleasant 50-year-old female who states she started having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pa... | 0 Allergy / Immunology |
PREOPERATIVE DIAGNOSES:, ,1. Spondylosis with cervical stenosis C5-C6 greater than C4-C5, C6-C7, (721.0, 723.0).,2. Neck pain with left radiculopathy, progressive (723.1/723.4).,3. Headaches, progressive (784.0).,POSTOPERATIVE DIAGNOSES:, ,1. Spondylosis with cervical stenosis C5-C6 greater than C4-C5, C6-C7, (72... | 27 Orthopedic |
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 is... | 15 General Medicine |
Patient had a normal MRI and normal neurological examination on August 24, 2010.,Assessment for peripheral vestibular function follows:,Most clinical tests were completed with difficulty and poor cooperation.,OTOSCOPY:, showed bilateral intact tympanic membranes with central Weber test and bilateral positive Rinne.,RO... | 5 Consult - History and Phy. |
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 s... | 15 General Medicine |
COMPREHENSIVE MENTAL STATUS EVALUATION,REASON FOR REFERRAL/GENERAL OBSERVATIONS:, The patient was referred for a Comprehensive Mental Status Evaluation for the purpose of assisting in the determination of eligibility for Disability. He is a 43-year-old married, white male who came unaccompanied to the evaluation. He... | 32 Psychiatry / Psychology |
Thereafter, he was evaluated and it was felt that further reconstruction as related to the anterior cruciate ligament was definitely not indicated. On December 5, 2008, Mr. XXXX did undergo a total knee replacement arthroplasty performed by Dr. X.,Thereafter, he did an extensive course of physical therapy, work harden... | 5 Consult - History and Phy. |
PROCEDURE: , Urgent cardiac catheterization with coronary angiogram.,PROCEDURE IN DETAIL: , The patient was brought urgently to the cardiac cath lab from the emergency room with the patient being intubated with an abnormal EKG and a cardiac arrest. The right groin was prepped and draped in usual manner. Under 2% lido... | 3 Cardiovascular / Pulmonary |
TITLE OF OPERATION:,1. Repair of total anomalous pulmonary venous connection.,2. Ligation of patent ductus arteriosus.,3. Repair secundum type atrial septal defect (autologous pericardial patch).,4. Subtotal thymectomy.,5. Insertion of peritoneal dialysis catheter.,INDICATION FOR SURGERY: , This neonatal was diagn... | 29 Pediatrics - Neonatal |
PROCEDURE: , Cardiac catheterization by:,a. Left heart catheterization.,b. Left ventriculography.,c. Selective coronary angiography.,d. Right femoral artery approach.,COMPLICATIONS:, None.,MEDICATIONS,1. IV Versed.,2. IV fentanyl.,3. Intravenous fluid administration.,4. Heparin 3000 units IV.,INDICATIONS: , Th... | 3 Cardiovascular / Pulmonary |
HISTORY:, The patient is 14 months old, comes in with a chief complaint of difficulty breathing. Difficulty breathing began last night. He was taken to Emergency Department where he got some Xopenex, given a prescription for amoxicillin and discharged home. They were home for about an hour when he began to get wors... | 29 Pediatrics - Neonatal |
OPERATION PERFORMED:, Full mouth dental rehabilitation in the operative room under general anesthesia.,PREOPERATIVE DIAGNOSIS: , Severe dental caries.,POSTOPERATIVE DIAGNOSES:,1. Severe dental caries.,2. Non-restorable teeth.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , Minimal.,DURATION OF SURGERY: , 43 minutes.,... | 7 Dentistry |
PREOPERATIVE DIAGNOSIS: , Right temporal lobe intracerebral hemorrhage.,POSTOPERATIVE DIAGNOSES:,1. Right temporal lobe intracerebral hemorrhage.,2. Possible tumor versus inflammatory/infectious lesion versus vascular lesion, pending final pathology and microbiology.,PROCEDURES:,1. Emergency right side craniotomy fo... | 22 Neurology |
CC:, Progressive lower extremity weakness.,HX: ,This 52y/o RHF had a h/o right frontal glioblastoma multiforme (GBM) diagnosed by brain biopsy/partial resection, on 1/15/1991. She had been healthy until 1/6/91, when she experienced a generalized tonic-clonic type seizure during the night. She subsequently underwent an ... | 22 Neurology |
REASON FOR CONSULTATION:, Pericardial effusion.,HISTORY OF PRESENT ILLNESS: , The patient is an 84-year-old female presented to emergency room with shortness of breath, fatigue, and tiredness. Low-grade fever was noted last few weeks. The patient also has chest pain described as dull aching type in precordial region... | 5 Consult - History and Phy. |
PREOPERATIVE DIAGNOSIS: , Endometrial cancer.,POSTOPERATIVE DIAGNOSIS: , Same.,OPERATION PERFORMED:, Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, right and left pelvic lymphadenectomy, common iliac lymphadenectomy, and endometrial cancer staging procedure.,ANESTHESIA:, Genera... | 38 Surgery |
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 resolve... | 22 Neurology |
PREOPERATIVE DIAGNOSIS:, Headaches, question of temporal arteritis.,POSTOPERATIVE DIAGNOSIS:, Headaches, question of temporal arteritis.,PROCEDURE:, Bilateral temporal artery biopsies.,DESCRIPTION OF PROCEDURE: , After obtaining an informed consent, the patient was brought to the operating room where her right tempo... | 23 Neurosurgery |
Sample Address,RE: Sample Patient,Dear Doctor:,We had the pleasure of seeing Abc and his mother in the clinic today. As you certainly know, he is now a 9-month-old male product of a twin gestation complicated by some very mild prematurity. He has been having problems with wheezing, cough and shortness of breath over... | 20 Letters |
PROCEDURE: , Right knee joint steroid injection.,PREOPERATIVE DIAGNOSIS:, Osteoarthritis of the right knee.,POSTOPERATIVE DIAGNOSIS:, Osteoarthritis of the right knee.,PROCEDURE: ,The patient was apprised of the risks and the benefits of the procedure and consented. The patient's right knee was sterilely prepped wi... | 28 Pain Management |
PREOPERATIVE DIAGNOSIS: , Right lower pole renal stone and possibly infected stent.,POSTOPERATIVE DIAGNOSIS: , Right lower pole renal stone and possibly infected stent.,OPERATION:, Cysto stent removal.,ANESTHESIA:, Local MAC.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid.,MEDICATIONS: , The patient was on va... | 21 Nephrology |
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