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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 |
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 |
PREOPERATIVE DIAGNOSES 1. Hallux abductovalgus right foot. 2. Hammertoe bilateral third fourth and fifth toes. POSTOPERATIVE DIAGNOSES 1. Hallux abductovalgus right foot. 2. Hammertoe bilateral third fourth and fifth toes. PROCEDURE PERFORMED 1. Bunionectomy with distal first metatarsal osteotomy and in... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Acute appendicitis. POSTOPERATIVE DIAGNOSIS Acute suppurative appendicitis. PROCEDURE PERFORMED Laparoscopic appendectomy. ANESTHESIA General endotracheal and Marcaine 0.25 local. INDICATIONS This 29-year-old female presents to ABCD General Hospital Emergency Department on 08/30/2... | 14 Gastroenterology |
DONOR S PERCEPTION OF RECIPIENT S ILLNESS What is your understanding of the recipient s illness and why they need a kidney - This kidney is for my mother who is on dialysis and my mother has been suffering long enough and I want to relieve the suffering so that she is able to have a kidney transplant. When and how ... | 21 Nephrology |
TITLE OF OPERATION Placement of right new ventriculoperitoneal VP shunts Strata valve and to removal of right frontal Ommaya reservoir. INDICATION FOR SURGERY The patient is a 2-month-old infant born premature with intraventricular hemorrhage and Ommaya reservoir recommendation for removal and replacement with... | 23 Neurosurgery |
CHIEF COMPLAINT Right ear pain with drainage. HISTORY OF PRESENT ILLNESS This is a 12-year-old white male here with his mother for complaints of his right ear hurting. Mother states he has been complaining for several days. A couple of days ago she noticed drainage from the right ear. The patient states it has... | 5 Consult - History and Phy. |
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... | 3 Cardiovascular / Pulmonary |
MULTISYSTEM EXAM CONSTITUTIONAL The vital signs showed that the patient was afebrile blood pressure and heart rate were within normal limits. The patient appeared alert. EYES The conjunctiva was clear. The pupil was equal and reactive. There was no ptosis. The irides appeared normal. EARS NOSE AND THROAT ... | 5 Consult - History and Phy. |
PREOPERATIVE DIAGNOSES Cervical disk protrusions at C5-C6 and C6-C7 cervical radiculopathy and cervical pain. POSTOPERATIVE DIAGNOSES Cervical disk protrusions at C5-C6 and C6-C7 cervical radiculopathy and cervical pain. PROCEDURES C5-C6 and C6-C7 anterior cervical discectomy two levels C5-C6 and C6-C7 a... | 23 Neurosurgery |
CHIEF COMPLAINT Vomiting and nausea. HPI The patient is a 52-year-old female who said she has had 1 week of nausea and vomiting which is moderate-to-severe. She states she has it at least once a day. It can be any time but can also be postprandial. She states she will vomit up some dark brown-to-green fluid.... | 5 Consult - History and Phy. |
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 f... | 38 Surgery |
GENERAL Negative weakness negative fatigue native malaise negative chills negative fever negative night sweats negative allergies. INTEGUMENTARY Negative rash negative jaundice. HEMATOPOIETIC Negative bleeding negative lymph node enlargement negative bruisability. NEUROLOGIC Negative headaches neg... | 5 Consult - History and Phy. |
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 u... | 14 Gastroenterology |
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 e... | 38 Surgery |
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 we... | 33 Radiology |
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 h... | 22 Neurology |
HISTORY OF PRESENT ILLNESS This 66-year-old white male was seen in my office on Month DD YYYY. Patient was recently discharged from Doctors Hospital at Parkway after he was treated for pneumonia. Patient continues to have severe orthopnea paroxysmal nocturnal dyspnea cough with greenish expectoration. His exer... | 3 Cardiovascular / Pulmonary |
PROCEDURE Bilateral L5 dorsal ramus block and bilateral S1 S2 and S3 lateral branch block. INDICATION Sacroiliac joint pain. INFORMED CONSENT The risks benefits and alternatives of the procedure were discussed with the patient. The patient was given opportunity to ask questions regarding the procedure its... | 28 Pain Management |
REASON FOR CONSULTATION Mesothelioma. HISTORY OF PRESENT ILLNESS The patient is a 73-year-old pleasant Caucasian male who is known to me from his previous hospitalization. He has also been seen by me in the clinic in the last few weeks. He was admitted on January 18 2008 with recurrent malignant pleural effus... | 5 Consult - History and Phy. |
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 T... | 12 Emergency Room Reports |
PREOPERATIVE DIAGNOSIS Herniated nucleus pulposus C5-C6. POSTOPERATIVE DIAGNOSIS Herniated nucleus pulposus C5-C6. PROCEDURE Anterior cervical discectomy fusion C5-C6 followed by instrumentation C5-C6 with titanium dynamic plating system Aesculap. Operating microscope was used for both illumination and magni... | 27 Orthopedic |
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... | 5 Consult - History and Phy. |
PREOPERATIVE DIAGNOSES 1. Hallux abductovalgus deformity right foot. 2. Tailor bunion deformity right foot. POSTOPERATIVE DIAGNOSES 1. Hallux abductovalgus deformity right foot. 2. Tailor bunion deformity right foot. PROCEDURES PERFORMED Tailor bunionectomy right foot Weil-type with screw fixation. ANEST... | 33 Radiology |
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... | 5 Consult - History and Phy. |
PREOPERATIVE DIAGNOSIS Desires permanent sterilization. POSTOPERATIVE DIAGNOSIS Desires permanent sterilization. PROCEDURE PERFORMED Laparoscopic bilateral tubal occlusion with Hulka clips. ANESTHESIA General. ESTIMATED BLOOD LOSS Less than 20 cc. COMPLICATIONS None. FINDINGS On bimanual exam the ... | 24 Obstetrics / Gynecology |
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. OPERAT... | 23 Neurosurgery |
PREOPERATIVE DIAGNOSES Open displaced infected left atrophic mandibular fracture failed dental implant. POSTOPERATIVE DIAGNOSES Open displaced infected left atrophic mandibular fracture failed dental implant. PROCEDURE PERFORMED Open reduction and internal fixation ORIF of left atrophic mandibular frac... | 7 Dentistry |
CC Gait difficulty. HX This 59 y/o RHF was admitted with complaint of gait difficulty. The evening prior to admission she noted sudden onset of LUE and LLE weakness. She felt she favored her right leg but did not fall when walking. She denied any associated dysarthria facial weakness chest pain SOB visual chan... | 5 Consult - History and Phy. |
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... | 37 Speech - Language |
PREOPERATIVE DIAGNOSIS Open left angle comminuted angle of mandible 802.35 and open symphysis of mandible 802.36. POSTOPERATIVE DIAGNOSIS Open left angle comminuted angle of mandible 802.35 and open symphysis of mandible 802.36. PROCEDURE Open reduction internal fixation ORIF of bilateral mandible fra... | 38 Surgery |
XYZ Street City State Dear Dr. CD Thank you for seeing Mr. XYZ a pleasant 19-year-old male who has seen you in 2005 for suspected seizure activity. He comes to my office today continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years. He is requesting to come off the Dilantin a... | 20 Letters |
SUBJECTIVE This is a 38-year-old female who comes for dietary consultation for gestational diabetes. Patient reports that she is scared to eat because of its impact on her blood sugars. She is actually trying not to eat while she is working third shift at Wal-Mart. Historically however she likes to eat out with ... | 5 Consult - History and Phy. |
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 ... | 9 Diets and Nutritions |
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 ... | 27 Orthopedic |
PREOPERATIVE DIAGNOSIS Degenerative arthritis of the left knee. POSTOPERATIVE DIAGNOSIS Degenerative arthritis of the left knee. PROCEDURE PERFORMED Total left knee replacement on 08/19/03. The patient also underwent a bilateral right total knee replacement in the same sitting and that will be dictated by Dr. X... | 38 Surgery |
PREOPERATIVE DIAGNOSES 1. Pelvic pain. 2. Hypermenorrhea. POSTOPERATIVE DIAGNOSES 1. Pelvic pain. 2. Hypermenorrhea. 3. Mild pelvic endometriosis. PROCEDURE PERFORMED 1. Dilatation and curettage D C . 2. Laparoscopic ablation of endometrial implants. ANESTHESIA General endotracheal. COMPLICATIONS None.... | 38 Surgery |
PREOPERATIVE DIAGNOSES 1. Non-small-cell carcinoma of the left upper lobe. 2. History of lymphoma in remission. POSTOPERATIVE DIAGNOSES 1. Non-small-cell carcinoma of the left upper lobe. 2. History of lymphoma in remission. PROCEDURE Left muscle sparing mini thoracotomy with left upper lobectomy and mediastin... | 3 Cardiovascular / Pulmonary |
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