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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 stat... | 15 General Medicine |
PREOPERATIVE DIAGNOSES 1. Pathologic insufficiency. 2. Fracture of the T8 vertebrae and T9 vertebrae. POSTOPERATIVE DIAGNOSES 1. Pathologic insufficiency. 2. Fracture of the T8 vertebra and T9 vertebra. PROCEDURE PERFORMED 1. Fracture reduction with insertion of prosthetic device at T8 with kyphoplasty. 2. Ver... | 27 Orthopedic |
REASON FOR VISIT Kyphosis. HISTORY OF PRESENT ILLNESS The patient is a 13-year-old new patient is here for evaluation of thoracic kyphosis. The patient has a family history in a maternal aunt and grandfather of kyphosis. She was noted by her parents to have round back posture. They have previously seen another... | 5 Consult - History and Phy. |
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... | 15 General Medicine |
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... | 33 Radiology |
PREOPERATIVE DIAGNOSIS Medial meniscal tear left knee. POSTOPERATIVE DIAGNOSIS Chondromalacia of medial femoral condyle. PROCEDURE PERFORMED 1. Arthroscopy of the left knee. 2. Left arthroscopic medial meniscoplasty of medial femoral condyle. 3. Chondroplasty of the left knee as well. ESTIMATED BLOOD LOSS ... | 38 Surgery |
PREOPERATIVE DIAGNOSES Bilateral inguinal hernia bilateral hydroceles. POSTOPERATIVE DIAGNOSES Bilateral inguinal hernia bilateral hydroceles. PROCEDURES Bilateral inguinal hernia and bilateral hydrocele repair with an ilioinguinal nerve block bilaterally by surgeon 20 mL given. ANESTHESIA General inhalat... | 38 Surgery |
PREOPERATIVE DIAGNOSES 1. Dysphagia. 2. Right parapharyngeal hemorrhagic lesion. POSTOPERATIVE DIAGNOSES 1. Dysphagia with no signs of piriform sinus pooling or aspiration. 2. No parapharyngeal hemorrhagic lesion noted. 3. Right parapharyngeal lesion likely thyroid cartilage nonhemorrhagic. PROCEDURE PERFORMED... | 11 ENT - Otolaryngology |
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 pa... | 14 Gastroenterology |
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 ... | 35 SOAP / Chart / Progress Notes |
PREOPERATIVE DIAGNOSIS 1. Right carpal tunnel syndrome. 2. | 38 Surgery |
HISTORY The patient is to come to the hospital for bilateral L5 kyphoplasty. The patient is an 86-year-old female with an L5 compression fracture. The patient has a history of back and buttock pain for some time. She was found to have an L5 compression fracture. She was treated conservatively over several months ... | 5 Consult - History and Phy. |
EXAM Transesophageal echocardiogram and direct current cardioversion. REASON FOR EXAM 1. Atrial fibrillation with rapid ventricular rate. 2. Shortness of breath. PROCEDURE After informed consent was obtained the patient was then sedated using a total of 4 mg of Versed and 50 mcg of fentanyl. Following this... | 33 Radiology |
PREOPERATIVE DIAGNOSES 1. Cervical radiculopathy C5-C6 and C6-C7. 2. Symptomatic cervical spondylosis C5-C6 and C6-C7. 3. Symptomatic cervical stenosis C5-C6 and C6-C7. 4. Symptomatic cervical disc herniations C5-C6 and C6-C7. POSTOPERATIVE DIAGNOSES 1. Cervical radiculopathy C5-C6 and C6-C7. 2. Symptomatic ... | 27 Orthopedic |
SUBJECTIVE This 45-year-old gravida 3 para 2 SAB 1 white female presents for exam and Pap. Last Pap was a year ago and normal. LMP was 08/29/2004. Her cycles are usually regular although that one came about a week early. Her husband has had a vasectomy. Overall she is feeling well. Health history form was r... | 24 Obstetrics / Gynecology |
CHIEF COMPLAINT Follicular non-Hodgkin s lymphoma. HISTORY OF PRESENT ILLNESS This is an extremely pleasant 69 year-old gentleman who I follow for his follicular lymphoma. His history is that in February of 1988 he had a biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin... | 16 Hematology - Oncology |
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 ... | 33 Radiology |
REASON FOR VISIT Mr. A is an 86-year-old man who returns for his first followup after shunt surgery. HISTORY OF PRESENT ILLNESS I have followed Mr. A since May 2008. He presented with eight to ten years of progressive gait impairment cognitive impairment and decreased bladder control. We established a diagnos... | 22 Neurology |
PRESENT COMPLAINTS The patient is reporting ongoing chronic right-sided back pain pain that radiates down her right leg intermittently. She is having difficulty with bending and stooping maneuvers. She cannot lift heavy objects. She states she continues to have pain in her right neck and pain in her right upper... | 18 IME-QME-Work Comp etc. |
REASON FOR VISIT Kyphosis. HISTORY OF PRESENT ILLNESS The patient is a 13-year-old new patient is here for evaluation of thoracic kyphosis. The patient has a family history in a maternal aunt and grandfather of kyphosis. She was noted by her parents to have round back posture. They have previously seen another... | 27 Orthopedic |
PREOPERATIVE DIAGNOSES 1. Radiation cystitis. 2. Refractory voiding dysfunction. 3. Status post radical retropubic prostatectomy and subsequent salvage radiation therapy. POSTOPERATIVE DIAGNOSES 1. Radiation cystitis. 2. Refractory voiding dysfunction. 3. Status post radical retropubic prostatectomy and subsequ... | 39 Urology |
HISTORY OF PRESENT ILLNESS The patient is an 18-year-old girl brought in by her father today for evaluation of a right knee injury. She states that approximately 3 days ago while playing tennis she had a non-contact injury in which she injured the right knee. She had immediate pain and swelling. At this time she... | 5 Consult - History and Phy. |
Pitocin was started quickly to allow for delivery as quickly as possible and the patient rapidly became complete and then as she began to push there were additional decelerations of the baby s heart rate which were suspicions of cord around the neck. These were variable decelerations occurring late in the contracti... | 24 Obstetrics / Gynecology |
PREOPERATIVE DIAGNOSES 1. Recurrent bladder tumor. 2. History of bladder carcinoma. POSTOPERATIVE DIAGNOSIS | 21 Nephrology |
PREOPERATIVE DIAGNOSES 1. Chronic eustachian tube dysfunction. 2. Retained right pressure equalization tube. 3. Retracted left tympanic membrane. 4. Dizziness. POSTOPERATIVE DIAGNOSES 1. Chronic eustachian tube dysfunction. 2. Retained right pressure equalization tube. 3. Retracted left tympanic membrane. 4. ... | 38 Surgery |
LEXISCAN MYOVIEW STRESS STUDY REASON FOR THE EXAM Chest discomfort. INTERPRETATION The patient exercised according to the Lexiscan study received a total of 0.4 mg of Lexiscan IV injection. At peak hyperemic effect 24.9 mCi of Myoview were injected for the stress imaging and earlier 8.2 mCi were injected for t... | 33 Radiology |
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 ha... | 25 Office Notes |
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 inc... | 22 Neurology |
TITLE OF OPERATION Mediastinal exploration and delayed primary chest closure. INDICATION FOR SURGERY The patient is a 12-day-old infant who has undergone a modified stage I Norwood procedure with a Sano modification. The patient experienced an unexplained cardiac arrest at the completion of the procedure which ... | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSIS Rotator cuff tear right shoulder. POSTOPERATIVE DIAGNOSIS Superior labrum anterior and posterior lesion peel-back right shoulder. PROCEDURE PERFORMED 1. Arthroscopy with arthroscopic SLAP lesion. 2. Repair of soft tissue subacromial decompression rotator cuff repair right shoulder. ... | 38 Surgery |
PREOPERATIVE DIAGNOSES 1. Intrauterine pregnancy at 35-1/7. 2. Rh isoimmunization. 3. Suspected fetal anemia. 4. Desires permanent sterilization. POSTOPERATIVE DIAGNOSES 1. Intrauterine pregnancy at 35-1/7. 2. Rh isoimmunization. 3. Suspected fetal anemia. 4. Desires permanent sterilization. OPERATION PERFORMED... | 24 Obstetrics / Gynecology |
PREPROCEDURE DIAGNOSIS History of colon polyps and partial colon resection right colon. POSTPROCEDURE DIAGNOSES 1. Normal operative site. 2. Mild diverticulosis of the sigmoid colon. 3. Hemorrhoids. PROCEDURE Total colonoscopy. PROCEDURE IN DETAIL The patient is a 60-year-old of Dr. ABC s being evaluat... | 38 Surgery |
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 d... | 15 General Medicine |
CC Headache. HX The patient is an 8y/o RHM with a 2 year history of early morning headaches 3 00-6 00AM intermittently relieved by vomiting only. He had been evaluated 2 years ago and an EEG was normal then but no brain imaging was performed. His headaches progressively worsened especially in the past two mon... | 22 Neurology |
PAST MEDICAL/SURGICAL HISTORY Briefly his past medical history is significant for hypertension of more than 5 years asthma and he has been on Advair and albuterol. He was diagnosed with renal disease in 02/2008 and has since been on hemodialysis since 02/2008. His past surgical history is only significant for l... | 5 Consult - History and Phy. |
PREOPERATIVE DIAGNOSIS Recurrent right inguinal hernia as well as phimosis. POSTOPERATIVE DIAGNOSIS Recurrent right inguinal hernia as well as phimosis. PROCEDURE PERFORMED Laparoscopic right inguinal herniorrhaphy with mesh as well as a circumcision. ANESTHESIA General endotracheal. COMPLICATIONS Non... | 38 Surgery |
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 mineralizatio... | 22 Neurology |
PREOPERATIVE DIAGNOSIS Cataract right eye. POSTOPERATIVE DIAGNOSIS Cataract right eye. TITLE OF OPERATION Phacoemulsification with intraocular lens insertion right eye. ANESTHESIA Topical. COMPLICATIONS None. PROCEDURE IN DETAIL The patient was brought to the operating room where tetracaine drops w... | 26 Ophthalmology |
PROCEDURE NOTE Pacemaker ICD interrogation. HISTORY OF PRESENT ILLNESS The patient is a 67-year-old gentleman who was admitted to the hospital. He has had ICD pacemaker implantation. This is a St. Jude Medical model current DRRS 12345 pacemaker. DIAGNOSIS Severe nonischemic cardiomyopathy with prior ventric... | 3 Cardiovascular / Pulmonary |
DELIVERY NOTE This G1 P0 with EDC 12/23/08 presented with SROM about 7.30 this morning. Her prenatal care complicated by GBS screen positive and a transfer of care at 34 weeks from Idaho. Exam upon arrival 2 to 3 cm 100 effaced -1 station and by report pool of fluid was positive for Nitrazine and positive fern... | 24 Obstetrics / Gynecology |
CHIEF COMPLAINT Here with a concern of possibly issues of short-term memory loss. She is under exceeding amount of stress over the last 5 to 10 years. She has been a widow over the last 11 years. Her husband died in an MVA from a drunk driver accident. She had previously worked at the bank in Conway Springs in N... | 15 General Medicine |
PREOPERATIVE DIAGNOSES 1. Intrauterine pregnancy of 39 weeks. 2. Herpes simplex virus positive by history. 3. Hepatitis C positive by history with low elevation of transaminases. 4. Cephalopelvic disproportion. 5. Asynclitism. 6. Postpartum macrosomia. POSTOPERATIVE DIAGNOSES 1. Intrauterine pregnancy of 39 ... | 24 Obstetrics / Gynecology |
VITRECTOMY OPENING The patient was brought to the operating room and appropriately identified. General anesthesia was induced by the anesthesiologist. The patient was prepped and draped in the usual sterile fashion. A lid speculum was used to provide exposure to the right eye. A limited conjunctival peritomy was cr... | 26 Ophthalmology |
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 w... | 3 Cardiovascular / Pulmonary |
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 evidenc... | 10 Discharge Summary |
HISTORY The patient is a 4-month-old who presented today with supraventricular tachycardia and persistent cyanosis. The patient is a product of a term pregnancy that was uncomplicated and no perinatal issues are raised. Parents however did note the patient to be quite dusky since the time of her birth however ... | 5 Consult - History and Phy. |
HISTORY The patient is a 10-1/2-year-old born with asplenia syndrome with a complex cyanotic congenital heart disease characterized by dextrocardia bilateral superior vena cava complete atrioventricular septal defect a total anomalous pulmonary venous return to the right-sided atrium and double-outlet to the righ... | 38 Surgery |
HISTORY OF PRESENT ILLNESS The patient is a 35-year-old lady who was admitted with chief complaints of chest pain left-sided with severe chest tightness after having an emotional argument with her boyfriend. The patient has a long history of psychological disorders. As per the patient she also has a history of s... | 5 Consult - History and Phy. |
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 hysterect... | 15 General Medicine |
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 intracardia... | 33 Radiology |
CHIEF COMPLAINT The patient does not have any chief complaint. HISTORY OF PRESENT ILLNESS This is a 93-year-old female who called up her next-door neighbor to say that she was not feeling well. The next-door neighbor came over and decided that she should go to the emergency room to be check out for her generaliz... | 5 Consult - History and Phy. |
PROCEDURE Left heart catheterization left ventriculography selective coronary angiography. INDICATION This lady with a previous left internal mammary graft to left anterior descending saphenous vein graft to obtuse margin branch saphenous vein graft to the diagonal branch and saphenous vein graft to the righ... | 3 Cardiovascular / Pulmonary |
OCULAR FINDINGS Anterior chamber space Cornea iris lens and pupils all unremarkable on gross examination in each eye. Ocular adnexal spaces appear very good in each eye. Cyclomydril x2 was used to dilate the pupil in each eye. Medial spaces are clear and the periphery is still hazy in each eye. Ocular disc spac... | 26 Ophthalmology |
PREOPERATIVE DIAGNOSIS Blighted ovum severe cramping. POSTOPERATIVE DIAGNOSIS Blighted ovum severe cramping. OPERATION PERFORMED Vacuum D C. DRAINS None. ANESTHESIA General. HISTORY This 21-year-old white female gravida 1 para 0 who was having severe cramping and was noted to have a blighted ovum w... | 38 Surgery |
PREOPERATIVE DIAGNOSES 1. Torn lateral meniscus right knee. 2. Chondromalacia of the patella right knee. POSTOPERATIVE DIAGNOSES 1. Torn lateral meniscus right knee. 2. Chondromalacia of the patella right knee. PROCEDURE PERFORMED 1. Arthroscopic lateral meniscoplasty. 2. Patellar shaving of the right knee... | 27 Orthopedic |
PROCEDURES PERFORMED 1. Insertion of subclavian dual-port Port-A-Cath. 2. Surgeon-interpreted fluoroscopy. OPERATIVE PROCEDURE IN DETAIL After obtaining informed consent from the patient including a thorough explanation of the risks and benefits of the aforementioned procedure patient was taken to the operating ... | 3 Cardiovascular / Pulmonary |
PROCEDURES 1. Left heart catheterization. 2. Coronary angiography. 3. Left ventriculogram. PREPROCEDURE DIAGNOSIS Atypical chest pain. POSTPROCEDURE DIAGNOSES 1. No angiographic evidence of coronary artery disease. 2. Normal left ventricular systolic function. 3. Normal left ventricular end diastolic pressure.... | 3 Cardiovascular / Pulmonary |
NERVE CONDUCTION STUDIES Bilateral ulnar sensory responses are absent. Bilateral median sensory distal latencies are prolonged with a severely attenuated evoked response amplitude. The left radial sensory response is normal and robust. Left sural response is absent. Left median motor distal latency is prolonged ... | 33 Radiology |
GENERAL Alert well developed in no acute distress. MENTAL STATUS Judgment and insight appropriate for age. Oriented to time place and person. No recent loss of memory. Affect appropriate for age. EYES Pupils are equal and reactive to light. No hemorrhages or exudates. Extraocular muscles intact. EAR N... | 25 Office Notes |
PROCEDURE PERFORMED Bassini inguinal herniorrhaphy. ANESTHESIA Local with MAC anesthesia. 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 l... | 39 Urology |
REASON FOR REFERRAL The patient was referred to me by Dr. X of the Hospitalist Service at Children s Hospital due to a recent admission for pseudoseizures. This was a 90-minute initial intake completed on 10/19/2007 with the patient s mother. I have reviewed with her the boundaries of confidentiality and the treat... | 5 Consult - History and Phy. |
PREOPERATIVE DIAGNOSES 1. Surgical absence of left nipple areola with personal history of breast cancer. 2. Breast asymmetry. POSTOPERATIVE DIAGNOSES 1. Surgical absence of left nipple areola with personal history of breast cancer. 2. Breast asymmetry. PROCEDURE 1. Left nipple areolar reconstruction utilizing a fu... | 6 Cosmetic / Plastic Surgery |
REASON FOR CONSULTATION Questionable need for antibiotic therapy for possible lower extremity cellulitis. HISTORY OF PRESENT ILLNESS The patient is a 51-year-old Caucasian female with past medical history of morbid obesity and chronic lower extremity lymphedema. She follows up at the wound care center at Hospita... | 5 Consult - History and Phy. |
PROBLEMS AND ISSUES 1. Headaches nausea and dizziness consistent with a diagnosis of vestibular migraine recommend amitriptyline for prophylactic treatment and Motrin for abortive treatment. 2. Some degree of peripheral neuropathy consistent with diabetic neuropathy encouraged her to watch her diet and exercis... | 22 Neurology |
CHIEF COMPLAINT Sinus problems. SINUSITIS HISTORY The problem began 2 weeks ago and is constant. Symptoms include postnasal drainage sore throat facial pain coughing headaches and congestion. Additional symptoms include snoring nasal burning and teeth pain. The symptoms are characterized as moderate to severe.... | 5 Consult - History and Phy. |
PREOPERATIVE DIAGNOSIS Left carpal tunnel syndrome. POSTOPERATIVE DIAGNOSIS Left carpal tunnel syndrome. OPERATIONS PERFORMED Endoscopic carpal tunnel release. ANESTHESIA I.V. sedation and local 1 Lidocaine . ESTIMATED BLOOD LOSS Zero. COMPLICATIONS None. PROCEDURE IN DETAIL With the patient unde... | 38 Surgery |
HISTORY OF PRESENT ILLNESS The patient is a 62-year old male with a Gleason score 8 adenocarcinoma of the prostate involving the left and right lobes. He has a PSA of 3.1 with a prostate gland size of 41 grams. This was initially found on rectal examination with a nodule on the right side of the prostate showing... | 5 Consult - History and Phy. |
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 vomi... | 33 Radiology |
PREOPERATIVE DIAGNOSIS Displaced left subtrochanteric femur fracture. POSTOPERATIVE DIAGNOSIS Displaced left subtrochanteric femur fracture. OPERATION Intramedullary rod in the left hip using the Synthes trochanteric fixation nail measuring 11 x 130 degrees with an 85-mm helical blade. COMPLICATIONS None. T... | 38 Surgery |
Pitocin was started quickly to allow for delivery as quickly as possible and the patient rapidly became complete and then as she began to push there were additional decelerations of the baby s heart rate which were suspicions of cord around the neck. These were variable decelerations occurring late in the contracti... | 38 Surgery |
INTENSITY-MODULATED RADIATION THERAPY SIMULATION The patient will receive intensity-modulated radiation therapy in order to deliver high-dose treatment to sensitive structures. The target volume is adjacent to significant radiosensitive structures. Initially the preliminary isocenter is set on a fluoroscopically-base... | 33 Radiology |
PRINCIPAL DIAGNOSES 1. A 61-year-old white male with a diagnosis of mantle cell lymphoma diagnosed in 2001 status post autologous transplant with BEAM regimen in 04/02 followed by relapse. 2. Allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant. 3. ... | 16 Hematology - Oncology |
PREOPERATIVE DIAGNOSIS Recurrent vulvar melanoma. POSTOPERATIVE DIAGNOSIS Recurrent vulvar melanoma. OPERATION PERFORMED Radical anterior hemivulvectomy. Posterior skinning vulvectomy. SPECIMENS Radical anterior hemivulvectomy posterior skinning vulvectomy. INDICATIONS FOR PROCEDURE The patient has a h... | 24 Obstetrics / Gynecology |
PREOPERATIVE DIAGNOSIS Missed abortion. POSTOPERATIVE DIAGNOSIS Missed abortion. PROCEDURE PERFORMED Suction dilation and curettage. ANESTHESIA Spinal. ESTIMATED BLOOD LOSS 50 mL. COMPLICATIONS None. FINDINGS Products of conception consistent with a 6-week intrauterine pregnancy. INDICATIONS T... | 38 Surgery |
EXAM Bilateral diagnostic mammogram left breast ultrasound and biopsy. HISTORY 30-year-old female presents for digital bilateral mammography secondary to a soft tissue lump palpated by the patient in the upper right shoulder. The patient has a family history of breast cancer within her mother at age 58. Patien... | 24 Obstetrics / Gynecology |
HISTORY The patient is a 10-1/2-year-old born with asplenia syndrome with a complex cyanotic congenital heart disease characterized by dextrocardia bilateral superior vena cava complete atrioventricular septal defect a total anomalous pulmonary venous return to the right-sided atrium and double-outlet to the righ... | 3 Cardiovascular / Pulmonary |
HISTORY AND CLINICAL DATA The patient is an 88-year-old gentleman followed by Dr. X his primary care physician Dr. Y for the indication of CLL and Dr. Z for his cardiovascular issues. He presents to the Care Center earlier today with approximately a one-week history of increased progressive shortness of breath o... | 15 General Medicine |
CONSULT REQUEST FOR Medical management. The patient has been in special procedures now for over 2 hours and I am unable to examine. HISTORY OF PRESENT ILLNESS Obtained from Dr. A on an 81-year-old white female who is right handed who by history had a large stroke to the right brain causing left body findings l... | 15 General Medicine |
Because children need hearing to learn speech hearing loss from fluid in the middle ear can result in speech delay. Children begin to speak some words by 18 months. Children with fluid in both ears can show significant delay in their use of language. In addition young children learn to pronounce words by hearing t... | 11 ENT - Otolaryngology |
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... | 15 General Medicine |
INTERPRETATION MRI of the cervical spine without contrast showed normal vertebral body height and alignment with normal cervical cord signal. At C4-C5 there were minimal uncovertebral osteophytes with mild associated right foraminal compromise. At C5-C6 there were minimal diffuse disc bulge and uncovertebral ost... | 22 Neurology |
CHIEF COMPLAINT Status post motor vehicle accident. HISTORY OF PRESENT ILLNESS The patient is a 17-year-old white male who is status post a high-speed motor vehicle accident in which he was ejected from the vehicle. He denies loss of consciousness although the EMT people report that he did have loss of consciou... | 12 Emergency Room Reports |
PREOPERATIVE DIAGNOSIS Colon polyps. POSTOPERATIVE DIAGNOSES 1. Universal diverticulosis. 2. Nonsurgical internal hemorrhoids. PROCEDURE PERFORMED Total colonoscopy with photos. ANESTHESIA Demerol 100 mg IV with Versed 3 mg IV. SPECIMENS None. ESTIMATED BLOOD LOSS Minimal. INDICATIONS FOR PROCEDURE ... | 38 Surgery |
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 insuff... | 10 Discharge Summary |
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 of lids lashes brows or conjunctivae noted. Funduscopic examination unremarkable. E... | 5 Consult - History and Phy. |
PROCEDURE Bilateral L5 S1 S2 and S3 radiofrequency ablation. 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 indications and the associat... | 28 Pain Management |
REASON FOR CONSULTATION Clogged AV shunt. HISTORY OF PRESENT ILLNESS This is a 32-year-old African-American male who came to ABCD General Hospital with the above chief complaint. The patient complains of fatigue nausea vomiting and fever. The patient states that the shunt was placed in February although acco... | 21 Nephrology |
CHIEF COMPLAINT The patient is a 49-year-old Caucasian male transported to the emergency room by his wife complaining of shortness of breath. HISTORY OF PRESENT ILLNESS The patient is known by the nursing staff here to have a long history of chronic obstructive pulmonary disease and emphysema. He has made multipl... | 3 Cardiovascular / Pulmonary |
ADMITTING DIAGNOSIS Right C5-C6 herniated nucleus pulposus. PRIMARY OPERATIVE PROCEDURE Anterior cervical discectomy at C5-6 and placement of artificial disk replacement. SUMMARY This is a pleasant 43-year-old woman who has been having neck pain and right arm pain for a period of time which has not responded... | 27 Orthopedic |
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... | 33 Radiology |
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 ... | 10 Discharge Summary |
PREOPERATIVE DIAGNOSIS Cervical spondylosis and herniated nucleus pulposus of C4-C5. POSTOPERATIVE DIAGNOSIS Cervical spondylosis and herniated nucleus pulposus of C4-C5. TITLE OF OPERATION Anterior cervical discectomy C4-C5 arthrodesis with 8 mm lordotic ACF spacer corticocancellous and stabilization with S... | 38 Surgery |
HISTORY The patient is a 9-year-old born with pulmonary atresia intact ventricular septum with coronary sinusoids. He also has VACTERL association with hydrocephalus. As an infant he underwent placement of a right modified central shunt. On 05/26/1999 he underwent placement of a bidirectional Glenn shunt pulm... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Congenital myotonic muscular dystrophy with bilateral planovalgus feet. POSTOPERATIVE DIAGNOSIS Congenital myotonic muscular dystrophy with bilateral planovalgus feet. PROCEDURE Bilateral Crawford subtalar arthrodesis with open Achilles Z-lengthening and bilateral long-leg cast. ANESTHES... | 27 Orthopedic |
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 minut... | 33 Radiology |
GROSS DESCRIPTION Specimen labeled right ovarian cyst is received fresh for frozen section. It consists of a smooth-walled clear fluid filled cyst measuring 13x12x7 cm and weighing 1351 grams with fluid. Both surfaces of the wall are pink-tan smooth and grossly unremarkable. No firm or thick areas or papilla... | 24 Obstetrics / Gynecology |
REASON FOR VISIT Mr. A is an 86-year-old man who returns for his first followup after shunt surgery. HISTORY OF PRESENT ILLNESS I have followed Mr. A since May 2008. He presented with eight to ten years of progressive gait impairment cognitive impairment and decreased bladder control. We established a diagnos... | 23 Neurosurgery |
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 ... | 10 Discharge Summary |
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 co... | 33 Radiology |
TITLE OF OPERATION 1. Austin-Akin bunionectomy with internal screw fixation of the first right metatarsophalangeal joint. 2. Weil osteotomy with internal screw fixation first right metatarsal. 3. Arthroplasty second right PIP joint. PREOPERATIVE DIAGNOSES 1. Bunion deformity right foot. 2. Dislocated second r... | 27 Orthopedic |
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