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PREOPERATIVE DIAGNOSES 1. Chondromalacia patella. 2. Patellofemoral malalignment syndrome. POSTOPERATIVE DIAGNOSES 1. Grade-IV chondromalacia patella. 2. Patellofemoral malalignment syndrome. PROCEDURE PERFORMED 1. Diagnostic arthroscopy with partial chondroplasty of patella. 2. Lateral retinacular release. 3. Open tibial tubercle transfer with fixation of two 4.5 mm cannulated screws. ANESTHESIA General. COMPLICATIONS None. TOURNIQUET TIME Approximately 70 minutes at 325 mmHg. INTRAOPERATIVE FINDINGS Grade-IV chondromalacia noted to the central and lateral facet of the patella. There was a grade II to III chondral changes to the patellar groove. The patella was noted to be displaced laterally riding on the edge of the lateral femoral condyle. The medial lateral meniscus showed small amounts of degeneration but no frank tears were seen. The articular surfaces and the remainder of the knee appeared intact. Cruciate ligaments also appeared intact to direct stress testing. HISTORY This is a 36-year-old Caucasian female with a long-standing history of right knee pain. She has been diagnosed in the past with chondromalacia patella. She has failed conservative therapy. It was discussed with her the possibility of a arthroscopy lateral release and a tubercle transfer anterior medialization of the tibial tubercle to release stress from her femoral patellofemoral joint. She elected to proceed with the surgical intervention. All risks and benefits of the surgery were discussed with her. She was in agreement with the treatment plan. PROCEDURE On 09/04/03 she was taken to Operating Room at ABCD General Hospital. She was placed supine on the operating table with the general anesthesia administered by the Anesthesia Department. Her leg was placed in a Johnson knee holder and sterilely prepped and draped in the usual fashion. A stab incision was made in inferolateral and parapatellar regions. Through this the cannula was placed and the knee was inflated with saline solution. Intraoperative pictures were obtained. The above findings were noted. Second portal site was initiated in the inferomedial parapatellar region. Through this a arthroscopic shaver was placed and the chondroplasty in the patella was performed and removed the loose articular debris. Next the camera was placed through the inferomedial portal. An arthroscopic Bovie was placed through the inferolateral portal. A release of lateral retinaculum was then performed using the Bovie. Hemostasis was controlled with electrocautery. Next the knee was suctioned dry. An Esmarch was used to exsanguinate the lower extremity. Tourniquet was inflated to 325 mmHg. An oblique incision was made along the medial parapatellar region of the knee. The subcuticular tissues were carefully dissected and the hemostasis was again controlled with electrocautery. The retinaculum was then incised in line with the incision. The patellar tendon was identified. The lateral and medial border of the tibial tubercle were cleared of all soft tissue debris. Next an osteotome was then used to cut the tibial tubercle to 45 degree angle leaving the base of the bone incision intact. The tubercle was then pushed anteriorly and medially decreasing her Q-angle and anteriorizing the tibial tubercle. It was then held in place with a Steinmann pin. Following this a two 4.5 mm cannulated screws partially threaded were drilled in place using standard technique to help fixate the tibial tubercle. There was excellent fixation noted. The Q-angle was noted to be decreased to approximately 15 degrees. She was transferred approximately 1 cm in length. The wound was copiously irrigated and suctioned dry. The medial retinaculum was then plicated causing further medialization of the patella. The retinaculum was reapproximated using #0 Vicryl. Subcuticular tissue were reapproximated with #2-0 Vicryl. Skin was closed with #4-0 Vicryl running PDS suture. Sterile dressing was applied to the lower extremities. She was placed in a Donjoy knee immobilizer locked in extension. It was noted that the lower extremity was warm and pink with good capillary refill following deflation of the tourniquet. She was transferred to recovery room in apparent stable and satisfactory condition. Prognosis of this patient is poor secondary to the advanced degenerative changes to the patellofemoral joint. She will remain in the immobilizer approximately six weeks allowing the tubercle to reapproximate itself to the proximal tibia. | 27 Orthopedic |
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 diagnosed postnatally with total anomalous pulmonary venous connection. Following initial stabilization she was transferred to the Hospital for complete correction. PREOP DIAGNOSIS 1. Total anomalous pulmonary venous connection. 2. Atrial septal defect. 3. Patent ductus arteriosus. 4. Operative weight less than 4 kilograms 3.2 kilograms . COMPLICATIONS None. CROSS-CLAMP TIME 63 minutes. CARDIOPULMONARY BYPASS TIME MONITOR 35 minutes profound hypothermic circulatory arrest time 4 plus 19 equals 23 minutes. Low flow perfusion 32 minutes. FINDINGS Horizontal pulmonary venous confluence with right upper and middle with two veins entering the confluence on the right and multiple entry sites for left-sided veins. Large patulous anastomosis between posterior aspect of the left atrium and anterior aspect of the pulmonary venous confluence. Nonobstructed ascending vein ligated. Patent ductus arteriosus diminutive left atrium with posterior atrial septal defect with deficient inferior margin. At completion of the procedure right ventricular pressure approximating one-half of systemic normal sinus rhythm good biventricular function by visual inspection. PROCEDURE After the informed consent the patient was brought to the operating room and placed on the operating room table in supine position. Upon induction of general endotracheal anesthesia and placement of indwelling arterial and venous monitoring lines. The patient was prepped and draped in the usual sterile fashion from chin to groins. A median sternotomy incision was performed. Dissection was carried through the deeper planes until the sternum was scored and divided with an oscillating saw. A subtotal thymectomy was performed. Systemic heparinization was achieved and the pericardium was entered and fashioned until cradle. A small portion of the anterior pericardium was procured and fixed in glutaraldehyde for patch closure of segment of the atrial septal defect during the procedure. Pursestrings were deployed on the ascending aorta on the right. Atrial appendage. The aorta was then cannulated with an 8-French aorta cannula and the right atrium with an 18-French Polystan right-angle cannula. With an ACT greater than 400 greater pulmonary bypass was commenced with excellent cardiac decompression and the patent ductus arteriosus was ligated with a 2-0 silk tie. Systemic cooling was started and the head was packed and iced and systemic steroids were administered. During cooling traction suture was placed in the apex of the left ventricle. After 25 minutes of cooling the aorta was cross-clamped and the heart arrested by administration of 30 cubic centimeter/kilogram of cold-blood cardioplegia delivered directly within the aortic root following the aorta cross-clamping. Following successful cardioplegic arrest a period of low flow perfusion was started and a 10-French catheter was inserted into the right atrial appendage substituting the 18-French Polystan venous cannula. The heart was then rotated to the right side and the venous confluence was exposed. It was incised and enlarged and a corresponding incision in the dorsal and posterior aspect of the left atrium was performed. The two openings were then anastomosed in an end-to-side fashion with several interlocking sutures to avoid pursestring effect with a running 7-0 PDS suture. Following completion of the anastomosis the heart was returned into the chest and the patient s blood volume was drained into the reservoir. A right atriotomy was then performed during the period of circulatory arrest. The atrial septal defect was very difficult to expose but it was sealed with an autologous pericardial patch was secured in place with a running 6-0 Prolene suture. The usual deairing maneuvers were carried out and lining was administered and the right atriotomy was closed in two layers with a running 6-0 Prolene sutures. The venous cannula was reinserted. Cardiopulmonary bypass restarted and the aorta cross-clamp was released. The patient returned to normal sinus rhythm spontaneously and started regaining satisfactory hemodynamics which following a prolonged period of rewarming allow for us to wean her from cardiopulmonary bypass successfully and moderate inotropic support and sinus rhythm. Modified ultrafiltration was carried out and two sets of atrial and ventricular pacing wires were placed as well as the peritoneal dialysis catheter and two 15-French Blake drains. Venous decannulation was followed by aortic decannulation and administration of protamine sulfate. All cannulation sites were oversewn with 6-0 Prolene sutures and the anastomotic sites noticed to be hemostatic. With good hemodynamics and hemostasis the sternum was then smeared with vancomycin placing closure with stainless steel wires. The subcutaneous tissues were closed in layers with the reabsorbable monofilament sutures. Sponge and needle counts were correct times 2 at the end of the procedure. The patient was transferred in very stable condition to the pediatric intensive care unit . I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case. Given the magnitude of the operation the unavailability of an appropriate level cardiac surgical resident Mrs. X attending pediatric cardiac surgery at the Hospital participated during the cross-clamp time of the procedure in quality of first assistant. | 38 Surgery |
PREPROCEDURE DIAGNOSIS Change in bowel function. POSTPROCEDURE DIAGNOSIS Proctosigmoiditis. PROCEDURE PERFORMED Colonoscopy with biopsy. ANESTHESIA IV sedation. POSTPROCEDURE CONDITION Stable. INDICATIONS The patient is a 33-year-old with a recent change in bowel function and hematochezia. He is here for colonoscopy. He understands the risks and wishes to proceed. PROCEDURE The patient was brought to the endoscopy suite where he was placed in left lateral Sims position underwent IV sedation. Digital rectal examination was performed which showed no masses and a boggy prostate. The colonoscope was placed in the rectum and advanced under direct vision to the cecum. In the rectum and sigmoid there were ulcerations edema mucosal abnormalities and loss of vascular pattern consistent with proctosigmoiditis. Multiple random biopsies were taken of the left and right colon to see if this was in fact pan colitis. RECOMMENDATIONS Follow up with me in 2 weeks and we will begin Canasa suppositories. | 38 Surgery |
NEUROLOGICAL EXAMINATION At present the patient is awake alert and fully oriented. There is no evidence of cognitive or language dysfunction. Cranial nerves Visual fields are full. Funduscopic examination is normal. Extraocular movements full. Pupils equal round react to light. There is no evidence of nystagmus noted. Fifth nerve function is normal. There is no facial asymmetry noted. Lower cranial nerves are normal. Manual motor testing reveals good tone and bulk throughout. There is no evidence of pronator drift or decreased fine finger movements. Muscle strength is 5/5 throughout. Deep tendon reflexes are 2+ throughout with downgoing toes. Sensory examination is intact to all modalities including stereognosis graphesthesia. TESTING OF STATION AND GAIT The patient is able to walk toe-heel and tandem walk. Finger-to-nose and heel-to-shin moves are normal. Romberg sign negative. I appreciate no carotid bruits or cardiac murmurs. Noncontrast CT scan of the head shows no evidence of acute infarction hemorrhage or extra-axial collection. | 35 SOAP / Chart / Progress Notes |
CHIEF COMPLAINT Blood in toilet. HISTORY Ms. ABC is a 77-year-old female who is brought down by way of ambulance from XYZ Nursing Home after nursing staff had noted there to be blood in the toilet after she had been sitting on the toilet. They did not note any urine or stool in the toilet and the patient had no acute complaints. The patient is unfortunately a poor historian in that she has dementia and does not recall any of the events. The patient herself has absolutely no complaints such as abdominal pain or back pain urinary and GI complaints. There is no other history provided by the nursing staff from XYZ. There apparently were no clots noted within there. She does not have a history of being on anticoagulants. PAST MEDICAL HISTORY Actually quite limited includes that of dementia asthma anemia which is chronic hypothyroidism schizophrenia positive PPD in the past. PAST SURGICAL HISTORY Unknown. SOCIAL HISTORY No tobacco or alcohol. MEDICATIONS Listed in the medical records. ALLERGIES No known drug allergies. PHYSICAL EXAMINATION VITAL SIGNS Stable. GENERAL This is a well-nourished well-developed female who is alert oriented in all spheres pleasant cooperative resting comfortably appearing otherwise healthy and well in no acute distress. HEENT Visually normal. Pupils are reactive. TMs canals nasal mucosa and oropharynx are intact. NECK No lymphadenopathy or JVD. HEART Regular rate and rhythm. S1 S2. No murmurs gallops or rubs. LUNGS Clear to auscultation. No wheeze rales or rhonchi. ABDOMEN Benign flat soft nontender and nondistended. Bowel sounds active. No organomegaly or mass noted. GU/RECTAL External rectum was normal. No obvious blood internally. There is no stool noted within the vault. There is no gross amount of blood noted within the vault. Guaiac was done and was trace positive. Visual examination anteriorly during the rectal examination noted no blood within the vaginal region. EXTREMITIES No significant abnormalities. WORKUP CT abdomen and pelvis was negative. CBC was entirely within normal limits without any signs of anemia with an H and H of 14 and 42 . CMP also within normal limits. PTT PT and INR were normal. Attempts at getting the patient to give A urine were unsuccessful and the patient was very noncompliant would not allow us to do any kind of Foley catheterization. ER COURSE Uneventful. I have discussed the patient in full with Dr. X who agrees that she does not require any further workup or evaluation as an inpatient. We have decided to send the patient back to XYZ with observation by the staff there. She will have a CBC done daily for the next 3 days with results to Dr. X. They are to call him if there is any recurrences of blood or worsening of symptoms and they are to do a urinalysis at XYZ for blood. ASSESSMENT Questionable gastrointestinal bleeding at this time stable without any obvious signs otherwise of significant bleed. | 14 Gastroenterology |
PROCEDURE IN DETAIL Following a barium enema prep and lidocaine ointment to the rectal vault perirectal inspection and rectal exam were normal. The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon. Withdrawal notes an otherwise normal descending rectosigmoid and rectum. Retroflexion noted no abnormality of the internal ring. No hemorrhoids were noted. Withdrawal from the patient terminated the procedure. | 14 Gastroenterology |
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. | 38 Surgery |
INDICATION FOR CONSULTATION Increasing oxygen requirement. HISTORY Baby boy XYZ is a 29-3/7-week gestation infant. His mother had premature rupture of membranes on 12/20/08. She then presented to the Labor and Delivery with symptoms of flu. The baby was then induced and delivered. The mother had a history of premature babies in the past. This baby was doing well and then we had a significant increasing oxygen requirement from room air up to 85 . He is now on 60 FiO2. PHYSICAL FINDINGS GENERAL He appears to be pink well perfused and slightly jaundiced. VITAL SIGNS Pulse 156 56 respiratory rate 92 sat and 59/28 mmHg blood pressure. SKIN He was pink. He was on the high-frequency ventilator with good wiggle. His echocardiogram showed normal structural anatomy. He has evidence for significant pulmonary hypertension. A large ductus arteriosus was seen with bidirectional shunt. A foramen ovale shunt was also noted with bidirectional shunt. The shunting for both the ductus and the foramen ovale was equal left to right and right to left. IMPRESSION My impression is that baby boy XYZ has significant pulmonary hypertension. The best therapy for this is to continue oxygen. If clinically worsens he may require nitric oxide. Certainly Indocin should not be used at this time. He needs to have lower pulmonary artery pressures for that to be considered. Thank you very much for allowing me to be involved in baby XYZ s care. | 5 Consult - History and Phy. |
PREOPERATIVE DIAGNOSES 1. Painful enlarged navicula right foot. 2. Osteochondroma of right fifth metatarsal. POSTOPERATIVE DIAGNOSES 1. Painful enlarged navicula right foot. 2. Osteochondroma of right fifth metatarsal. PROCEDURE PERFORMED 1. Partial tarsectomy navicula right foot. 2. Partial metatarsectomy right foot. HISTORY This 41-year-old Caucasian female who presents to ABCD General Hospital with the above chief complaint. The patient states that she has extreme pain over the navicular bone with shoe gear as well as history of multiple osteochondromas of unknown origin. She states that she has been diagnosed with hereditary osteochondromas. She has had previous dissection of osteochondromas in the past and currently has not been diagnosed in her feet as well as spine and back. The patient desires surgical treatment at this time. PROCEDURE An IV was instituted by the Department of Anesthesia in the preoperative holding area. The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap. Copious amounts of Webril were placed on the left ankle followed by a blood pressure cuff. After adequate sedation by the Department of Anesthesia a total of 5 cc of 1 1 mixture of 1 lidocaine plain and 0.5 Marcaine plain were injected in the diamond block type fashion around the navicular bone as well as the fifth metatarsal. Foot was then prepped and draped in the usual sterile orthopedic fashion. Foot was elevated from the operating table and exsanguinated with an Esmarch bandage. The pneumatic ankle tourniquet was then inflated to 250 mmHg. The foot was lowered as well as the operating table. The sterile stockinet was reflected and the foot was cleansed with wet and dry sponge. Attention was then directed to the navicular region on the right foot. The area was palpated until the bony prominence was noted. A curvilinear incision was made over the area of bony prominence. At that time a total of 10 cc with addition of 1 additional lidocaine plain was injected into the surgical site. The incision was then deepened with #15 blade. All vessels encountered were ligated for hemostasis. The dissection was carried down to the level of the capsule and periosteum. A linear incision was made over the navicular bone obliquely from proximal dorsal to distal plantar over the navicular bone. The periosteum and the capsule were then reflected from the navicular bone at this time. A bony prominence was noted both medially and plantarly to the navicular bone. An osteotome and mallet were then used to resect the enlarged portion of the navicular bone. After resection with an osteotome there was noted to be a large plantar shelf. The surrounding soft tissues were then freed from this plantar area. Care was taken to protect the attachments of the posterior tibial tendon as much as possible. Only minimal resection of its attachment to the fiber was performed in order to expose the bone. Sagittal saw was then used to resect the remaining plantar medial prominent bone. The area was then smoothed with reciprocating rasp until no sharp edges were noted. The area was flushed with copious amount of sterile saline at which time there was noted to be a palpable where the previous bony prominence had been noted. The area was then again flushed with copious amounts of sterile saline and the capsule and periosteum were then reapproximated with #3-0 Vicryl. The subcutaneous tissues were then reapproximated with #4-0 Vicryl to reduce tension from the incision and running #5-0 Vicryl subcuticular stitch was performed. Attention was then directed to the fifth metatarsal. There was noted to be a palpable bony prominence dorsally with fifth metatarsal head as well as radiographic evidence laterally of an osteochondroma at the neck of the fifth metatarsal. Approximately 7 cm incision was made dorsolaterally over the fifth metatarsal. The incision was then deepened with #15 blade. Care was taken to preserve the extensor tendon. The incision was then created over the capsule and periosteum of the fifth metatarsal head. Capsule and periosteum were reflected both dorsally laterally and plantarly. At that time there was noted to be a visible osteochondroma on the plantar lateral aspect of the fifth metatarsal neck as well as on the dorsal aspect of the head of the fifth metatarsal. A sagittal saw was used to resect both of these osteal prominences. All remaining sharp edges were then smoothed with reciprocating rasp. The area was inspected for the remaining bony prominences and none was noted. The area was flushed with copious amounts of sterile saline. The capsule and periosteum were then reapproximated with #3-0 Vicryl. Subcutaneous closure was then performed with #4-0 Vicryl in order to reduce tension around the incision line. Running #5-0 subcutaneous stitch was then performed. Steri-Strips were applied to both surgical sites. Dressings consisted of Adaptic soaked in Betadine 4x4s Kling Kerlix and Coban. The pneumatic ankle tourniquet was released and the hyperemic flush was noted to all five digits of the right foot. The patient tolerated the above procedure and anesthesia well without complications. The patient was transferred to the PACU with vital signs stable and vascular status intact. The patient was given postoperative pain prescription and instructed to be partially weightbearing with crutches as tolerated. The patient is to follow-up with Dr. X in his office as directed or sooner if any problems or questions arise. | 31 Podiatry |
IDENTIFYING DATA The patient is a 45-year-old white male. He is unemployed presumably on disability and lives with his partner. CHIEF COMPLAINT I m in jail because I was wrongly arrested. The patient is admitted on a 72-hour Involuntary Treatment Act for grave disability. HISTORY OF PRESENT ILLNESS The patient has minimal insight into the circumstances that resulted in this admission. He reports being diagnosed with AIDS and schizophrenia for some time but states he believes that he has maintained his stable baseline for many months of treatment for either condition. Prior to admission the patient was brought to Emergency Room after he attempted to shoplift from a local department store during which he apparently slapped his partner. The patient was disorganized with police and emergency room staff and he was ultimately detained on a 72-hour Involuntary Treatment Act for grave disability. On the interview the patient is still disorganized and confused. He believes that he has been arrested and is in jail. Reports a history of mental health treatment but denies benefiting from this in the past and does not think that it is currently necessary. I was able to contact his partner by telephone. His partner reports the patient is paranoid and has bizarre behavior at baseline over the time that he has known him for the last 16 years with occasional episodes of symptomatic worsening from which he spontaneously recovers. His partner estimates the patient spends about 20 of the year in episodes of worse symptoms. His partner states that in the last one to two months the patient has become worse than he has ever seen him with increased paranoia above the baseline and he states the patient has been barricading himself in his house and unplugging all electrical appliances for unclear reasons. He also reports the patient has been sleeping less and estimates his average duration to be three to four hours a night. He also reports the patient has been spending money impulsively in the last month and has actually incurred overdraft charges on his checking account on three different occasions recently. He also reports that the patient has been making threats of harm to him and that His partner no longer feels that he is safe having him at home. He reports that the patient has been eating regularly with no recent weight loss. He states that the patient is observed responding to internal stimuli occasionally at baseline but this has gotten worse in the last few months. His partner was unaware of any obvious medical changes in the last one to two months coinciding with onset of recent symptomatic worsening. He reports of the patient s longstanding poor compliance with treatment of his mental health or age-related conditions and attributes this to the patient s dislike of taking medicine. He also reports that the patient has expressed the belief in the past that he does not suffer from either condition. PAST PSYCHIATRIC HISTORY The patient s partner reports that the patient was diagnosed with schizophrenia in his 20s and he has been hospitalized on two occasions in the 1980s and that there was a third admission to a psychiatric facility but the date of this admission is currently unknown. The patient was last enrolled in an outpatient mental health treatment in mid 2009. He dropped out of care about six months ago when he moved with his partner. His partner reports the patient was most recently prescribed Seroquel which though the patient denied benefiting from his partner felt was useful but not dosed high enough. Past medication trials that the patient reports include Haldol and lithium neither of which he found to be particularly helpful. MEDICAL HISTORY The patient reports being diagnosed with HIV and AIDS in 1994 and believes this was secondary to unprotected sexual contact in the years prior to his diagnosis. He is currently followed at Clinic where he has both an assigned physician and a case manager but treatment compliance has been poor with no use of antiretroviral meds in the last year. The patient is fairly vague on his history of AIDS related conditions but does identify the following Thrush skin lesions and lung infections additional details of these problems are not currently known. CURRENT MEDICATIONS None. ALLERGIES No known drug allergies. SOCIAL AND DEVELOPMENTAL HISTORY The patient lives with his partner. He is unemployed. Details of his educational and occupational history are not currently known. His source of finances is also unknown though social security disability is presumed. SUBSTANCE AND ALCOHOL HISTORY The patient smoked one to two packs per day for most of the last year but has increased this to two to three packs per day in the last month. His partner reports that the patient consumed alcohol occasionally but denies any excessive or binge use recently. The patient reports smoking marijuana a few times in his life but not recently. Denies other illicit substance use. LEGAL HISTORY Unknown. GENETIC PSYCHIATRIC HISTORY Also unknown. MENTAL STATUS EXAM Attitude The patient demonstrates only variable cooperation with interview requires frequent redirection to respond to questions. His appearance is cachectic. The patient is poorly groomed. Psychomotor There is no psychomotor agitation or retardation. No other observed extrapyramidal symptoms or tardive dyskinesia. Affect His affect is fairly detached. Mood Describes his mood is okay. Speech His speech is normal rate and volume. Tone his volume was decreased initially but this improved during the course of the interview. Thought Process His thought processes are markedly tangential. Thought content The patient is fairly scattered. He will provide history with frequent redirection but he does not appear to stay on one topic for any length of time. He denies currently auditory or visual hallucinations though his partner says that this is a feature present at baseline. Paranoid delusions are elicited. Homicidal/Suicidal Ideation He denies suicidal or homicidal ideation. Denies previous suicide attempts. Cognitive Assessment Cognitively he is alert and oriented to person and year only. His memory is intact to names of his Madison Clinic providers. Insight/Judgment His insight is absent as evidenced by his repeated questioning of the validity of his AIDS and mental health diagnoses. His judgment is poor as evidenced by his longstanding pattern of minimal engagement in treatment of his mental health and physical health conditions. Assets His assets include his housing and his history of supportive relationship with his partner over many years. Limitations His limitations include his AIDS and his history of poor compliance with treatment. FORMULATION The patient is a 45-year-old white male with a history of schizophrenia and AIDS. He was admitted for disorganized and assaultive behaviors while off all medications for the last six months. It is unclear to me how much his presentation is a direct expression of an AIDS-related condition though I suspect the impact of his HIV status is likely to be substantial. DIAGNOSES AXIS I Schizophrenia by history. Rule out AIDS-induced psychosis. Rule out AIDS-related cognitive disorder. AXIS II Deferred. AXIS III AIDS stable by his report . Anemia. AXIS IV Relationship strain and the possibility that he may be unable to return to his home upon discharge minimal engagement in mental health and HIV-related providers. AXIS V Global Assessment Functioning is currently 15. PLAN I will attempt to increase the database will specifically request records from the last mental health providers. The Internal Medicine Service will evaluate and treat any acute medical issues that could be helpful to collaborate with his providers at Clinic regarding issues related to his AIDS diagnosis. With the patient s permission I will start quetiapine at a dose of 100 mg at bedtime given the patient s partner report of partial but response to this agent in the past. I anticipate titrating further for effect during the course of his admission. | 32 Psychiatry / Psychology |
PREOPERATIVE DIAGNOSIS Right undescended testis ectopic position . POSTOPERATIVE DIAGNOSES Right undescended testis ectopic position right inguinal hernia. PROCEDURES Right orchiopexy and right inguinal hernia repair. ANESTHESIA General inhalational anesthetic with caudal block. FLUIDS RECEIVED 100 mL of crystalloids. ESTIMATED BLOOD LOSS Less than 5 mL. SPECIMENS No tissues sent to pathology. TUBES AND DRAINS No tubes or drains were used. INDICATIONS FOR OPERATION The patient is an almost 4-year-old boy with an undescended testis on the right plan is for repair. DESCRIPTION OF OPERATION The patient was taken to the operating room surgical consent operative site and patient identification were verified. Once he was anesthetized a caudal block was placed. He was then placed in the supine position and sterilely prepped and draped. Since the testis was in the ectopic position we did an upper curvilinear scrotal incision with a 15-blade knife and further extended it with electrocautery. Electrocautery was also used for hemostasis. A subdartos pouch was then created with a curved tenotomy scissors. The tunica vaginalis was grasped with a curved mosquito clamp and then dissected from its gubernacular attachments. As we were dissecting it we then found the testis itself into the sac and we opened the sac and it was found to be slightly atrophic about 12 mm in length and had a type III epididymal attachment not being attached to the top. We then dissected the hernia sac off of the testis some traction using the straight Joseph scissors and straight and curved mosquito clamps. Once this was dissected off we then twisted it upon itself and then dissected it down towards the external ring but on traction. We then twisted it upon itself suture ligated it with 3-0 Vicryl and released it allowing it to spring back into the canal. Once this was done we then had adequate length of the testis into the scrotal sac. Using a curved mosquito clamp we grasped the base of the scrotum internally and using the subcutaneous tissue we tacked it to the base of the testis using a 4-0 chromic suture. The testis was then placed into the scrotum in the proper orientation. The upper aspect of the pouch was closed with a pursestring suture of 4-0 chromic. The scrotal skin and dartos were then closed with subcutaneous closure of 4-0 chromic and Dermabond tissue adhesive was used on the incision. IV Toradol was given. Both testes were well descended in the scrotum at the end of the procedure. | 39 Urology |
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. | 27 Orthopedic |
CC Falling to left. HX 26y/oRHF fell and struck her head on the ice 3.5 weeks prior to presentation. There was no associated loss of consciousness. She noted a dull headache and severe sharp pain behind her left ear 8 days ago. The pain lasted 1-2 minutes in duration. The next morning she experienced difficulty walking and consistently fell to the left. In addition the left side of her face had become numb and she began choking on food. Family noted her pupils had become unequal in size. She was seen locally and felt to be depressed and admitted to a psychiatric facility. She was subsequently transferred to UIHC following evaluation by a local ophthalmologist. MEDS Prozac and Ativan both recently started at the psychiatric facility . PMH 1 Right esotropia and hyperopia since age 1year. 2 Recurrent UTI. FHX Unremarkable. SHX Divorced. Lives with children. No spontaneous abortions. Denied ETOH/Tobacco/Illicit Drug use. EXAM BP 138/110. HR 85. RR 16. Temp 37.2C. MS A O to person place time. Speech fluent and without dysarthria. Intact naming comprehension repetition. CN Pupils 4/2 decreasing to 3/1 on exposure to light. Optic Disks flat. VFFTC. Esotropia OD otherwise EOM full. Horizontal nystagmus on leftward gaze. Decreased corneal reflex OS. Decreased PP/TEMP sensation on left side of face. Light touch testing normal. Decreased gag response on left. Uvula deviates to right. The rest of the CN exam was unremarkable. Motor 5/5 strength throughout with normal muscle bulk and tone. Sensory Decreased PP and TEMP on right side of body. PROP/VIB intact. Coord Difficulty with FNF/HKS/RAM on left. Normal on right side. Station No pronator drift. Romberg test not noted. Gait unsteady with tendency to fall to left. Reflexes 3/3 throughout BUE and Patellae. 2+/2+ Achilles. Plantar responses were flexor bilaterally. Gen Exam Obese. In no acute distress. Otherwise unremarkable. HEENT No carotid/vertebral/cranial bruits. COURSE PT/PTT GS CBC TSH FT4 and Cholesterol screen were all within normal limits. HCT on admission was negative. MRI Brain done locally 2/2/93 was reviewed and a left lateral medullary stroke was appreciated. The patient underwent a cerebral angiogram on 2/3/93 which revealed significant narrowing of the left vertebral artery beginning at C2 and extending to and involving the basilar artery. There is severe irregular narrowing of the horizontal portion above the posterior arch of C1. The findings were felt consistent with a left vertebral artery dissection. Neuro-opthalmology confirmed a left Horner s pupil by clinical exam and history. Cookie swallow study was unremarkable. The Patient was placed on Heparin then converted to Coumadin. The PT on discharge was 17. She remained on Coumadin for 3 months and then was switched to ASA for 1 year. An Otolaryngologic evaluation on 10/96 noted true left vocal cord paralysis with full glottic closure. A prosthesis was made and no surgical invention was done. | 33 Radiology |
PREOPERATIVE DIAGNOSIS Low Back Syndrome - Low back pain with left greater than right lower extremity radiculopathy. POSTOPERATIVE DIAGNOSIS Same. PROCEDURE 1. Nerve root decompression at L45 on the left side. 2. Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left. 3. Interpretation of radiograph. ANESTHESIA IV sedation with Versed and Fentanyl. ESTIMATED BLOOD LOSS None. COMPLICATIONS None. INDICATION FOR PROCEDURE Severe and excruciating pain in the lumbar spine and lower extremity. MRI shows disc pathology as well as facet arthrosis. SUMMARY OF PROCEDURE The patient was admitted to the operating room consent was obtained and signed. The patient was taken to the Operating room and was placed in the prone position. Monitors were placed including EKG pulse oximeter and blood pressure monitoring. After adequate IV sedation with Versed and Fentanyl the procedure was begun. The lumbar sacral region was prepped and draped in sterile fashion with Betadine and four sterile towels. After the towels were places then sterile drapes were placed on top of that. After which time the Epimed catheter was then placed this was done by first repositioning the C-Arm to visualize the lumbar spine and the vertebral bodies were then counted beginning at L5 verifying the sacral hiatus. The skin over the sacral hiatus was then injected with 1 Lidocaine and an #18-gauge needle was used for skin puncture. The #18-gauge needle was inserted off of midline. A #16-gauge RK needle was then placed into the skin puncture and using the paramedian approach and loss-of-resistance technique the needle was placed. Negative aspiration was carefully performed. Omnipaque 240 dye was then injected through the #16-gauge RK needle. The classical run off was noted. A filling defect was noted L45 nerve root on the left side. After which time 10 cc of 0.25 Marcaine/Triamcinolone 9/1 mixture was then infused through the 16 R-K Needle. Some additional lyses of adhesions were visualized as the local anesthetic displaced the Omnipaque 240 dye using this barbotage technique. An Epimed Tun-L catheter was then inserted through the #16-gauage R-K needle and threaded up to the L45 interspace under continuous fluoroscopic guidance. As the catheter was threaded up under continuous fluoroscopic visualization lyses of adhesions were visualized. The tip of the catheter was noted to be L45 level on the left side. After this the #16-gauge RK needle was then removed under fluoroscopic guidance verifying that the tip of the catheter did not migrate from the L45 nerve root region on the left side. After this was successfully done the catheter was then secured in place this was done with Neosporin ointment a Split 2x2 Op site and Hypofix tape. The catheter was then checked with negative aspiration and the Omnipaque 240 dye was then injected. The classical run off was noted in the lumbar region. Some lyses of adhesions were also visualized at this time with barbotage technique. Good dye spread was noted to extend one level above and one level below the L45 nerve root and bilateral spread was noted. Nerve root decompression was visualized as dye spread into the nerve root whereas prior this was a filling defect. After which time negative aspiration was again performed through the Epimed® Tun-L catheter and then 10 cc of solution was then infused through the catheter this was done over a 10-minute period with initial 3 cc test dose. Approximately 3 minutes elapsed and then the remaining 7 cc were infused Solution consisting of 8 cc of 0.25 Marcaine 2 cc of Triamcinolone and 1 cc of Wydase. The catheter was then capped with a bacterial filter. The patient was noted to have tolerated the procedure well without any complications. Interpretation of radiograph revealed nerve root adhesions present with lysis of these adhesions as the procedure was performed. A filling defect was seen at the L45 nerve root and this filling defect being significant of fibrosis and adhesions in this region was noted to be lysed with the insertion of the catheter as well as the barbotage procedure. This verified positive nerve root decompression. The tip of the Epimed Tun L catheter was noted to be at L45 level on the left side. Positive myelogram without dural puncture was noted during this procedure no sub-dural spread of Omnipaque 240 dye was noted. This patient did not report any problems and reported pain reduction. | 28 Pain Management |
PREOPERATIVE DIAGNOSES Bladder cancer and left hydrocele. POSTOPERATIVE DIAGNOSES Bladder cancer and left hydrocele. OPERATION Left hydrocelectomy cystopyelogram bladder biopsy and fulguration for hemostasis. ANESTHESIA Spinal. ESTIMATED BLOOD LOSS Minimal. FLUIDS Crystalloid. BRIEF HISTORY The patient is a 66-year-old male with history of smoking and hematuria had bladder tumor which was dissected. He has received BCG. The patient is doing well. The patient was supposed to come to the OR for surveillance biopsy and pyelograms. The patient had a large left hydrocele which was increasingly getting worse and was making it very difficult for the patient to sit to void or put clothes on etc. Options such as watchful waiting drainage in the office and hydrocelectomy were discussed. Risks of anesthesia bleeding infection pain MI DVT PE infection in the scrotum enlargement of the scrotum recurrence and pain were discussed. The patient understood all the options and wanted to proceed with the procedure. PROCEDURE IN DETAIL The patient was brought to the OR. Anesthesia was applied. The patient was placed in dorsal lithotomy position. The patient was prepped and draped in usual sterile fashion. A transverse scrotal incision was made over the hydrocele sac and the hydrocele fluid was withdrawn. The sac was turned upside down and sutures were placed. Careful attention was made to ensure that the cord was open. The testicle was in normal orientation throughout the entire procedure. The testicle was placed back into the scrotal sac and was pexed with 4-0 Vicryl to the outside dartos to ensure that there was no risk of torsion. Orchiopexy was done at 3 different locations. Hemostasis was obtained using electrocautery. The sac was closed using 4-0 Vicryl. The sac was turned upside down so that when it heals the fluid would not recollect. The dartos was closed using 2-0 Vicryl and the skin was closed using 4-0 Monocryl and Dermabond was applied. Incision measured about 2 cm in size. Subsequently using ACMI cystoscope a cystoscopy was performed. The urethra appeared normal. There was some scarring at the bulbar urethra but the scope went in through that area very easily into the bladder. There was a short prostatic fossa. The bladder appeared normal. There was some moderate trabeculation throughout the bladder some inflammatory changes in the bag part but nothing of much significance. There were no papillary tumors or stones inside the bladder. Bilateral pyelograms were obtained using 8-French cone-tip catheter which appeared normal. A cold cup biopsy of the bladder was done and was fulgurated for hemostasis. The patient tolerated the procedure well. The patient was brought to recovery at the end of the procedure after emptying the bladder. The patient was given antibiotics and was told to take it easy. No heavy lifting pushing or pulling. Plan was to follow up in about 2 months. | 39 Urology |
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. | 15 General Medicine |
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. | 33 Radiology |
PREOPERATIVE DIAGNOSIS Refractory urgency and frequency. POSTOPERATIVE DIAGNOSIS Refractory urgency and frequency. OPERATION Stage I and II neuromodulator. ANESTHESIA Local MAC. ESTIMATED BLOOD LOSS Minimal. FLUIDS Crystalloid. The patient was given Ancef preop antibiotic. Ancef irrigation was used throughout the procedure. BRIEF HISTORY The patient is a 63-year-old female who presented to us with urgency and frequency on physical exam. There was no evidence of cystocele or rectocele. On urodyanamcis the patient has significant overactivity of the bladder. The patient was tried on over three to four different anticholinergic agents such as Detrol Ditropan Sanctura and VESIcare for at least one month each. The patient had pretty much failure from each of the procedure. The patient had less than 20 improvement with anticholinergics. Options such as continuously trying anticholinergics continuation of the Kegel exercises and trial of InterStim were discussed. The patient was interested in the trial. The patient had percutaneous InterStim trial in the office with over 70 to 80 improvement in her urgency frequency and urge incontinence. The patient was significantly satisfied with the results and wanted to proceed with stage I and II neuromodulator. Risks of anesthesia bleeding infection pain MI DVT and PE were discussed. Risk of failure of the procedure in the future was discussed. Risk of lead migration that the treatment may or may not work in the long-term basis and data on the long term were not clear were discussed with the patient. The patient understood and wanted to proceed with stage I and II neuromodulator. Consent was obtained. DETAILS OF THE OPERATION The patient was brought to the OR. The patient was placed in prone position. A pillow was placed underneath her pelvis area to slightly lift the pelvis up. The patient was awake was given some MAC anesthesia through the IV but the patient was talking and understanding and was able to verbalize issues. The patient s back was prepped and draped in the usual sterile fashion. Lidocaine 1 was applied on the right side near the S3 foramen. Under fluoroscopy the needle placement was confirmed. The patient felt stimulation in the vaginal area which was tapping in nature. The patient also had a pressure feeling in the vaginal area. The patient had no back sensation or superficial sensation. There was no sensation down the leg. The patient did have which turned in slide bellows response indicating the proper positioning of the needle. A wire was placed. The tract was dilated and lead was placed. The patient felt tapping in the vaginal area which is an indication that the lead is in its proper position. Most of the leads had very low amplitude and stimulation. Lead was tunneled under the skin and was brought out through an incision on the left upper buttocks. Please note that the lidocaine was injected prior to the tunneling. A pouch was created about 1 cm beneath the subcutaneous tissue over the muscle where the actual unit was connected to the lead. Screws were turned and they were dropped. Attention was made to ensure that the lead was all the way in into the InterStim. Irrigation was performed after placing the main unit in the pouch. Impedance was checked. Irrigation was again performed with antibiotic irrigation solution. The needle site was closed using 4-0 Monocryl. The pouch was closed using 4-0 Vicryl and the subcutaneous tissue with 4-0 Monocryl. Dermabond was applied. The patient was brought to recovery in a stable condition. | 38 Surgery |
PREOPERATIVE DIAGNOSES Coronal hypospadias with chordee and asthma. POSTOPERATIVE DIAGNOSES Coronal hypospadias with chordee and asthma. PROCEDURE Hypospadias repair TIP with tissue flap relocation and chordee release Nesbit tuck . ANESTHETIC General inhalational anesthetic with a caudal block. FLUIDS RECEIVED 300 mL of crystalloid. ESTIMATED BLOOD LOSS 20 mL. TUBES/DRAINS An 8-French Zaontz catheter. INDICATIONS FOR OPERATION The patient is a 17-month-old boy with hypospadias abnormality. The plan is for repair. DESCRIPTION OF OPERATION The patient was taken to the operating room where surgical consent operative site and patient identification were verified. Once he was anesthetized a caudal block was placed. IV antibiotics were given. He was then placed in the supine position. The foreskin was retracted and cleansed. He was then sterilely prepped and draped. A stay stitch of 4-0 Prolene was then placed on the glans. The urethra was calibrated with the lacrimal duct probes to an 8-French. We then marked out the coronal cuff the penile shaft skin as well as the glanular plate for future surgery with a marking pen. We then used a 15-blade knife to circumscribe the penis around the coronal cuff. We then degloved the penis using the curved tenotomy scissors and electrocautery was used for hemostasis. The patient had some splaying of the spongiosum tissue which was also incised laterally and rotated to make a secondary flap. Once the penis was degloved and the excessive chordee tissue was released we then placed a vessel loop tourniquet around the base of the penis and using IV grade saline injected the penis for an artifical erection. He was still noted to have chordee so a midline incision through the Buck fascia was made with a 15-blade knife and Heineke-Mikulicz closure using 5-0 Prolene was then used for the chordee Nesbit tuck. We repeated the artificial erection and the penis was straight. We then incised the urethral plate with an ophthalmic blade in the midline and then elevated the glanular wings using a 15-blade knife to elevate and then incise them. Using the curved iris scissors we then also further mobilized the glanular wings. The 8-French Zaontz was then placed while the tourniquet was still in place into the urethral plate. The upper aspect of the distal meatus was then closed with an interrupted suture of 7-0 Vicryl and then using a running subcuticular closure we closed the urethral plates over the Zaontz catheter. We then mobilized subcutaneous tissue from the penile shaft skin and the inner perpetual skin on the dorsum and then buttonholed the flap placed it over the head of the penis and then used it to cover of the hypospadias repair with tacking sutures of 7-0 Vicryl. We then rolled the spongiosum flap to cover the distal urethra that was also somewhat dysplastic 7-0 Vicryl was used for that as well. 5-0 Vicryl was used to roll the glans with 2 deep sutures and then horizontal mattress sutures of 7-0 Vicryl were used to reconstitute the glans. Interrupted sutures of 7-0 Vicryl were used to approximate the urethral meatus to the glans. Once this was done we then excised the excessive penile shaft skin and used the interrupted sutures of 6-0 chromic to attach the penile shaft skin to the coronal cuff. On the ventrum itself we used horizontal mattress sutures to close the defect. At the end of the procedure the Zaontz catheter was sutured into place with a 4-0 Prolene suture Dermabond tissue adhesive and Surgicel was used as a dressing and a second layer of Telfa and clear eye tape was then used to tape it into place. IV Toradol was given at the procedure. The patient tolerated the procedure well and was in a stable condition upon transfer to the recovery room. | 38 Surgery |
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. | 24 Obstetrics / Gynecology |
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. | 33 Radiology |
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. | 25 Office Notes |
GENERAL XXX VITAL SIGNS Blood pressure XXX pulse XXX temperature XXX respirations XXX. Height XXX weight XXX. HEAD Normocephalic. Negative lesions negative masses. EYES PERLA EOMI. Sclerae clear. Negative icterus negative conjunctivitis. ENT Negative nasal hemorrhages negative nasal obstructions negative nasal exudates. Negative ear obstructions negative exudates. Negative inflammation in external auditory canals. Negative throat inflammation or masses. SKIN Negative rashes negative masses negative ulcers. No tattoos. NECK Negative palpable lymphadenopathy negative palpable thyromegaly negative bruits. HEART Regular rate and rhythm. Negative rubs negative gallops negative murmurs. LUNGS Clear to auscultation. Negative rales negative rhonchi negative wheezing. ABDOMEN Soft nontender adequate bowel sounds. Negative palpable masses negative hepatosplenomegaly negative abdominal bruits. EXTREMITIES Negative inflammation negative tenderness negative swelling negative edema negative cyanosis negative clubbing. Pulses adequate bilaterally. MUSCULOSKELETAL Negative muscle atrophy negative masses. Strength adequate bilaterally. Negative movement restriction negative joint crepitus negative deformity. NEUROLOGIC Cranial nerves I through XII intact. Negative gait disturbance. Balance and coordination intact. Negative Romberg negative Babinski. DTRs equal bilaterally. GENITOURINARY Deferred. | 5 Consult - History and Phy. |
PROCEDURE Upper endoscopy with foreign body removal. PREOPERATIVE DIAGNOSIS ES Esophageal foreign body. POSTOPERATIVE DIAGNOSIS ES Penny in proximal esophagus. ESTIMATED BLOOD LOSS None. COMPLICATIONS None. DESCRIPTION OF PROCEDURE After informed consent was obtained the patient was taken to the pediatric endoscopy suite. After appropriate sedation by the anesthesia staff and intubation an upper endoscope was inserted into the mouth over the tongue into the esophagus at which time the foreign body was encountered. It was grasped with a coin removal forcep and removed with an endoscope. At that time the endoscope was reinserted advanced to the level of the stomach and stomach was evaluated and was normal. The esophagus was normal with the exception of some mild erythema where the coin had been sitting. There were no erosions. The stomach was decompressed of air and fluid. The scope was removed without difficulty. SUMMARY The patient underwent endoscopic removal of esophageal foreign body. PLAN To discharge home follow up as needed. | 14 Gastroenterology |
CC Left hemiplegia. HX A 58 y/o RHF awoke at 1 00AM on 10/23/92 with left hemiplegia and dysarthria which cleared within 15 minutes. She was seen at a local ER and neurological exam and CT Brain were reportedly unremarkable. She was admitted locally. She then had two more similar spells at 3AM and 11AM with resolution of the symptoms within an hour. She was placed on IV Heparin following the 3rd episode and was transferred to UIHC. She had not been taking ASA. PMH 1 HTN. 2 Psoriasis. SHX denied ETOH/Tobacco/illicit drug use. FHX Unknown. MEDS Heparin only. EXAM BP160/90 HR145 supine . BP105/35 HR128 light headed standing RR12 T37.7C MS Dysarthria only. Lucid thought process. CN left lower facial weakness only. Motor mild left hemiparesis with normal muscle bulk. Mildly increased left sided muscle tone. Sensory unremarkable. Coordination impaired secondary to weakness on left. Otherwise unremarkable. Station left pronator drift. Romberg testing not done. Gait not tested. Reflexes symmetric 2+ throughout. Gen Exam CV Tachycardic without murmur. COURSE The patients signs and symptoms worsening during and after standing to check orthostatic blood pressures. She was immediately placed in a reverse Trendelenburg position and given IV fluids. Repeat neurologic exam at 5PM on the day of presentation revealed a return to the initial presentation of signs and symptoms. PT/PTT/GS/CBC/ABG were unremarkable. EKG revealed sinus tachycardia with rate dependent junctional changes. CXR unremarkable. MRI Brain was obtained and showed an evolving right thalamic/lentiform nucleus infarction best illustrated by increased signal on the Proton density weighted images. Over the ensuing days of admission she had significant fluctuations of her BP 200mmHG to 140mmHG systolic . Her symptoms worsened with falls in BP. Her BP was initially controlled with esmolol or labetalol. Renal Ultrasound abdominal/pelvic CT renal function scan serum and urine osmolality urine catecholamines/metanephrine studies were unremarkable. Carotid doppler study revealed 0-15 BICA stenosis and antegrade vertebral artery flow bilaterally. Transthoracic echocardiogram was unremarkable. Cerebral angiogram was performed to r/o vasculitis. This revealed narrowing of the M1 segment of the right MCA. This was thought secondary to atherosclerosis and not vasculitis. She was discharged on ASA Procardia XL and Labetalol. | 33 Radiology |
CHIEF COMPLAINT Intractable epilepsy here for video EEG. HISTORY OF PRESENT ILLNESS The patient is a 9-year-old male who has history of global developmental delay and infantile spasms. Ultimately imaging study shows an MRI with absent genu of the corpus callosum and thinning of the splenium of the corpus callosum showing a pattern of cerebral dysgenesis. He has had severe global developmental delay and is nonverbal. He can follow objects with his eyes but has no ability to interact with his environment to any great degree. He has noted if any purposeful use of the hands. He has abnormal movements constantly which are more choreiform and dystonic. He has spastic quadriparesis which is variable at times. The patient is unable to sit or stand and receives all his nutrition via G-tube. The patient began having seizures in infancy presenting as infantile spasms. I began seeing him at 20 months of age. At that point he had undergone workup in Seattle Washington and then was seeing Dr. X child neurologist in Mexico who started Vigabatrin for infantile spasms. The patient had benefit from this medication and was doing well at that time with regard to that seizure type. He initially was on phenobarbital which failed to give him benefit. He continued on phenobarbital however for a long period time thereafter. The patient then began having more tonic seizures after his episodic spasms had subsided and failed several medication trials including valproic acid Topamax and Zonegran at least briefly. Upon starting Lamictal he began to have benefit and then actually had 1-year seizure freedom before having an isolated seizure or 2. Over the next 6 months to a year he only had few further seizures and was doing well in a general sense. It was more recently that he began having new seizure events that have not responded to higher doses of Lamictal up to 15 mg/kg/day. These events manifest as tonic spells with eye deviation and posturing. Mother reports flexion of the upper extremities extension with lower extremities. During that time he is not able to cry or say any sounds. These events last from seconds to minutes and occur at least multiple times per week. There are times where he has none for a few days and other times where he has multiple days in a row with events. He has another event manifesting as flexion of the upper extremities and extension lower extremities where he turns red and cries throughout. He may vomit after these episodes then seems to calm down. It is unclear whether this is a seizure or whether the patient is still responsive. MEDICATIONS The patient s medications include Lamictal for a total of 200 mg twice a day. It is a 150 mg tablet and 25 mg tablets. He is on Zonegran using 25 mg capsules 2 capsules twice daily and baclofen 10 mg three times day. He has other medications including the Xopenex and Atrovent. REVIEW OF SYSTEMS At this time is negative any fevers nausea vomiting diarrhea abdominal complaints rashes arthritis or arthralgias. No respiratory or cardiovascular complaints. He has no change in his skills at this point. FAMILY HISTORY Noncontributory. PHYSICAL EXAMINATION GENERAL The patient is a slender male who is microcephalic. He has EEG electrodes in place and is on the video EEG at that time. HEENT His oropharynx shows no lesions. NECK Supple without adenopathy. CHEST Clear to auscultation. CARDIOVASCULAR Regular rate and rhythm. No murmurs. ABDOMEN Benign with G-tube in place. EXTREMITIES Reveal no clubbing cyanosis or edema. NEUROLOGICAL The patient is alert and has bilateral esotropia. He is able to fix and follow objects briefly. He is unable to reach for objects. He exhibits constant choreiform movements when excited. These are more prominent in the upper extremities and lower extremities. He has some dystonic posture with flexion of the wrist and fingers bilaterally. He also has plantar flexion at the ankles bilaterally. His cranial nerves reveal that his pupils are equal round and reactive to light. Extraocular movements are intact other than bilateral esotropia. His face moves symmetrically. Palate elevates in midline. Hearing appears intact bilaterally. Motor exam reveals dystonic and variable tone overall there is mild in spasticity both upper and lower extremities as described above. He has clonus at the ankles bilaterally and some valgus contracture of the ankles. His sensation is intact to light touch bilaterally. Deep tendon reflexes are 2 to 3+ bilaterally. IMPRESSION/PLAN This is a 9-year-old male with congenital brain malformation and intractable epilepsy. He has microcephaly as well as dystonic cerebral palsy. He had a re-emergence of seizures which are difficult to classify although some sound like tonic episodes and others are more concerning for non-epileptic phenomenon such as discomfort. He is admitted for video EEG to hopefully capture both of these episodes and further clarify the seizure type or types. He will remain hospitalized for probably at least 48 hours to 72 hours. He could be discharged sooner if multiple events are captured. His medications we will continue his current dose of Zonegran and Lamictal for now. Both of these medications are very long acting discontinuing them while in the hospital may simply result in severe seizures after discharge. | 5 Consult - History and Phy. |
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. | 22 Neurology |
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 were reassured by the pediatrician that this was normal. The patient demonstrates good interval weight gain and only today presented to an outside hospital with significant duskiness some irritability and rapid heart rate. Parents do state that she does appear to breathe rapidly tires somewhat with the feeding with increased respiratory effort and diaphoresis. The patient is exclusively breast fed and feeding approximately 2 hours. Upon arrival at Children s Hospital the patient was found to be in a narrow complex tachycardia with the rate in excess of 258 beats per minute with a successful cardioversion to sinus rhythm with adenosine. The electrocardiogram following the cardioversion had demonstrated normal sinus rhythm with a right atrial enlargement northwest axis and poor R-wave progression possible right ventricular hypertrophy. FAMILY HISTORY Family history is remarkable for an older sibling found to have a small ventricular septal defect that is spontaneously closed. REVIEW OF SYSTEMS A complete review of systems including neurologic respiratory gastrointestinal genitourinary are otherwise negative. PHYSICAL EXAMINATION GENERAL Physical examination that showed a sedated acyanotic infant who is in no acute distress. VITAL SIGNS Heart rate of 170 respiratory rate of 65 saturation it is nasal cannula oxygen of 74 with a prostaglandin infusion at 0.5 mcg/kg/minute. HEENT Normocephalic with no bruit detected. She had symmetric shallow breath sounds clear to auscultation. She had full symmetrical pulses. HEART There is normoactive precordium without a thrill. There is normal S1 single loud S2 and a 2/6 continuous shunt type of murmur could be appreciated at the left upper sternal border. ABDOMEN Soft. Liver edge is palpated at 3 cm below the costal margin and no masses or bruits detected. X-RAYS Review of the chest x-ray demonstrated a normal situs normal heart size and adequate pulmonary vascular markings. There is a prominent thymus. An echocardiogram demonstrated significant cyanotic congenital heart disease consisting of normal situs a left superior vena cava draining into the left atrium a criss-cross heart with atrioventricular discordance of the right atrium draining through the mitral valve into the left-sided morphologic left ventricle. The left atrium drained through the tricuspid valve into a right-sided morphologic right ventricle. There is a large inlet ventricular septal defect as pulmonary atresia. The aorta was malopposed arising from the right ventricle in the anterior position with the left aortic arch. There was a small vertical ductus as a sole source of pulmonary artery blood flow. The central pulmonary arteries appeared confluent although small measuring 3 mm in the diameter. Biventricular function is well maintained. FINAL IMPRESSION The patient has significant cyanotic congenital heart disease physiologically with a single ventricle physiology and ductal-dependent pulmonary blood flow and the incidental supraventricular tachycardia now in the sinus rhythm with adequate ventricular function. The saturations are now also adequate on prostaglandin E1. RECOMMENDATION My recommendation is that the patient be continued on prostaglandin E1. The patient s case was presented to the cardiothoracic surgical consultant Dr. X. The patient will require further echocardiographic study in the morning to further delineate the pulmonary artery anatomy and confirm the central confluence. A consideration will be made for diagnostic cardiac catheterization to fully delineate the pulmonary artery anatomy prior to surgical intervention. The patient will require some form of systemic to pulmonary shunt modified pelvic shunt or central shunt as a durable source of pulmonary blood flow. Further surgical repair was continued on the size and location of the ventricular septal defect over the course of the time for consideration of possible Rastelli procedure. The current recommendation is for proceeding with a central shunt and followed then by bilateral bidirectional Glenn shunt with then consideration for a septation when the patient is 1 to 2 years of age. These findings and recommendations were reviewed with the parents via a Spanish interpreter. | 3 Cardiovascular / Pulmonary |
SUBJECTIVE Patient presents with Mom and Dad for her 5-year 3-month well-child check. Family has not concerns stating patient has been doing well overall since last visit. Taking in a well-balanced diet consisting of milk and dairy products fruits vegetables proteins and grains with minimal junk food and snack food. No behavioral concerns. Gets along well with peers as well as adults. Is excited to start kindergarten this upcoming school year. Does attend daycare. Normal voiding and stooling pattern. No concerns with hearing or vision. Sees the dentist regularly. Growth and development Denver II normal passing all developmental milestones per age in areas of fine motor gross motor personal and social interaction and speech and language development. See Denver II form in the chart. ALLERGIES None. MEDICATIONS None. FAMILY SOCIAL HISTORY Unchanged since last checkup. Lives at home with mother father and sibling. No smoking in the home. REVIEW OF SYSTEMS As per HPI otherwise negative. OBJECTIVE Vital Signs Weight 43 pounds. Height 42-1/4 inches. Temperature 97.7. Blood pressure 90/64. General Well-developed well-nourished cooperative alert and interactive 5-year -3month-old white female in no acute distress. HEENT Atraumatic normocephalic. Pupils equal round and reactive. Sclerae clear. Red reflex present bilaterally. Extraocular muscles intact. TMs clear bilaterally. Oropharynx Mucous membranes moist and pink. Good dentition. Neck Supple no lymphadenopathy. Chest Clear to auscultation bilaterally. No wheeze or crackles. Good air exchange. Cardiovascular Regular rate and rhythm. No murmur. Good pulses bilaterally. Abdomen Soft nontender. Nondistended. Positive bowel sounds. No masses or organomegaly. GU Tanner I female genitalia. Femoral pulses equal bilaterally. No rash. Extremities Full range of motion. No cyanosis clubbing or edema. Back Straight. No scoliosis. Integument Warm dry and pink without lesions. Neurological Alert. Good muscle tone and strength. Cranial nerves II-XII grossly intact. DTRs 2+/4+ bilaterally. ASSESSMENT/PLAN 1. Well 5-year 3-month-old white female. 2. Anticipatory guidance for growth and diet development and safety issues as well as immunizations. Will receive MMR DTaP and IPV today. Discussed risks and benefits as well as possible side effects and symptomatic treatment. Gave 5-year well-child check handout to mom. Completed school pre-participation physical. Copy in the chart. Completed vision and hearing screening. Reviewed results with family. 3. Follow up in one year for next well-child check or as needed for acute care. | 5 Consult - History and Phy. |
PREOPERATIVE DIAGNOSIS ES 1. Cholelithiasis. 2. Cholecystitis. POSTOPERATIVE DIAGNOSIS ES 1. Acute perforated gangrenous cholecystitis. 2. Cholelithiasis. PROCEDURE 1. Attempted laparoscopic cholecystectomy. 2. Open cholecystectomy. ANESTHESIA General endotracheal anesthesia. COUNTS Correct. COMPLICATIONS None apparent. ESTIMATED BLOOD LOSS 275 mL. SPECIMENS 1. Gallbladder. 2. Lymph node. DRAINS One 19-French round Blake. DESCRIPTION OF THE OPERATION After consent was obtained and the patient was properly identified the patient was transported to the operating room and after induction of general endotracheal anesthesia the patient was prepped and draped in a normal sterile fashion. After infiltration with local a vertical incision was made at the umbilicus and utilizing graspers the underlying fascia was incised and was divided sharply. Dissecting further the peritoneal cavity was entered. Once this done a Hasson trocar was secured with #1 Vicryl and the abdomen was insufflated without difficulty. A camera was placed into the abdomen and there was noted to be omentum overlying the subhepatic space. A second trocar was placed in the standard fashion in the subxiphoid area this was a 10/12 mm non-bladed trocar. Once this was done a grasper was used to try and mobilize the omentum and a second grasper was added in the right costal margin this was a 5-mm port placed it was non-bladed and placed in the usual fashion under direct visualization without difficulty. A grasper was used to mobilize free the omentum which was acutely friable and after a significant time-consuming effort was made to mobilize the omentum it was clear that the gallbladder was well incorporated by the omentum and it would be unsafe to proceed with a laparoscopy procedure and then the procedure was converted to open. The trocars were removed and a right subcostal incision was made incorporating the 10/12 subxiphoid port. The subcutaneous space was divided with electrocautery as well as the muscles and fascia. The Bookwalter retraction system was then set up and retractors were placed to provide exposure to the right subhepatic space. Then utilizing a right-angle and electrocautery the omentum was freed from the gallbladder. An ensuing retrograde cholecystectomy was performed in which electrocautery and blunt dissection were used to mobilize the gallbladder from the gallbladder fossa this was done down to the infundibulum. After meticulous dissection the cystic artery was identified and it was ligated between 3-0 silks. Several other small ties were placed on smaller bleeding vessels and the cystic duct was identified was skeletonized and a 3-0 stick tie was placed on the proximal portion of it. After it was divided the gallbladder was freed from the field. Once this was done the liver bed was inspected for hemostasis and this was achieved with electrocautery. Copious irrigation was also used. A 19-French Blake drain was placed in Morrison s pouch lateral to the gallbladder fossa and was secured in place with 2-0 nylon this was a 19-French round Blake. Once this was done the umbilical port was closed with #1 Vicryl in an interrupted fashion and then the wound was closed in two layers with #1 Vicryl in an interrupted fashion. The skin was closed with and absorbable stitch. The patient was then awakened from anesthesia extubated and transported to the recovery room in stable condition. | 14 Gastroenterology |
PREOPERATIVE DIAGNOSES 1. Metastatic carcinoma of the bladder. 2. Bowel obstruction. POSTOPERATIVE DIAGNOSES 1. Metastatic carcinoma of the bladder. 2. Bowel obstruction. PROCEDURE Port insertion through the right subclavian vein percutaneously under radiological guidance. PROCEDURE DETAIL The patient was electively taken to the operating room after obtaining an informed consent. A time-out process was followed. Antibiotics were given. Then the patient s right deltopectoral area was prepped and draped in the usual fashion. Xylocaine 1 was infiltrated. The right subclavian vein was percutaneously cannulated without any difficulty. Then using the Seldinger technique the catheter part of the port which was a single-lumen port was passed through the introducer under x-ray guidance and placed in the junction of the superior vena cava and the right atrium. A pocket had been fashioned and a single-lumen drum of the port was connected to the catheter which had been trimmed and affixed to the pectoralis fascia with couple of sutures of Vicryl. Then the fascia was closed using subcuticular suture of Monocryl. The drum was aspirated and irrigated with heparinized saline and then was put in the pocket and the skin was closed. A dressing was applied including the needle and the port with the catheter so that the floor could use the catheter right away. The patient tolerated the procedure well and was sent to recovery room in satisfactory condition. A chest x-ray was performed that showed that there were no complications of procedure and that the catheter was in right place. | 38 Surgery |
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. | 10 Discharge Summary |
PREOPERATIVE DIAGNOSIS Acute cholecystitis. POSTOPERATIVE DIAGNOSIS Acute cholecystitis. PROCEDURE PERFORMED Laparoscopic cholecystectomy. ANESTHESIA General. ESTIMATED BLOOD LOSS Zero. COMPLICATIONS None. PROCEDURE The patient was taken to the operating room and after obtaining adequate general anesthesia the patient was placed in the supine position. The abdominal area was prepped and draped in the usual sterile fashion. A small skin incision was made below the umbilicus. It was carried down in the transverse direction on the side of her old incision. It was carried down to the fascia. An open pneumoperitoneum was created with Hasson technique. Three additional ports were placed in the usual fashion. The gallbladder was found to be acutely inflamed distended and with some necrotic areas. It was carefully retracted from the isthmus and the cystic structure was then carefully identified dissected and divided between double clips. The gallbladder was then taken down from the gallbladder fossa with electrocautery. There was some bleeding from the gallbladder fossa that was meticulously controlled with a Bovie. The gallbladder was then finally removed via the umbilical port with some difficulty because of the size of the gallbladder and size of the stones. The fascia had to be opened. The gallbladder had to be opened and the stones had to be extracted carefully. When it was completed I went back to the abdomen and achieved complete hemostasis. The ports were then removed under direct vision with the scope. The fascia of the umbilical wound was closed with a figure-of-eight 0 Vicryl. All the incisions were injected with 0.25 Marcaine closed with 4-0 Monocryl Steri-Strips and sterile dressing. The patient tolerated the procedure satisfactorily and was transferred to the recovery room in stable condition. | 14 Gastroenterology |
INDICATIONS FOR PROCEDURE The patient was here for joint injection. She is a 14-year-old Hispanic female with history of pauciarticular arthritis in particular arthritis of her left knee although she has complaints of arthralgias in multiple joints. What bother her the most is the joint swelling of her left knee that has been for several months. She has been taking Naprosyn on her last visit. She was feeling better but still has significant symptoms especially when she was active. After evaluation in the clinic she decided to have a joint injection as it was discussed before. I discussed the side effects and the complications with the parents and the patient and the possibility of doing it in the clinic but she decided that she did not want to do it in the clinic and she wanted to be sedated for this. DESCRIPTION OF PROCEDURE So under aseptic technique and under general anesthesia 20 mg of Aristospan were injected on the left knee. No fluid was obtained. Her swelling was about 1+. No complications. No bleeding was observed and the patient tolerated the procedure without any complications or side effects. After that she went to the recovery room where is going to be discharged with her parents and see her back in the clinic for re-evaluation in a few weeks after the procedure. If the patient has any problems overnight she is going to call us. If she had any fevers or strange swelling she is to call us for advice. We will see her in the clinic as scheduled. | 28 Pain Management |
TITLE OF OPERATION Total thyroidectomy for goiter. INDICATION FOR SURGERY This is a 41-year-old woman who notes that compressive thyroid goiter and symptoms related to such who wishes to undergo surgery. Risks benefits alternatives of the procedures were discussed in great detail with the patient. Risks include but were not limited to anesthesia bleeding infection injury to nerve vocal fold paralysis hoarseness low calcium need for calcium supplementation tumor recurrence need for additional treatment need for thyroid medication cosmetic deformity and other. The patient understood all these issues and they wished to proceed. PREOP DIAGNOSIS Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration. POSTOP DIAGNOSIS Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration. ANESTHESIA General endotracheal. PROCEDURE DETAIL After identifying the patient the patient was placed supine in a operating room table. After establishing general anesthesia via oral endotracheal intubation with a 6 Nerve Integrity monitoring system endotracheal tube. The eyes were then tacked with Tegaderm. The Nerve Integrity monitoring system endotracheal tube was confirmed to be working adequately. Essentially a 7 cm incision was employed in the lower skin crease of the neck. A 1 lidocaine with 1 100 000 epinephrine were given. Shoulder roll was applied. The patient prepped and draped in a sterile fashion. A 15-blade was used to make the incision. Subplatysmal flaps were raised to the thyroid notch and sternal respectively. The strap muscles were separated in the midline. As we then turned to the left side where the sternohyoid muscle was separated from the sternothyroid muscle there was a very dense and firm thyroid mass on the left side. The sternothyroid muscle was transected horizontally. Similar procedure was performed on the right side. Attention was then turned to identify the trachea in the midline. Veins in this area and the pretracheal region were ligated with a harmonic scalpel. Subsequently attention was turned to dissecting the capsule off of the left thyroid lobe. Again this was very firm in nature. The superior thyroid pole was dissected in the superior third artery vein and the individual vessels were ligated with a harmonic scalpel. The inferior and superior parathyroid glands were protected. Recurrent laryngeal nerve was identified in the tracheoesophageal groove. This had arborized early as a course underneath the inferior thyroid artery to a very small tiny anterior motor branch. This was followed superiorly. The level of cricothyroid membrane upon complete visualization of the entire nerve Berry s ligament was transected and the nerve protected and then the thyroid gland was dissected over the trachea. A prominent pyramidal level was also appreciated and dissected as well. Attention was then turned to the right side. There was significant amount of thyroid tissue that was very firm. Multiple nodules were appreciated. In a similar fashion the capsule was dissected. The superior and inferior parathyroid glands protected and preserved. The superior thyroid artery and vein were individually ligated with the harmonic scalpel and the inferior thyroid artery was then ligated close to the thyroid gland capsule. Once the recurrent laryngeal nerve was identified again on this side the nerve had arborized early prior to the coursing underneath the inferior thyroid artery. The anterior motor branch was then very fine almost filamentous and stimulated at 0.5 milliamps completely dissected toward the cricothyroid membrane with complete visualization. A small amount of tissue was left at the Berry s ligament as the remainder of thyroid level was dissected over the trachea. The entire thyroid specimen was then removed marked with a stitch upon the superior pole. The wound was copiously irrigated Valsalva maneuver was given bleeding points controlled. The parathyroid glands appeared to be viable. Both the anterior motor branches that were tiny were stimulated at 5 milliamps and confirmed to be working with the Nerve Integrity monitoring system. Attention was then turned to burying the Surgicel on the wound bed on both sides. The strap muscles were reapproximated in the midline using a 3-0 Vicryl suture of the sternothyroid horizontal transection and the strap muscles in the midline were then reapproximated. The 1/8th inch Hemovac drain was placed and secured with a 3-0 nylon. The incision was then closed with interrupted 3-0 Vicryl and Indermil for the skin. The patient has a history of keloid formation and approximately 1 cubic centimeter of 40 mg per cubic centimeter Kenalog was injected into the incisional line using a tuberculin syringe and 25-gauge needle. The patient tolerated the procedure well was extubated in the operating room table and sent to postanesthesia care unit in a good condition. Upon completion of the case fiberoptic laryngoscopy revealed intact bilateral true vocal fold mobility. | 13 Endocrinology |
PREOPERATIVE DIAGNOSIS Right failed total knee arthroplasty. POSTOPERATIVE DIAGNOSIS Right failed total knee arthroplasty. PROCEDURE PERFORMED Revision right total knee arthroplasty. FIRST ANESTHESIA Spinal. ESTIMATED BLOOD LOSS Approximately 75 cc. TOURNIQUET TIME 123 minutes. Then it was let down for approximately 15 minutes and then reinflated for another 26 minutes for a total of 149 minutes. COMPONENTS A Zimmer NexGen Legacy knee size D right stemmed femoral component was used. A NexGen femoral component with a distal femoral augmented block size 5 mm. A NexGen tibial component size 3 mm was used. A size 14 mm constrained polyethylene surface was used as well. Original patellar component that the patient had was maintained. COMPLICATIONS None. BRIEF HISTORY The patient is a 68-year-old female with a history of knee pain for 13 years. She had previous total knee arthroplasty and revision at an outside facility. She had continued pain snapping malalignment difficulty with ambulation and giving away and wished to undergo additional revision surgery. PROCEDURE The patient was taken to the operative suite and placed on the operating table. Department of Anesthesia administered the spinal anesthetic. Once adequately anesthetized the patient was placed in a supine position. Care was ensured and she was adequately secured and well padded in position. Once this was obtained the right lower extremity was prepped and draped in the usual sterile fashion. Tourniquet was inflated to approximately 325 mmHg on the right thigh. At this point an incision was made over her anterior previous knee scar taking this down to the subcutaneous tissue of the overlying retinaculum. A medial parapatellar arthrotomy was then made by using a second knife and this was taken both distally and proximally to allow us to sublux the patella on the lateral aspect to allow exposure to the joint surface. There was noted to be no evidence of purulence or gross clinical appearance of infection however intraoperative cultures were taken to asses this as well. At this point the previous articular surface was then removed using an osteotome until this was left free and then removed. This was done without difficulty. Attention was then directed removing the femoral component. Osteotome was taken around each of the edges until this was gently lifted up and then a femoral extractor was placed around it and this was back flapped until this was easily removed. After this was performed attention was then directed to the tibial component. An osteotome was again inserted around the surface and this was easily pried loose. There was noted to be minimal difficulty with this and did not appear to have adequate cement fixation. This was evaluated. The bone stalk appeared to be adequate however there were noted to be some deficits where we need to trim cement so we elected to proceed with stemmed component. The attention was first directed to the femur and the femoral canal was opened up and superficially reamed up to a size 18 mm proximal portion for the Zimmer stemmed component. At this point the distal femoral cut was evaluated with a intramedullary guide and this was noted to be cut in a varus cut leaving us a large deficit of the medial femoral cut. We elected because of this large amount of retic to take off the medial condyle to correct this varus cut to a six degree valgus cut. We elected to augment the medial aspect and take only 5 mm off of the lateral condyle instead of a full 10 to 12. At this point the distal femoral cutting guide based on the intramedullary head was then placed. Care was ensured that this was aligned in proper rotation with the external epicondylar axis. Once this was pinned in position approximately a six degree valgus cut was then made. This allowed a portion of the medial condyle to be removed distally. The anterior cut was checked next using the intramedullary guide. The anterior surface cutting block was then placed. This aligned us to anterior cutting block. We ensured again that rotation was aligned with the epicondylar axis. Once this was adequately aligned with this and gave us some external rotation this was pinned in position and new anterior cut was made. It was noted that minimal bone was taken off the surface only a slight portion on the medial anterior surface. was then removed and the chamfer cutting guide was then placed on. This allowed us to make a box cut and recut some of the angled cuts of the distal femur. Once this was placed and pinned in position. Care was then again taken to check that this was in proper rotation and then the chamfer cuts were recut. It was noted that the anterior chamfers did not need to be cut take off no bone. The posterior chamfers did remove some bony aspects. This was also taken off some of the posterior aspects of the condyles and then the ossicle saw and reciprocal saw were used to take off a notch cut to open up a constrained component. After all these cuts were taken the guides were then removed and the trial component with a medial 5 mm augment was then placed. This appeared to have an adequate fit and then packed in position. It appeared to be satisfactory. At this point this was removed and attention was then directed to the tibia. The intramedullary canal was again opened up using a proximal drill and this was reamed to the appropriate size until good was obtained. At this point the intramedullary guide was used to evaluate a tibial cut. This appeared to be adequate however we elected to remove 2 mm of bone to give us a new fresh bony surface. The cutting guide was placed in adequate alignment and checked both the with intramedullary guide and an external alignment rod which allowed us to ensure that we had proper external rotation of this tibial component. At this point this was pinned in position and the tibial cut was made to remove an extra 2 mm of bone. This was again removed and a trial tibial stemmed component was then placed as well as the trial augmented stemmed femoral component. This was placed in a proper position. A 10 mm articular surface was placed in the knee and this was taken through range of motion. This was found to have better alignment and satisfactory position. We elected to take an intraoperative x-ray at this point to evaluate our cut. The intraoperative x-ray demonstrates satisfactory cuts and alignment of the prosthesis. At this point all trials were removed. The patella was then examined. The rongeur was used to remove the surrounding synovium. The patella was evaluated and found to have mild wear on the lateral aspect of the inferior butt however this was very mild and overall had a good position and was well fixed to the bone. It was elected at this time to maintain this anatomic patella that was previously placed. At this point the joint again was reevaluated and any bone loose fragments removed. There was noted to be some posterior tightness and mild osteophytes. These were removed with a rongeur. At this time while preparing the canals the tourniquet was deflated due to it being 123 minutes. Approximately 10 minutes did get by as the knee was copiously irrigated and suctioned dried. The tourniquet was then reinflated. The canals were prepped for cementing. They were suction-dried and cleaned. The tibial component was cemented and then impacted into position and ensured it was adequately aligned in proper external rotation and alignment that was previously tried with the trial. Once this was fixed and secured all extra cement was removed and attention was directed to the femoral component. The stemmed femoral component was then impacted in position and cemented. Again care was ensured that it was in adequate position and proper rotation. A size 14 mm poly was then inserted in between to provide compression. This was then taken through extension and held until cement cured. This was then removed and the components were evaluated. All excess cement was removed and they were well fixed. Size 14 mm trial Poly was then placed and this was taken through range of motion. This was found to have excellent range of motion and good stability. It was elected at this time that we would go with the size 14 mm Poly. This gave us extra Poly for ware and then provide excellent contact throughout the range of motion. The final articular surface was then placed and tightened into position to allow to secured. The knee was then reduced and the knee was taken through range of motion. The patella was tracking with no-touch technique and adequately positioned. At this point the tourniquet was deflated for second time and then the knee was copiously irrigated and suctioned dry. All bleeding was cauterized using a Bovie cautery. The retinaculum was then repaired using #1 Ethibond in a figure-of-eight fashion. This was reinforced with a running #2-0 Vicryl. The knee was then flexed and noted that the patella was tracking with good alignment. The wound was again copiously irrigated and suctioned dry. A drain was placed prior to retinaculum repair deep to this to provide adequate drainage. At this point the subcutaneous tissue was closed with #2-0 Vicryl. Skin was approximated with skin clips. Sterile dressing of Adaptic 4x4 Webril and ABDs were then placed. A large Dupre dressing was then placed up the entire lower extremity. The patient was then transferred back to recovery in supine position. DISPOSITION The patient tolerated the procedure well with no complications and transferred to PACU in satisfactory condition. | 27 Orthopedic |
PREOPERATIVE DIAGNOSIS Left masticator space infection secondary to necrotic tooth #17. POSTOPERATIVE DIAGNOSIS Left masticator space infection secondary to necrotic tooth #17. SURGICAL PROCEDURE Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17. FLUIDS 500 mL of crystalloid. ESTIMATED BLOOD LOSS 60 mL. SPECIMENS Cultures and sensitivities Aerobic and anaerobic were sent for micro studies. DRAINS One 0.25-inch Penrose placed in the medial aspect of the masticator space. CONDITION Good extubated breathing spontaneously to PACU. INDICATIONS FOR PROCEDURE The patient is a 26-year-old Caucasian male with a 2-week history of a toothache and 5-day history of increasing swelling of his left submandibular region presents to Clinic complaining of difficulty swallowing and breathing. Oral surgery was consulted to evaluate the patient. After evaluation of the facial CT with tracheal deviation and abscess in the left muscular space it was determined that the patient needed to be taken urgently to the operating room under general anesthesia and have the abscess incision and drainage and removal of tooth #17. Risks benefits alternatives treatments were thoroughly discussed with the patient and consent was obtained. DESCRIPTION OF PROCEDURE The patient was transported to operating room #4 at Clinic. He was laid supine on the operating room table. ASA monitors were attached and general anesthesia was induced with IV anesthetics and maintained with oral endotracheal intubation and inhalation of anesthetics. The patient was prepped and draped in the usual oral and maxillofacial surgery fashion. The surgeon approached the operating room table in sterile fashion. Approximately 2 mL of 1 lidocaine with 1 100 000 epinephrine were injected into the left submandibular area in the area of the incision. After waiting appropriate time for local anesthesia to take effect an 18-gauge needle was introduced into the left masticator space and approximately 5 mL of pus was removed. This was sent for aerobic and anaerobic micro. Using a 15-blade a 2-cm incision was made in the left submandibular region then a hemostat was introduced in blunt dissection into the medial border of the mandible was performed. The left masticator space was thoroughly explored as well as the left submandibular space and submental space. Pus was drained from this site. Copious amounts of sterile fluid were irrigated into the site. Attention was then directed intraorally where a moistened Ray-Tec sponge was placed in the posterior oropharynx to act as a throat pack. Approximately 4 mL of 1 lidocaine with 1 100 000 epinephrine were injected into the left inferior alveolar nerve block. Using a 15-blade a full-thickness mucoperiosteal flap was developed around tooth #17. The tooth was elevated and delivered and the lingual area of tooth #17 was explored and more pus was expressed. This pus was evacuated intraorally suction. The extraction site and the left masticator space were irrigated and it was noted that the irrigation was communicating with extraoral incision in the neck. A 0.25-inch Penrose drain was placed in the lingual aspect of the mandible extraorally through the neck and secured with 2-0 silk suture. A tack stitch intraorally with 3-0 chromic suture was placed. The throat pack was then removed. An orogastric tube was placed and removed all other stomach contents and then removed. At this point the procedure was then determined to be over. The patient was extubated breathing spontaneously and transported to PACU in good condition. | 7 Dentistry |
Her past medical history includes insulin requiring diabetes mellitus for the past 28 years. She also has a history of gastritis and currently is being evaluated for inflammatory bowel disease. She is scheduled to see a gastroenterologist in the near future. She is taking Econopred 8 times a day to the right eye and Nevanac OD three times a day. She is allergic to penicillin. The visual acuity today was 20/50 pinholing no improvement in the right eye. In the left eye the visual acuity was 20/80 pinholing no improvement. The intraocular pressure was 14 OD and 9 OS. Anterior segment exam shows normal lids OU. The conjunctiva is quiet in the right eye. In the left eye she has an area of sectoral scleral hyperemia superonasally in the left eye. The cornea on the right eye shows a paracentral area of mild corneal edema. In the left eye cornea is clear. Anterior chamber in the right eye shows trace cell. In the left eye the anterior chamber is deep and quiet. She has a posterior chamber intraocular lens well centered and in sulcus of the left eye. The lens in the left eye shows 3+ nuclear sclerosis. Vitreous is clear in both eyes. The optic nerves appear healthy in color and normal in size with cup-to-disc ratio of approximately 0.48. The maculae are flat in both eyes. The retinal periphery is flat in both eyes. Ms. ABC is recovering well from her cataract operation in the right eye with residual corneal swelling which should resolve in the next 2 to 3 weeks. She will continue her current drops. In the left eye she has an area of what appears to be sectoral scleritis. I did a comprehensive review of systems today and she reports no changes in her pulmonary dermatologic neurologic gastroenterologic or musculoskeletal systems. She is however being evaluated for inflammatory bowel disease. The mild scleritis in the left eye may be a manifestation of this. We will notify her gastroenterologist of this possibility of scleritis and will start Ms. ABC on a course of indomethacin 25 mg by mouth two times a day. I will see her again in one week. She will check with her primary physician prior to starting the Indocin. | 26 Ophthalmology |
PREOPERATIVE DIAGNOSIS Severe neurologic or neurogenic scoliosis. POSTOPERATIVE DIAGNOSIS Severe neurologic or neurogenic scoliosis. PROCEDURES 1. Anterior spine fusion from T11-L3. 2. Posterior spine fusion from T3-L5. 3. Posterior spine segmental instrumentation from T3-L5 placement of morcellized autograft and allograft. ESTIMATED BLOOD LOSS 500 mL. FINDINGS The patient was found to have a severe scoliosis. This was found to be moderately corrected. Hardware was found to be in good positions on AP and lateral projections using fluoroscopy. INDICATIONS The patient has a history of severe neurogenic scoliosis. He was indicated for anterior and posterior spinal fusion to allow for correction of the curvature as well as prevention of further progression. Risks and benefits were discussed at length with the family over many visits. They wished to proceed. PROCEDURE The patient was brought to the operating room and placed on the operating table in the supine position. General anesthesia was induced without incident. He was given a weight-adjusted dose of antibiotics. Appropriate lines were then placed. He had a neuromonitoring performed as well. He was then initially placed in the lateral decubitus position with his left side down and right side up. An oblique incision was then made over the flank overlying the 10th rib. Underlying soft tissues were incised down at the skin incision. The rib was then identified and subperiosteal dissection was performed. The rib was then removed and used for autograft placement later. The underlying pleura was then split longitudinally. This allowed for entry into the pleural space. The lung was then packed superiorly with wet lap. The diaphragm was then identified and this was split to allow for access to the thoracolumbar spine. Once the spine was achieved subperiosteal dissection was performed over the visualized vertebral bodies. This required cauterization of the segmental vessels. Once the subperiosteal dissection was performed to the posterior and anterior extents possible the diskectomies were performed. These were performed from T11-L3. This was over 5 levels. Disks and endplates were then removed. Once this was performed morcellized rib autograft was placed into the spaces. The table had been previously bent to allow for easier access of the spine. This was then straightened to allow for compression and some correction of the curvature. The diaphragm was then repaired as was the pleura overlying the thoracic cavity. The ribs were held together with #1 Vicryl sutures. Muscle layers were then repaired using a running #2-0 PDS sutures and the skin was closed using running inverted #2-0 PDS suture as well. Skin was closed as needed with running #4-0 Monocryl. This was dressed with Xeroform dry sterile dressings and tape. The patient was then rotated into a prone position. The spine was prepped and draped in a standard fashion. Longitudinal incision was made from T2-L5. The underlying soft tissues were incised down at the skin incision. Electrocautery was then used to maintain hemostasis. The spinous processes were then identified and the overlying apophyses were split. This allowed for subperiosteal dissection over the spinous processes lamina facet joints and transverse processes. Once this was completed the C-arm was brought in which allowed for easy placement of screws in the lumbar spine. These were placed at L4 and L5. The interspaces between the spinous processes were then cleared of soft tissue and ligamentum flavum. This was done using a rongeur as well as a Kerrison rongeur. Spinous processes were then harvested for morcellized autograft. Once all the interspaces were prepared Songer wires were then passed. These were placed from L3-T3. Once the wires were placed a unit rod was then positioned. This was secured initially at the screws distally on both the left and right side. The wires were then tightened in sequence from the superior extent to the inferior extent first on the left-sided spine where I was operating and then on the right side spine. This allowed for excellent correction of the scoliotic curvature. Decortication was then performed and placement of a morcellized autograft and allograft was then performed after thoroughly irrigating the wound with 4 liters of normal saline mixed with bacitracin. This was done using pulsed lavage. The wound was then closed in layers. The deep fascia was closed using running #1 PDS suture subcutaneous tissue was closed using running inverted #2-0 PDS suture the skin was closed using #4-0 Monocryl as needed. The wound was then dressed with Steri-Strips Xeroform dry sterile dressings and tape. The patient was awakened from anesthesia and taken to the intensive care unit in stable condition. All instrument sponge and needle counts were correct at the end of the case. The patient will be managed in the ICU and then on the floor as indicated. | 23 Neurosurgery |
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. | 38 Surgery |
PREOPERATIVE DIAGNOSIS 1. Left carpal tunnel syndrome. 2. de Quervain s tenosynovitis. POSTOPERATIVE DIAGNOSIS 1. Left carpal tunnel syndrome. 2. de Quervain s tenosynovitis. OPERATIONS PERFORMED 1. Endoscopic carpal tunnel release. 2. de Quervain s release. ANESTHESIA I.V. sedation and local 1 Lidocaine . ESTIMATED BLOOD LOSS Zero. COMPLICATIONS None. PROCEDURE IN DETAIL ENDOSCOPIC CARPAL TUNNEL RELEASE With the patient under adequate anesthesia the upper extremity was prepped and draped in a sterile manner. The arm was exsanguinated. The tourniquet was elevated at 290 mm/Hg. Construction lines were made on the left palm to identify the ring ray. A transverse incision was made in the wrist between FCR and FCU one fingerbreadth proximal to the interval between the glabrous skin of the palm and normal forearm skin. Blunt dissection exposed the antebrachial fascia. Hemostasis was obtained with bipolar cautery. A distal-based window in the antebrachial fascia was then fashioned. Care was taken to protect the underlying contents. A proximal forearm fasciotomy was performed under direct vision. A synovial elevator was used to palpate the undersurface of the transverse carpal ligament and synovium was elevated off this undersurface. Hamate sounds were then used to palpate the hook of hamate. The endoscopic instrument was then inserted into the proximal incision. The transverse carpal ligament was easily visualized through the portal. Using palmar pressure the transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end. The distal end of the transverse carpal ligament was then identified in the window. The blade was then elevated and the endoscopic instrument was withdrawn dividing the transverse carpal ligament under direct vision. After complete division o the transverse carpal ligament the instrument was reinserted. Radial and ulnar edges of the transverse carpal ligament were identified and complete release was confirmed. The wound was then closed with running subcuticular stitch. Steri-Strips were applied and sterile dressing was applied over the Steri-Strips. The tourniquet was deflated. The patient was awakened from anesthesia and returned to the Recovery Room in satisfactory condition having tolerated the procedure well. DE QUERVAIN S RELEASE With the patient under adequate regional anesthesia applied by surgeon using 1 plain Xylocaine the upper extremity was prepped and draped in a sterile manner. The arm was exsanguinated. The tourniquet was elevated to 290 mm/Hg. A transverse incision was then made over the radial aspect of the wrist overlying the first dorsal tunnel. Using blunt dissection the radial sensory nerve branches were dissected and retracted out of the operative field. The first dorsal tunnel was then identified. The first dorsal tunnel was incised along the dorsal ulnar border completely freeing the stenosing tenosynovitis de Quervain s release . EPB and APL tendons were inspected and found to be completely free. The radial sensory nerve was inspected and found to be without damage. The skin was closed with a running 3-0 Prolene subcuticular stitch and Steri-Strips were applied and over the Steri-Strips a sterile dressing and over the sterile dressing a volar splint with the hand in safe position. The tourniquet was deflated. The patient was returned to the holding area in satisfactory condition having tolerated the procedure well. | 27 Orthopedic |
PREOPERATIVE DIAGNOSIS Volar laceration to right ring finger with possible digital nerve injury with possible flexor tendon injury. POSTOPERATIVE DIAGNOSES 1. Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis. 2. 25 laceration to the flexor digitorum profundus of the right ring finger and laceration 100 of the ulnar digital nerve to the right ring finger. PROCEDURE PERFORMED 1. Repair of nerve and tendon right ring finger. 2. Exploration of digital laceration. ANESTHESIA General. ESTIMATED BLOOD LOSS Less than 10 cc. TOTAL TOURNIQUET TIME 57 minutes. COMPLICATIONS None. DISPOSITION To PACU in stable condition. BRIEF HISTORY OF PRESENT ILLNESS This is a 13-year-old male who had sustained a laceration from glass and had described numbness and tingling in his right ring finger. GROSS OPERATIVE FINDINGS After wound exploration it was found there was a 100 laceration to the ulnar digital neurovascular bundle. The FDS had a partial ulnar slip laceration and the FDP had a 25 transverse laceration as well. The radial neurovascular bundle was found to be completely intact. OPERATIVE PROCEDURE The patient was taken to the operating room and placed in the supine position. All bony prominences were adequately padded. Tourniquet was placed on the right upper extremity after being packed with Webril but not inflated at this time. The right upper extremity was prepped and draped in the usual sterile fashion. The hand was inspected. Palmar surface revealed approximally 0.5 cm laceration at the base of the right ring finger at the base of proximal phalanx which was approximated with nylon suture. The sutures were removed and the wound was explored. It was found that the ulnar digital neurovascular bundle was 100 transected. The radial neurovascular bundle on the right ring finger was found to be completely intact. We explored the flexor tendon and found that there was a partial laceration of the ulnar slip of the FDS and a 25 laceration in a transverse fashion to the FDP. We copiously irrigated the wound. Repair was undertaken of the FDS with #3-0 undyed Ethibond suture. The laceration of the FDP was not felt that it need to repair due to majority of the substance in the FDP was still intact. Attention during our repair at the flexor tendon the A1 pulley was incised for better visualization as well as better tendon excursion after repair. Attention was then drawn to the ulnar digital bundle which has been transected prior during the injury. The digital nerve was dissected proximally and distally to likely visualize the nerve. The nerve was then approximated using microvascular technique with #8-0 nylon suture. The hands were well approximated. The nerve was not under undue tension. The wound was then copiously irrigated and the skin was closed with #4-0 nylon interrupted horizontal mattress alternating with simple suture. Sterile dressing was placed and a dorsal extension Box splint was placed. The patient was transferred off of the bed and placed back on a gurney and taken to PACU in stable condition. Overall prognosis is good. | 23 Neurosurgery |
IDENTIFYING DATA The patient is a 30-year-old white male with a history of schizophrenia chronic paranoid was admitted for increasing mood lability paranoia and agitation. CHIEF COMPLAINT I am not sure. The patient has poor insight into hospitalization and need for treatment. HISTORY OF PRESENT ILLNESS The patient has a history of schizophrenia and chronic paranoid for which she has received treatment in Houston Texas. According to mental health professionals the patient had been noncompliant with medications for approximately two weeks. The patient had taken an airplane from Houston to Seattle but became agitated paranoid expressing paranoid delusions that the stewardess and pilots were trying to reject him and was deplaned in Seattle. The patient was taken to the local shelter where he remained labile breaking a window and was taken to jail. The patient has now been discharged from jail but involuntarily detained for persistent paranoia and disorganization no jail hold . PAST PSYCHIATRIC HISTORY History of schizophrenia chronic paranoid. The patient as noted has been treated in Houston but has not had recent treatment or medications. PAST MEDICAL HISTORY No acute medical problems noted. CURRENT MEDICATIONS None. The patient was most recently treated with Invega and Abilify according to his records. FAMILY SOCIAL HISTORY The patient resides with his father in Houston. The patient has no known history of substances abuse. The patient as noted was in jail prior to admission after breaking a window at the local shelter but has no current jail hold. FAMILY PSYCHIATRIC HISTORY Need to increase database. MENTAL STATUS EXAMINATION Attitude Calm and cooperative. Appearance Shows poor hygiene and grooming. Psychomotor Behavior is within normal limits without agitation or retardation. No EPS or TDS noted. Affect Is suspicious. Mood Anxious but cooperative. Speech Shows normal rate and rhythm. Thoughts Disorganized Thought Content Remarkable for paranoia they want to hurt me. Psychosis The patient endorses paranoid delusions as above. The patient denies auditory hallucinations. Suicidal/Homicidal Ideation The patient denies on admission. Cognitive Assessment Grossly intact. The patient is alert and oriented x 3. Judgment Poor shown by noncompliance with treatment. Assets Include stable physical status. Limitations Include recurrent psychosis. FORMULATION The patient with a history of schizophrenia was admitted for increasing mood lability and psychosis due to noncompliance with treatment. INITIAL IMPRESSION AXIS I Schizophrenia chronic paranoid. AXIS II None. AXIS III None. AXIS IV Severe. AXIS V 10. ESTIMATED LENGTH OF STAY 12 days. PLAN The patient will be restarted on Invega and Abilify for psychosis. The patient will also be continued on Cogentin for EPS. Increased database will be obtained. | 5 Consult - History and Phy. |
CHIEF COMPLAINT 1/1 This 62 year old female presents today for evaluation of angina. Associated signs and symptoms Associated signs and symptoms include chest pain nausea pain radiating to the arm and pain radiating to the jaw. Context The patient has had no previous treatments for this condition. Duration Condition has existed for 5 hours. Quality Quality of the pain is described by the patient as crushing. Severity Severity of condition is severe and unchanged. Timing onset/frequency Onset was sudden and with exercise. Patient has the following coronary risk factors smoking 1 packs/day for 40 years and elevated cholesterol for 5 years. Patient s elevated cholesterol is not being treated with medication. Menopause occurred at age 53. ALLERGIES No known medical allergies. MEDICATION HISTORY Patient is currently taking Estraderm 0.05 mg/day transdermal patch. PMH Past medical history unremarkable. PSH No previous surgeries. SOCIAL HISTORY Patient admits tobacco use She relates a smoking history of 40 pack years. FAMILY HISTORY Patient admits a family history of heart attack associated with father deceased . ROS Unremarkable with exception of chief complaint. PHYSICAL EXAMINATION General Patient is a 62 year old female who appears pleasant her given age well developed oriented well nourished alert and moderately overweight. Vital Signs BP Sitting 174/92 Resp 28 HR 88 Temp 98.6 Height 5 ft. 2 in. Weight 150 lbs. HEENT Inspection of head and face shows head that is normocephalic atraumatic without any gross or neck masses. Ocular motility exam reveals muscles are intact. Pupil exam reveals round and equally reactive to light and accommodation. There is no conjunctival inflammation nor icterus. Inspection of nose reveals no abnormalities. Inspection of oral mucosa and tongue reveals no pallor or cyanosis. Inspection of the tongue reveals normal color good motility and midline position. Examination of oropharynx reveals the uvula rises in the midline. Inspection of lips teeth gums and palate reveals healthy teeth healthy gums no gingival hypertrophy no pyorrhea and no abnormalities. Neck Neck exam reveals neck supple and trachea that is midline without adenopathy or crepitance palpable. Thyroid examination reveals smooth and symmetric gland with no enlargement tenderness or masses noted. Carotid pulses are palpated bilaterally are symmetric and no bruits auscultated over the carotid and vertebral arteries. Jugular veins examination reveals no distention or abnormal waves were noted. Neck lymph nodes are not noted. Back Examination of the back reveals no vertebral or costovertebral angle tenderness and no kyphosis or scoliosis noted. Chest Chest inspection reveals intercostal interspaces are not widened no splinting chest contours are normal and normal expansion. Chest palpation reveals no abnormal tactile fremitus. Lungs Chest percussion reveals resonance. Assessment of respiratory effort reveals even respirations without use of accessory muscles and diaphragmatic movement normal. Auscultation of lungs reveal diminished breath sounds bibasilar. Heart The apical impulse on heart palpation is located in the left border of cardiac dullness in the midclavicular line in the left fourth intercostal space in the midclavicular line and no thrill noted. Heart auscultation reveals rhythm is regular normal S1 and S2 no murmurs gallop rubs or clicks and no abnormal splitting of the second heart sound which moves normally with respiration. Right leg and left leg shows evidence of edema +6. Abdomen Abdomen soft nontender bowel sounds present x 4 without palpable masses. Palpation of liver reveals no abnormalities with respect to size tenderness or masses. Palpation of spleen reveals no abnormalities with respect to size tenderness or masses. Examination of abdominal aorta shows normal size without presence of systolic bruit. Extremities Right thumb and left thumb reveals clubbing. Pulses The femoral popliteal dorsalis pedis and posterior tibial pulses in the lower extremities are equal and normal. The brachial radial and ulnar pulses in the upper extremities are equal and normal. Examination of peripheral vascular system reveals varicosities absent extremities warm to touch edema present - pitting and pulses are full to palpation. Femoral pulses are 2 /4 bilateral. Pedal pulses are 2 /4 bilateral. Neurological Testing of cranial nerves reveals nerves intact. Oriented to person place and time. Mood and affect normal and appropriate to situation.Deep tendon reflexes normal. Touch pin vibratory and proprioception sensations are normal. Babinski reflex is absent. Coordination is normal. Speech is not aphasic. Musculoskeletal Muscle strength is 5/5 for all groups tested. Gait and station examination reveals midposition without abnormalities. Skin No skin rash subcutaneous nodules lesions or ulcers observed. Skin is warm and dry with normal turgor and there is no icterus. Lymphatics No lymphadenopathy noted. IMPRESSION Angina pectoris other and unspecified. PLAN DIAGNOSTIC LAB ORDERS Ordered serum creatine kinase isoenzymes CK isoenzymes . Electrocardiogram routine ECG with at least 12 leads with interpretation and report. The following cardiac risk factor modifications are recommended quit smoking and reduce LDL cholesterol to below 120 mg/dl. PATIENT INSTRUCTIONS | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSIS Dentigerous cyst left mandible associated with full bone impacted wisdom tooth #17. POSTOPERATIVE DIAGNOSIS Dentigerous cyst left mandible associated with full bone impacted wisdom tooth #17. PROCEDURE Removal of benign cyst and extraction of full bone impacted tooth #17. ANESTHESIA General anesthesia with nasal endotracheal intubation. SPECIMEN Cyst and section tooth #17. ESTIMATED BLOOD LOSS 10 mL. FLUIDS 1200 of Lactated Ringer s. COMPLICATIONS None. CONDITION The patient was extubated and transported to the PACU in good condition. Breathing spontaneously. INDICATION FOR PROCEDURE The patient is a 38-year-old Caucasian male who was referred to clinic to evaluate a cyst in his left mandible. Preoperatively a biopsy of the cyst was obtained and it was noted to be a benign dentigerous cyst. After evaluation of the location of the cyst and the impacted wisdom tooth approximately the inferior border of the mandible it was determined that the patient would benefit from removal of the cyst and removal of tooth #17 under general anesthesia in the operating room. Risks benefits and alternatives of treatment were thoroughly discussed with the patient and consent was obtained. DESCRIPTION OF PROCEDURE The patient was taken to the operating room #1 at Hospital and laid in the supine fashion on the operating room table. As stated general anesthesia was induced with IV anesthetics and maintained with nasal endotracheal intubation and inhalation anesthetics. The patient was prepped and draped in usual oro-maxillofacial surgery fashion. Approximately #6 mL of 2 lidocaine with 1 100 000 epinephrine was injected in the usual nerve block fashion. After waiting appropriate time for local anesthesia to take effect a moistened Ray-Tec sponge was placed in the posterior pharynx. Peridex mouth rinse was used to prep the oral cavity. This was removed with suction. Using a #15 blade a sagittal split osteotomy incision was made along the left ramus. A full-thickness mucoperiosteal flap was elevated and the crest of the bone was identified where the crown had super-erupted since the biopsy 6 weeks earlier. Using a Hall drill a buccal osteotomy was developed the tooth was sectioned in half fractured with an elevator and delivered in two pieces. Using a double-ended curette the remainder of the cystic lining was removed from the left mandible and sent to pathology with the tooth for review. The area was irrigated with copious amounts of sterile water and closed with 3-0 chromic gut suture. The throat pack was removed. The procedure was then determined to be over and the patient was extubated breathing spontaneously and transported to the PACU in good condition. | 38 Surgery |
PREOPERATIVE DIAGNOSIS Gross hematuria. POSTOPERATIVE DIAGNOSIS Gross hematuria. OPERATIONS Cystopyelogram clot evacuation transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder. ANESTHESIA Spinal. FINDINGS Significant amount of bladder clots measuring about 150 to 200 mL two cupful of clots were removed. There was papillary tumor on the left wall right at the bladder neck and one on the right dome near the bladder neck on the right side. The right ureteral opening was difficult to visualize the left one was normal. BRIEF HISTORY The patient is a 78-year-old male with history of gross hematuria and recurrent UTIs. The patient had hematuria. Cystoscopy revealed atypical biopsy. The patient came in again with gross hematuria. The first biopsy was done about a month ago. The patient was to come back and have repeat biopsies done but before that came into the hospital with gross hematuria. The options of watchful waiting removal of the clots and biopsies were discussed. Risk of anesthesia bleeding infection pain MI DVT and PE were discussed. Morbidity and mortality of the procedure were discussed. Consent was obtained from the daughter-in-law who has the power of attorney in Florida. DESCRIPTION OF PROCEDURE The patient was brought to the OR. Anesthesia was applied. The patient was placed in the dorsal lithotomy position. The patient was prepped and draped in the usual sterile fashion. The patient had been off of the Coumadin for about 4 days and INR had been reversed. The patient has significant amount of clot upon entering the bladder. There was a tight bladder neck contracture. The prostate was not enlarged. Using ACMI 24-French sheath using Ellick irrigation about 2 cupful of clots were removed. It took about half an hour to just remove the clots. After removing the clots using 24-French cutting loop resectoscope tumor on the left upper wall near the dome or near the 2 o clock position was resected. This was lateral to the left ureteral opening. The base was coagulated for hemostasis. Same thing was done at 10 o clock on the right side where there was some tumor that was visualized. The back wall and the rest of the bladder appeared normal. Using 8-French cone-tip catheter left-sided pyelogram was normal. The right-sided pyelogram was very difficult to obtain and there was some mucosal irritation from the clots. The contrast did go up to what appeared to be the right ureteral opening but the mucosa seemed to be very much irritated and it was very difficult to actually visualize the opening. A little bit of contrast went out but the force was not made just to avoid any secondary stricture formation. The patient did have CT with contrast which showed that the kidneys were normal. At this time a #24 three-way irrigation was started. The patient was brought to Recovery room in stable condition. | 39 Urology |
REASON FOR VISIT Mr. ABC is a 61-year-old Caucasian male who presents to us today as a new patient. He states that he has difficulty with both his distance vision and also with fine print at near. HISTORY OF PRESENT ILLNESS Mr. ABC states that over the last year he has had increasing difficulty with distance vision particularly when he is driving. He is also having trouble when he is reading. He does occasionally wear over-the-counter reading glasses which do help with his near vision. Past ocular history is significant for astigmatism for which he wore glasses since he was 18 years old. However Mr. ABC mentioned today that he has not worn his glasses for the last few years. His past medical history is significant for hypertension low serum testosterone level hypercholesterolemia GERD depression actinic keratoses and a history of Pityrosporum folliculitis. His family history is significant for diabetes in both parents. He states that his mother is seen by Mrs. Goldberg but he is not aware of her ocular history. He has no known family history of glaucoma age-related macular degeneration or hereditary blindness. MEDICATIONS Wellbutrin XL 450 mg daily Ritalin long-acting 60 mg daily hydrochlorothiazide at an unknown dose Vytorin at an unknown dose and aspirin. ALLERGIES No known drug allergies. FINDINGS Visual acuity today without correction was 20/20 -2 pinholing to 20/16 in the right eye and 20/40 +2 pinholing to 20/16 in the left eye. Near vision unaided was J2 in both eyes. Manifest refraction today following pharmacological dilation was -0.50 +0.50 times 155 in the right eye revealing a vision of 20/16. Manifest refraction was -1.00 +0.25 times 005 revealing a vision of 20/16 in the left eye. The add was +2 in both eyes. Visual fields are full to finger counting in both eyes. Extraocular movements were within normal limits. Intraocular pressure by applanation was 16 mmHg in the right eye and 18 mmHg in the left eye measured at 11.30 in the morning. Examination of the anterior segment was unremarkable in both eyes except for mild nuclear sclerotic opacities in both eyes. Dilated fundus examination of the right eye revealed a sharp and pink optic disc with a healthy rim and cup-to-disc ratio of 0.7 however there was central excavation of the disc but no disc hemorrhages were noted. On examination of the macula there were drusen scattered temporally. Examination of the vasculature was normal. Peripheral retinal examination was entirely normal. On funduscopic examination of the left eye there was a sharp and pink disc with a healthy rim but with central excavation and a cup-to-disc ratio of 0.6. Of note there were no disc hemorrhages. On examination of the macula there was scattered tiny drusen centrally and superiorly. Examination of the vasculature was entirely normal. Peripheral fundus examination was unremarkable. ASSESSMENT 1. Age-related macular degeneration category three right greater than sign left . 2. Glaucoma suspect based on disc appearance increased cup-to-disc ratio and disc asymmetry . 3. Presbyopia and astigmatism. 4. Non-visually significant cataracts bilaterally. PLANS 1. The above diagnoses and management plans each were discussed with the patient who expressed understanding. 2. Commence Ocuvite PreserVision capulets one tablet twice a day by mouth for age-related macular degeneration. 3. Humphrey visual field and disc photographs today for baseline documentation in view of glaucoma suspicion. 4. Followup in Glaucoma Clinic arranged in 4 months time with repeat Humphrey visual fields at this time for reevaluation and comparison. 5. Follow up with Mrs. Braithwaite in the Comprehensive Eye Service Clinic for undilated refraction. 6. We will follow up this gentleman in our clinic in 12 months time however I have asked him to return to us soon should he develop any worsening ocular symptoms in the interim. | 5 Consult - History and Phy. |
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. | 22 Neurology |
REASON FOR VISIT The patient presents for a followup for history of erythema nodosum. HISTORY OF PRESENT ILLNESS This is a 25-year-old woman who is attending psychology classes. She was diagnosed with presumptive erythema nodosum in 2004 based on a biopsy consistent with erythema nodosum but not entirely specific back in Netherlands. At that point she had undergone workup which was extensive for secondary diseases associated with erythema nodosum. Part of her workup included a colonoscopy. The findings were equivocal characterizes not clearly abnormal biopsies of the terminal ileum. The skin biopsy in particular mentions some fibrosis basal proliferation and inflammatory cells in the subcutis. Prior to the onset of her erythema nodosum she had a tibia-fibula fracture several years before on the right which was not temporarily associated with the skin lesions which are present in both legs anyway. Even a jaw cosmetic surgery she underwent was long before she started developing her skin lesions. She was seen in our clinic and by Dermatology on several occasions. Apart from the first couple of visits when she presented stating a recurrent skin rash with a description suggestive of erythema nodosum in the lower extremities and ankle and there is discomfort pointing towards a possible inflammatory arthritis and an initial high sed rate of above 110 with an increased CRP. In the following visits no evident abnormality has been detected. In the first visit here some MTP discomfort detected. It was thought that erythema nodosum may be present. However the evaluation of Dermatology did not concur and it was thought that the patient had venous stasis which could be related to her prior fracture. When she was initially seen here a suspicion of IBD sarcoid inflammatory arthropathy and lupus was raised. She had an equivocal rheumatoid fracture but her CCP was negative. She had an ANA which was positive at 1 40 with a speckled pattern persistently but the rest of the lupus serologies including double-stranded DNA RNP Smith Ro La were negative. Her cardiolipin panel antibodies were negative as well. We followed the IgM IgG and IgA being less than 10. However she did have a beta-2 glycoprotein 1 or an RVVT tested and this may be important since she has a livedo pattern. It was thought that the onset of lupus may be the case. It was thought that rheumatoid arthritis could not be the case since it is not associated with erythema nodosum. For the fear of possible lymphoma she underwent CT of the chest abdomen and pelvis. It was done also in order to rule out sarcoid and the result was unremarkable. Based on some changes in her bowel habits and evidence of B12 deficiency with a high methylmalonic and high homocystine levels along with a low normal B12 in addition to iron studies consistent with iron deficiency and an initially low MCV the possibility of inflammatory bowel disease was employed. The patient underwent an initially unrevealing colonoscopy and a capsule endoscopy which was normal. A second colonoscopy was done recently and microscopically no evidence of inflammatory bowel disease was seen. However eosinophil aggregations were noted in microscopy and this was told to be consistent with an allergic reaction or an emerging Crohn disease and I will need to discuss with Gastroenterology what is the significance of that. Her possible B12 deficiency and iron deficiency were never addressed during her stay here in the United States. In the initial appointment she was placed on prednisone 40 mg which was gradually titrated down this led to an exacerbation of her acne. We decided to take her off prednisone due to adverse effects and start her on colchicine 0.6 mg daily. While this kept things under control with the inflammatory markers being positive and no overt episodes of erythema nodosum the patient still complains for sensitivity with less suspicious skin rash in the lower extremities and occasional ankle swelling and pain. She was reevaluated by Dermatology for that and no evidence of erythema nodosum was felt to be present. Out plan was to proceed with a DEXA scan at some point check a vitamin D level and order vitamin D and calcium over the counter for bone protection purposes. However the later was deferred until we have resolved the situation and find out what is the underlying cause of her disease. Her past medical history apart from the tibia-fibular fracture and the jaw cosmetic surgery is significant for varicella and mononucleosis. Her physical examination had shown consistently diffuse periarticular ankle edema and also venous stasis changes at least until I took over her care last August. I have not been able to detect any erythema nodosum however a livedo pattern has been detected consistently. She also has evidence of acne which does not seem to be present at the moment. She also was found to have a heart murmur present and we are going to proceed with an echocardiogram placed. Her workup during the initial appointment included an ACE level which was normal. She also had a rather higher sed rate up to 30 but prior to that per report it was even higher above 110. Her RVVT was normal her rheumatoid factor was negative. Her ANA was 1 40 speckled pattern. The double-stranded DNA was negative. Her RNP and Smith were negative as well. RO and LA were negative and cardiolipin antibodies were negative as well. A urinalysis at the moment was completely normal. A CRP was 2.3 in the initial appointment which was high. A CCP was negative. Her CBC had shown microcytosis and hypochromia with a hematocrit of 37.7. This improved later without any evidence of hypochromia microcytosis or anemia with a hematocrit of 40.3. The patient returns here today as I mentioned complaining of milder bouts of skin rash which she calls erythema nodosum which is accompanied by arthralgias especially in the ankles. I am mentioning here that photosensitivity rash was mentioned in the past. She tells me that she had it twice back in Europe after skiing where her whole face was swollen. Her acne has been very stable after she was taken off prednisone and was started on colchicine 0.6 daily. Today we discussed about the effect of colchicine on a possible pregnancy. MEDICATIONS Prednisone was stopped. Vitamin D and calcium over the counter we need to verify that. Colchicine 0.6 mg daily which we are going to stop ranitidine 150 mg as needed which she does not take frequently. FINDINGS On physical examination she is very pleasant alert and oriented x 3 and not in any acute distress. There is some evidence of faint subcutaneous lesions in both shins bilaterally but with mild tenderness but no evidence of classic erythema nodosum. Stasis dermatitis changes in both lower extremities present. Mild livedo reticularis is present as well. There is some periarticular ankle edema as well. Laboratory data from 04/23/07 show a normal complete metabolic profile with a creatinine of 0.7 a CBC with a white count of 7880 hematocrit of 40.3 and platelets of 228. Her microcytosis and hypochromia has resolved. Her serum electrophoresis does not show a monoclonal abnormality. Her vitamin D levels were 26 which suggests some mild insufficiency and she would probably benefit by vitamin D supplementation. This points again towards some ileum pathology. Her ANCA B and C were negative. Her PF3 and MPO were unremarkable. Her endomysial antibodies were negative. Her sed rate at this time were 19. The highest has been 30 but prior to her appointment here was even higher. Her ANA continues to be positive with a titer of 1 40 speckled pattern. Her double-stranded DNA is negative. Her serum immunofixation confirmed the absence of monoclonal abnormality. Her urine immunofixation was not performed. Her IgG IgA and IgM levels are normal. Her IgE levels are normal as well. A urinalysis was not performed this time. Her CRP is 0.4. Her tissue transglutaminase antibodies are negative. Her ASCA is normal and anti-OmpC was not tested. Gliadin antibodies IgA is 12 which is in the borderline to be considered equivocal but these are nonspecific. I am reminding here that her homocystine levels have been 15.7 slightly higher and that her methylmalonic acid was 385 which is obviously abnormal. Her B12 levels were 216 which is rather low possibly indicating a B12 deficiency. Her iron studies showed a ferritin of 15 a saturation of 9 and an iron of 30. Her TIBC was 345 pointing towards an iron deficiency anemia. I am reminding you that her ACE levels in the past were normal and that she has a microcytosis. Her radiologic workup including a thoracic abdominal and pelvic CT did not show any suspicious adenopathy but only small aortocaval and periaortic nodes the largest being 8 mm in short axis likely reactive. Her pelvic ultrasound showed normal uterus adnexa. Her bladder was normal as well. Subcentimeter inguinal nodes were found. There was no large lytic or sclerotic lesion noted. Her recent endoscopy was unremarkable but the microscopy showed some eosinophil aggregation which may be pointing towards allergy or an evolving Crohn disease. Her capsule endoscopy was limited secondary to rapid transit. There was only a tiny mucosal red spot in the proximal jejunum without active bleeding 2 possible erosions were seen in the distal jejunum and proximal ileum. However no significant inflammation or bleeding was seen and this could be small bowel crisis. Neither evidence of bleeding or inflammation were seen as well. Specifically the terminal ileum appeared normal. Recent evaluation by a dermatologist did not verify the presence of erythema nodosum. ASSESSMENT This is a 25-year-old woman diagnosed with presumptive erythema nodosum in 2004. She has been treated with prednisone as in the beginning she had also a wrist and ankle discomfort and high inflammatory markers. Since I took over her care I have not seen a clear-cut erythema nodosum being present. No evidence of synovitis was there. Her serologies apart from an ANA of 1 40 were negative. She has a livedo pattern which has been worrisome. The issue here was a possibility of inflammatory bowel disease based on deficiency in vitamin B12 as indicated by high methylmalonic and homocystine levels and also iron deficiency. She also has low vitamin D levels which point towards terminal ileum pathology as well and she had a history of decreased MCV. We never received the x-ray of her hands which she had and she never had a DEXA scan. Lymphoma has been ruled out and we believe that inflammatory bowel disease after repeated colonoscopies and the capsule endoscopy has been ruled out as well. Sarcoid is probably not the case since the patient did not have any lymphadenopathies and her ACE levels were normal. We are going check a PPD to rule out tuberculosis. We are going to order an RVVT and glycoprotein beta-1 levels in her workup to make sure that an antiphospholipid syndrome is not present given the livedo pattern. An anti-intrinsic factor will be added as well. Her primary care physician needs to workup the possible B12 and iron deficiency and also the vitamin D deficiency. In the meanwhile we feel that the patient should stop taking the colchicine and if she has a flare of her disease then she should present to her dermatologist and have the skin biopsy performed in order to have a clear-cut answer of what is the nature of this skin rash. Regarding her heart murmur we are going to proceed with an echocardiogram. A PPD should be placed as well. In her next appointment we may fax a requisition for vitamin B replacement. PROBLEMS/DIAGNOSES 1. Recurrent erythema nodosum with ankle and wrist discomfort arthritis. 2. Iron deficiencies according to iron studies. 3. Borderline B12 with increased methylmalonic acid and homocystine. 4. On chronic steroids vitamin D and calcium is needed she needs a DEXA scan. 5. Typical ANCA per records were not verified here. ANCA and ASCA were negative and the OmpC was not ordered. 6. Acne. 7. Recurrent arthralgia not present. Rheumatoid factor CCP negative ANA 1 40 speckled. 8. Livedo reticularis beta 2-glycoprotein was not checked we are going to check it today. Needs vaccination for influenza and pneumonia. 9. Vitamin D deficiency. She needs replacement with ergocalciferol but this may point towards pathology as this was not detected. 10. Recurrent ankle discomfort which necessitates ankle x-rays. PLANS We can proceed with part of her workup here in clinic PPD echocardiogram ankle x-rays and anti-intrinsic factor antibodies. We can start repleting her vitamin D with weeks of ergocalciferol 50 000 weekly. We can add an RVVT and glycoprotein to her workup in order to rule out any antiphospholipid syndrome. She should be taking vitamin D and calcium after the completion of vitamin D replacement. She should be seen by her primary care physician have the iron and B12 deficiency worked up. She should stop the colchicine and if the skin lesion recurs then she should be seen by her dermatologist. Based on the physical examination we do not suspect that the patient has the presence of any other disease associated with erythema nodosum. We are going to add an amylase and lipase to evaluate her pancreatic function RPR HIV serologies. Given the evidence of possible malabsorption it may be significant to proceed with an upper endoscopy to rule out Whipple disease or celiac disease which can sometimes be associated with erythema nodosum. An anti-intrinsic factor would be added as I mentioned. I doubt whether the patient has Behcet disease given the absence of oral or genital ulcers. She does not give a history of oral contraceptives or medications that could be related to erythema nodosum. She does not have any evidence of lupus mycosis. Histoplasmosis coccidioidomycosis would be accompanied by other symptoms. Hodgkin disease has probably been ruled out with a CAT scan. However we are going to add an LDH in future workup. I need to discuss with her primary care physician regarding the need for workup of her vitamin B12 deficiency and also with her gastroenterologist regarding the need for an upper endoscopy. The patient will return in 1 month. | 8 Dermatology |
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. | 16 Hematology - Oncology |
PREOPERATIVE DIAGNOSIS Cervical myelopathy C3-4 secondary to stenosis from herniated nucleus pulposus C3-4. POSTOPERATIVE DIAGNOSES Cervical myelopathy C3-4 secondary to stenosis from herniated nucleus pulposus C3-4. OPERATIVE PROCEDURES 1. Anterior cervical discectomy with decompression C3-4. 2. Arthrodesis with anterior interbody fusion C3-4. 3. Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws all titanium . 4. Implant using PEEK 7 mm. 5. Allograft using Vitoss. DRAINS Round French 10 JP drain. FLUIDS 1800 mL of crystalloids. URINE OUTPUT 1000 mL. SPECIMENS None. COMPLICATIONS None. ANESTHESIA General endotracheal anesthesia. ESTIMATED BLOOD LOSS Less than 100 mL. CONDITION To postanesthesia care unit extubated with stable vital signs. INDICATIONS FOR THE OPERATION This is a case of a very pleasant 32-year-old Caucasian male who had been experiencing posterior neck discomfort and was shooting basketball last week during which time he felt a pop. Since then the patient started complaining of acute right arm and right leg weakness which had been progressively worsening. About two days ago he started noticing weakness on the left arm. The patient also noted shuffling gait. The patient presented to a family physician and was referred to Dr. X for further evaluation. Dr. X could not attempt to this so he called me at the office and the patient was sent to the emergency room where an MRI of the brain was essentially unremarkable as well as MRI of the thoracic spine. MRI of the cervical spine however revealed an acute disk herniation at C3-C4 with evidence of stenosis and cord changes. Based on these findings I recommended decompression. The patient was started on Decadron at 10 mg IV q.6h. Operation expected outcome risks and benefits were discussed with him. Risks to include but not exclusive of bleeding and infection. Bleeding can be superficial but can compromise airway for which he has been told that he may be brought emergently back to the operating room for evacuation of said hematoma. The hematoma could also be an epidural hematoma which may compress the spinal cord and result in weakness of all four extremities numbness of all four extremities and impairment of bowel and bladder function. Should this happen he needs to be brought emergently back to the operating room for evacuation of said hematoma. There is also the risk by removing the hematoma that he can deteriorate as far as neurological condition but this hopefully with the steroid prep will be prevented or if present will only be transient. There is also the possibility of infection which can be superficial and treated with IV and p.o. antibiotics. However should the infection be extensive or be deep he may require return to the operating room for debridement and irrigation. This may pose a medical problem since in the presence of infection the graft as well as spinal instrumentation may have to be removed. There is also the possibility of dural tear with its attendant complaints of headache nausea vomiting photophobia as well as the development of pseudomeningocele. This too can compromise airway and may require return to the operating room for repair of the dural tear. There is also potential risk of injury to the esophagus the trachea as well as the carotid. The patient can also have a stroke on the right cerebral circulation should the plaque be propelled into the right circulation. The patient understood all these risks together with the risk associated with anesthesia and agreed to have the procedure performed. DESCRIPTION OF PROCEDURE The patient was brought to the operating room awake alert and not in any form of distress. After smooth induction and intubation a Foley catheter was inserted. No monitoring leads were placed. The patient was then positioned supine on the operating table with the head supported on a foam doughnut and the neck placed on hyperextension with a shoulder roll under both shoulders. Localizing x-ray verified the marker to be right at the C3-4 interspace. Proceeded to mark an incision along the anterior border of the sternocleidomastoid with the central point at the area of the marker measuring about 3 cm in length. The area was then prepped with DuraPrep. After sterile drapes were laid out an incision was made using a scalpel blade #10. Wound edge bleeders were controlled with bipolar coagulation and a hot knife was utilized to cut the platysma in a similar fashion. The anterior border of the sternocleidomastoid was identified and dissection was carried superior to and lateral to the esophagus and trachea but medial to the carotid sheath. The prevertebral fascia was identified. Localizing x-ray verified another marker to be at the C3-4 interspace. Proceeded to strip the longus colli muscles off the vertebral body of C3 and C4 and a self-retaining retractor was then laid out. There was some degree of anterior osteophyte and this was carefully drilled down with a Midas 5-mm bur. The disk was then cut through the annulus and removal of the disk was done with the use of the Midas 5-mm bur and later a 3-mm bur. The inferior endplate of C3 and the superior endplate of C4 were likewise drilled out together with posterior inferior osteophyte at the C3 and the posterior superior osteophyte at C4. There was note of a central disk herniation centrally but more marked displacement of the cord on the left side. By careful dissection of this disk posterior longitudinal ligament was removed and pressure on the cord was removed. Hemostasis of the epidural bleeders was done with a combination of bipolar coagulation but we needed to put a small piece of Gelfoam on the patient s left because of profuse venous bleeder. With this completed the Valsalva maneuver showed no evidence of any CSF leakage. A 7-mm implant with its interior packed with Vitoss was then tapped into place. An 18-mm plate was then screwed down with four 14 x 4.0 mm screws. The area was irrigated with saline with bacitracin solution. Postoperative x-ray showed excellent placement of the graft and spinal instrumentation. A round French 10 JP drain was laid over the construct and exteriorized though a separate stab incision on the patient s right inferiorly. The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures for the platysma Vicryl 4-0 subcuticular stitch for the dermis and Dermabond. The catheter was anchored to the skin with a nylon 3-0 stitch. Dressing was placed only on the exit site of the drain. C-collar was placed and the patient was transferred to the recovery awake and moving all four extremities. | 27 Orthopedic |
HISTORY OF PRESENT ILLNESS This 57-year-old black female was seen in my office on Month DD YYYY for further evaluation and management of hypertension. Patient has severe backache secondary to disc herniation. Patient has seen an orthopedic doctor and is scheduled for surgery. Patient also came to my office for surgical clearance. Patient had cardiac cath approximately four years ago which was essentially normal. Patient is documented to have morbid obesity and obstructive sleep apnea syndrome. Patient does not use a CPAP mask. Her exercise tolerance is eight to ten feet for shortness of breath. Patient also has two-pillow orthopnea. She has intermittent pedal edema. PHYSICAL EXAMINATION VITAL SIGNS Blood pressure is 135/70. Respirations 18 per minute. Heart rate 70 beats per minute. Weight 258 pounds. HEENT Head normocephalic. Eyes no evidence of anemia or jaundice. Oral hygiene is good. NECK Supple. JVP is flat. Carotid upstroke is good. LUNGS Clear. CARDIOVASCULAR There is no murmur or gallop heard over the precordium. ABDOMEN Soft. There is no hepatosplenomegaly. EXTREMITIES The patient has no pedal edema. MEDICATIONS 1. BuSpar 50 mg daily. 2. Diovan 320/12.5 daily. 3. Lotrel 10/20 daily. 4. Zetia 10 mg daily. 5. Ambien 10 mg at bedtime. 6. Fosamax 70 mg weekly. DIAGNOSES 1. Controlled hypertension. 2. Morbid obesity. 3. Osteoarthritis. 4. Obstructive sleep apnea syndrome. 5. Normal coronary arteriogram. 6. Severe backache. PLAN 1. Echocardiogram stress test. 2 Routine blood tests. 3. Sleep apnea study. 4. Patient will be seen again in my office in two weeks. | 3 Cardiovascular / Pulmonary |
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. | 5 Consult - History and Phy. |
PREOPERATIVE DIAGNOSIS Bilateral hydroceles. POSTOPERATIVE DIAGNOSIS Bilateral hydroceles. PROCEDURE Bilateral scrotal hydrocelectomies large for both and 0.5 Marcaine wound instillation 30 mL given. ESTIMATED BLOOD LOSS Less than 10 mL. FLUIDS RECEIVED 800 mL. TUBES AND DRAINS A 0.25-inch Penrose drains x4. INDICATIONS FOR OPERATION The patient is a 17-year-old boy who has had fairly large hydroceles noted for some time. Finally he has decided to have them get repaired. Plan is for surgical repair. DESCRIPTION OF OPERATION The patient was taken to the operating room where surgical consent operative site and patient identification were verified. Once he was anesthetized he was then shaved prepped and then sterilely prepped and draped. IV antibiotics were given. Ancef 1 g given. A scrotal incision was then made in the right hemiscrotum with a 15-blade knife and further extended with electrocautery. Electrocautery was used for hemostasis. Once we got to the hydrocele sac itself we then opened and delivered the testis drained clear fluid. There was moderate amount of scarring on the testis itself from the tunica vaginalis. It was then wrapped around the back and sutured in place with a running suture of 4-0 chromic in a Lord maneuver. Once this was done a drain was placed in the base of the scrotum and then the testis was placed back into the scrotum in the proper orientation. A similar procedure was performed on the left which has also had a hydrocele of the cord which were both addressed and closed with Lord maneuver similarly. This testis also was normal but had moderate amount of scarring on the tunic vaginalis from this. A similar drain was placed. The testes were then placed back into the scrotum in a proper orientation and the local wound instillation and wound block was then placed using 30 mL of 0.5 Marcaine without epinephrine. IV Toradol was given at the end of the procedure. The skin was then sutured with a running interlocking suture of 3-0 Vicryl and the drains were sutured to place with 3-0 Vicryl. Bacitracin dressing ABD dressing and jock strap were placed. The patient was in stable condition upon transfer to the recovery room. | 38 Surgery |
SUBJECTIVE This is an 18-year-old white female who presents for complete physical Pap and breast exam and to have paperwork filled out for college. She denies any problems at this time. Her last Pap smear was 06/25/2003 and was normal. She is requesting to switch from Ortho-Tri-Cyclen to Seasonale at this time. We did discuss that she may have increased episodes of breakthrough bleeding. PAST MEDICAL HISTORY Fever blisters and allergic rhinitis. MEDICATIONS Allegra 180 mg q.d. trazodone 50 mg p.r.n. q.h.s. and Ortho-Tri-Cyclen. ALLERGIES None. SOCIAL HISTORY Denies tobacco or drug use rare alcohol use. She is sexually active and has had one partner. FAMILY HISTORY Positive for rheumatoid arthritis. REVIEW OF SYSTEMS HEENT pulmonary cardiovascular GI GU musculoskeletal neurologic dermatologic constitutional and psychiatric all negative except for HPI. OBJECTIVE Vital Signs Height 5 feet 6 inches. Weight 153 pounds. Blood pressure 106/72. Pulse 68. Respirations 12. Temperature 97.5. Last menstrual period 05/30/2004. General She is a well-developed well-nourished white female in no acute distress. HEENT Tympanic membranes unremarkable. Oropharynx nonerythematous. Pupils equal round and reactive to light. Extraocular muscles intact. Neck Supple. No lymphadenopathy and no thyromegaly. Chest Clear to auscultation bilaterally. CV Regular rate and rhythm without murmur. Abdomen Positive bowel sounds. Soft and nontender. No hepatosplenomegaly. Breasts No nipple discharge. No lumps or masses palpated. No dimpling of the skin. No axillary lymph nodes palpated. Self-breast exam discussed and encouraged. Pelvic Normal female genitalia. Normal vaginal rugation. No cervical lesions. No cervical motion tenderness. No adnexal tenderness or masses palpated. Extremities No cyanosis clubbing or edema. Neurologic 2+/4 DTRs in all extremities. 5/5 motor strength in all extremities. Negative Romberg. Musculoskeletal No abnormalities or laxity noted in any of her joints. ASSESSMENT/PLAN 1. Complete physical Pap and breast exam completed. 2. School physical form completed and returned to the patient. 3. Hepatitis B second injection will be given today. 4. Contraceptive surveillance. We will put patient to Seasonale to start at the end of this cycle a pill. 5. Allergic rhinitis. Prescription was given for Allegra 180 mg q.d. #30 carrying refills for her to take with her school Cowley County Community College. 6. Insomnia. Prescription for trazodone 50 mg p.r.n. q.h.s. was given for her to take with her to school. She will follow up as needed. | 24 Obstetrics / Gynecology |
CHIEF COMPLAINT Leaking nephrostomy tube. HISTORY OF PRESENT ILLNESS This 61-year-old male was referred in today secondary to having urine leaked around the ostomy site for his right sided nephrostomy tube. The leaking began this a.m. The patient denies any pain does not have fever and has no other problems or complaints. The patient had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure. The patient states he feels like his usual self and has no other problems or concerns. The patient denies any fever or chills. No nausea or vomiting. No flank pain no abdominal pain no chest pain no shortness of breath no swelling to the legs. REVIEW OF SYSTEMS Review of systems otherwise negative and noncontributory. PAST MEDICAL HISTORY Metastatic prostate cancer anemia hypertension. MEDICATIONS Medication reconciliation sheet has been reviewed on the nurses note. ALLERGIES NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY The patient is a nonsmoker. PHYSICAL EXAMINATION VITAL SIGNS Temperature 97.7 oral blood pressure 150/85 pulse is 91 respirations 16 oxygen saturation 97 on room air and interpreted as normal. CONSTITUTIONAL The patient is well nourished well developed appears to be healthy calm comfortable no acute distress looks well. HEENT Eyes are normal with clear sclerae and cornea. NECK Supple full range of motion. CARDIOVASCULAR Heart has regular rate and rhythm without murmur rub or gallop. Peripheral pulses are +2. No dependent edema. RESPIRATIONS Clear to auscultation bilaterally. No shortness of breath. No wheezes rales or rhonchi. Good air movement bilaterally. GASTROINTESTINAL Abdomen is soft nontender nondistended. No rebound or guarding. Normal benign abdominal exam. MUSCULOSKELETAL The patient has nontender back and flank. No abnormalities noted to the back other than the bilateral nephrostomy tubes. The nephrostomy tube left has no abnormalities no sign of infection. No leaking of urine nontender nephrostomy tube on the right has a damp dressing which has a small amount of urine soaked into it. There is no obvious active leak from the ostomy site. No sign of infection. No erythema swelling or tenderness. The collection bag is full of clear urine. The patient has no abnormalities on his legs. SKIN No rashes or lesions. No sign of infection. NEUROLOGIC Motor and sensory are intact to the extremities. The patient has normal ambulation normal speech. PSYCHIATRIC Alert and oriented x4. Normal mood and affect. HEMATOLOGIC AND LYMPHATIC No bleeding or bruising. EMERGENCY DEPARTMENT COURSE Reviewed the patient s admission record from one month ago when he was admitted for the placement of the nephrostomy tubes both Dr. X and Dr. Y have been consulted and both had recommended nephrostomy tubes there was not the name mentioned as to who placed the nephrostomy tubes. There was no consultation dictated for this and no name was mentioned in the discharge summary paged Dr. X as this was the only name that the patient could remember that might have been involved with the placement of the nephrostomy tubes. Dr. A responded to the page and recommended off a BMP and discussing it with Dr. B the radiologist as he recalled that this was the physician who placed the nephrostomy tubes paged Dr. X and received a call back from Dr. X. Dr. X stated that he would have somebody get in touch with us about scheduling a time for which they will change out the nephrostomy tube to a larger and check a nephrogram at that time that came down and stated that they would do it at 10 a.m. tomorrow. This was discussed with the patient and instructions to return to the hospital at 10 a.m. to have this tube changed out by Dr. X was explained and understood. DIAGNOSES 1. WEAK NEPHROSTOMY SITE FOR THE RIGHT NEPHROSTOMY TUBE. 2. PROSTATE CANCER METASTATIC. 3. URETERAL OBSTRUCTION. The patient on discharge is stable and dispositioned to home. PLAN We will have the patient return to the hospital tomorrow at 10 a.m. for the replacement of his right nephrostomy tube by Dr. X. The patient was asked to return in the emergency room sooner if he should develop any new problems or concerns. | 12 Emergency Room Reports |
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. | 38 Surgery |
PREOPERATIVE DIAGNOSIS Severe degenerative joint disease of the right knee. POSTOPERATIVE DIAGNOSIS Severe degenerative joint disease of the right knee. PROCEDURE Right total knee arthroplasty using a Biomet cemented components 62.5-mm right cruciate-retaining femoral component 71-mm Maxim tibial component and 12-mm polyethylene insert with 31-mm patella. All components were cemented with Cobalt G. ANESTHESIA Spinal. ESTIMATED BLOOD LOSS Minimal. TOURNIQUET TIME Less than 60 minutes. The patient was taken to the Postanesthesia Care Unit in stable condition. The patient tolerated the procedure well. INDICATIONS The patient is a 51-year-old female complaining of worsening right knee pain. The patient had failed conservative measures and having difficulties with her activities of daily living as well as recurrent knee pain and swelling. The patient requested surgical intervention and need for total knee replacement. All risks benefits expectations and complications of surgery were explained to her in great detail and she signed informed consent. All risks including nerve and vessel damage infection and revision of surgery as well as component failure were explained to the patient and she did sign informed consent. The patient was given antibiotics preoperatively. PROCEDURE DETAIL The patient was taken to the operating suite and placed in supine position on the operating table. She was placed in the seated position and a spinal anesthetic was placed which the patient tolerated well. The patient was then moved to supine position again and a well-padded tourniquet was placed on the right thigh. Right lower extremity was prepped and draped in sterile fashion. All extremities were padded prior to this. The right lower extremity after being prepped and draped in the sterile fashion the tourniquet was elevated and maintained for less than 60 minutes in this case. A midline incision was made over the right knee and medial parapatellar arthrotomy was performed. Patella was everted. The infrapatellar fat pad was incised and medial and lateral meniscectomy was performed and the anterior cruciate ligament was removed. The posterior cruciate ligament was intact. There was severe osteoarthritis of the lateral compartment on the lateral femoral condyle as well as mild-to-moderate osteoarthritis in the medial femoral compartment as well severe osteoarthritis along the patellofemoral compartment. The medial periosteal tissue on the proximal tibia was elevated to the medial collateral ligament and medial collateral ligament was left intact throughout the entirety of the case. At the extramedullary tibial guide an extended cut was made adjusting for her alignment. Once this was performed excess bone was removed. The reamer was placed along on the femoral canal after which a 6-degree valgus distal cut was made along the distal femur. Once this was performed the distal femoral size in 3 degrees external rotation 62.5-mm cutting block was placed in 3 degrees external rotation with anterior and posterior cuts as well as anterior and posterior Chamfer cuts remained in the standard fashion. Excess bone was removed. Next the tibia was brought anterior and excised to 71 mm. It was then punched in standard fashion adjusting for appropriate rotation along the alignment of the tibia. Once this was performed a 71-mm tibial trial was placed as well as a 62.5-mm femoral trial was placed with a 12-mm polyethylene insert. Next the patella was cut in the standard fashion measuring 31 mm and a patella bed was placed. The knee was taken for range of motion had excellent flexion and extension as well as adequate varus and valgus stability. There was no loosening appreciated. There is no laxity appreciated along the posterior cruciate ligament. Once this was performed the trial components were removed. The knee was irrigated with fluid and antibiotics after which the cement was put on the back table this being Cobalt G it was placed on the tibia. The tibial components were tagged in position and placed on the femur. The femoral components were tagged into position. All excess cement was removed placement of patella. It was tagged in position. A 12-mm polyethylene insert was placed knee was held in extension and all excess cement was removed. The cement hardened with the knee in full extension after which any extra cement was removed. The wounds were copiously irrigated with saline and antibiotics and medial parapatellar arthrotomy was closed with #2 Vicryl. Subcutaneous tissue was approximated with #2-0 Vicryl and the skin was closed with staples. The patient was awakened from general anesthetic transferred to the gurney and taken into postanesthesia care unit in stable condition. The patient tolerated the procedure well. | 38 Surgery |
PROCEDURE Punch biopsy of right upper chest skin lesion. ESTIMATED BLOOD LOSS Minimal. FLUIDS Minimal. COMPLICATIONS None. PROCEDURE The area around the lesion was anesthetized after she gave consent for her procedure. Punch biopsy including some portion of lesion and normal tissue was performed. Hemostasis was completed with pressure holding. The biopsy site was approximated with non-dissolvable suture. The area was hemostatic. All counts were correct and there were no complications. The patient tolerated the procedure well. She will see us back in approximately five days. | 8 Dermatology |
IDENTIFYING DATA Mr. T is a 45-year-old white male. CHIEF COMPLAINT Mr. T presented with significant muscle tremor constant headaches excessive nervousness poor concentration and poor ability to focus. His confidence and self-esteem are significantly low. He stated he has excessive somnolence his energy level is extremely low motivation is low and he has a lack for personal interests. He has had suicidal ideation but this is currently in remission. Furthermore he continues to have hopeless thoughts and crying spells. Mr. T stated these symptoms appeared approximately two months ago. HISTORY OF PRESENT ILLNESS On March 25 2003 Mr. T was fired from his job secondary to an event at which he stated he was first being harassed by another employee. This other employee had confronted Mr. T with a very aggressive verbal style where this employee had placed his face directly in front of Mr. T was spitting on him and called him bitch. Mr. T then retaliated and went to hit the other employee. Due to this event Mr. T was fired. It should be noted that Mr. T stated he had been harassed by this individual for over a year and had reported the harassment to his boss and was told to deal with it. There are no other apparent stressors in Mr. T s life at this time or in recent months. Mr. T stated that work was his entire life and he based his entire identity on his work ethic. It should be noted that Mr. T was a process engineer for Plum Industries for the past 14 years. PAST PSYCHIATRIC HISTORY There is no evidence of any psychiatric hospitalizations or psychiatric interventions other than a recent visit to Mr. T s family physician Dr. B at which point Mr. T was placed on Lexapro with an unknown dose at this time. Mr. T is currently seeing Dr. J for psychotherapy where he has been in treatment since April 2003. PAST PSYCHIATRIC REVIEW OF SYSTEMS Mr. T denied any history throughout his childhood adolescence and early adulthood for depressive anxiety or psychotic disorders. He denied any suicide attempts or profound suicidal or homicidal ideation. Mr. T furthermore stated that his family psychiatric history is unremarkable. SUBSTANCE ABUSE HISTORY Mr. T stated he used alcohol following his divorce in 1993 but has not used it for the last two years. No other substance abuse was noted. LEGAL HISTORY Currently charges are pending over the above described incident. MEDICAL HISTORY Mr. T denied any hospitalizations surgeries or current medications use for any heart disease lung disease liver disease kidney disease gastrointestinal disease neurological disease closed head injury endocrine disease infectious blood or muscles disease other than stating he has a hiatal hernia and hypercholesterolemia. PERSONAL AND SOCIAL HISTORY Mr. T was born in Dwyne Missouri with no complications associated with his birth. Originally he was raised by both parents but they separated at an early age. When he was about seven years old he was raised by his mother and stepfather. He did not sustain a relationship with his biological father from that time on. He stated his parents moved a lot and because this many times he was picked on in his new environments Mr. T stated he was at times a rebellious teenager but he denied any significant inability to socialize and denied any learning disabilities or the need for special education. Mr. T stated his stepfather was somewhat verbally abusive and that he committed suicide when Mr. T was 18 years old. He graduated from high school and began work at Dana Corporation for two to three years after which he worked as an energy auditor for a gas company. He then became a homemaker while his wife worked for Chrysler for approximately two years. Mr. T was married for eleven years and divorced in 1993. He has a son who is currently 20 years old. After being a home maker Mr. T worked for his mother in a restaurant and moved on from there to work for Borg-Warner corporation for one to two years before beginning at Plum Industries where he worked for 14 years and worked his way up to lead engineer. Mental Status Exam Mr. T presented with a hyper vigilant appearance his eye contact was appropriate to the interview and his motor behavior was tense. At times he showed some involuntary movements that would be more akin to a resting tremor. There was no psychomotor retardation but there was some mild psychomotor excitement. His speech was clear concise but pressured. His attitude was overly negative and his mood was significant for moderate depression anxiety anhedonia and loneliness and mild evidence of anger. There was no evidence of euphoria or diurnal mood variation. His affective expression was restricted range but there was no evidence of lability. At times his affective tone and facial expressions were inappropriate to the interview. There was no evidence of auditory visual olfactory gustatory tactile or visceral hallucinations. There was no evidence of illusions depersonalizations or derealizations. Mr. T presented with a sequential and goal directed stream of thought. There was no evidence of incoherence irrelevance evasiveness circumstantiality loose associations or concrete thinking. There was no evidence of delusions however there was some ambivalence guilt and self-derogatory thoughts. There was evidence of concreteness for similarities and proverbs. His intelligence was average. His concentration was mildly impaired and there was no evidence of distractibility. He was oriented to time place person and situation. There was no evidence of clouded consciousness or dissociation. His memory was intact for immediate recent and remote events. He presented with poor appetite easily fatigued and decreased libidinal drive as well as excessive somnolence. There was a moderate preoccupation with his physical health pertaining to his headaches. His judgment was poor for finances family relations social relations employment and at this time he had no future plans. Mr. T s insight is somewhat moderate as he is aware of his contribution to the problem. His motivation for getting well is good as he accepts offered treatment complies with recommended treatment and seeks effective treatments. He has a well-developed empathy for others and capacity for affection. There was no evidence of entitlement egocentricity controllingness intimidation or manipulation. His credibility seemed good. There was no evidence for potential self-injury suicide or violence. The reliability and completeness of information was very good and there were no barriers to communication. The information gathered was based on the patient s self-report and objective testing and observation. His attitude toward the examiner was neutral and his attitude toward the examination process was neutral. There was no evidence for indices of malingering as there was no marked discrepancy between claimed impairment and objective findings and there was no lack of cooperation with the evaluation or poor compliance with treatment and no evidence of antisocial personality disorder. IMPRESSIONS Major Depressive Disorder single episode RECOMMENDATIONS AND PLAN I recommend Mr. T continue with psychopharmacologic care as well as psychotherapy. At this time the excessive amount of psychiatric symptoms would impede Mr. T from seeking employment. Furthermore it appears that the primary precipitating event had occurred on March 25 2003 when Mr. T was fired from his job after being harassed for over a year. As Mr. T placed his entire identity and sense of survival on his work this was a deafening blow to his psychological functioning. Furthermore it only appears logical that this would precipitate a major depressive episode. | 5 Consult - History and Phy. |
NUCLEAR CARDIOLOGY/CARDIAC STRESS REPORT INDICATION FOR STUDY Recurrent angina pectoris in a patient with documented ischemic heart disease and underlying ischemic cardiomyopathy. PROCEDURE The patient was studied in the resting state following intravenous delivery of adenosine triphosphate at 140 mcg/kg/min delivered over a total of 4 minutes. At completion of the second minute of infusion the patient received technetium Cardiolite per protocol. During this interval the blood pressure 150/86 dropped to near 136/80 and returned to near 166/84 at completion. No diagnostic electrocardiographic abnormalities were elaborated during this study. REGIONAL MYOCARDIAL PERFUSION WITH ADENOSINE PROVOCATION Scintigraphic study reveals at this time multiple fixed defects in perfusion suggesting indeed multivessel coronary artery disease yet no active ischemia at this time. A fixed defect is seen in the high anterolateral segment. A further fixed perfusion defect is seen in the inferoapical wall extending from close to the septum. There is no evidence for active ischemia in either distribution. Lateral wall moving towards the apex of the left ventricle is further involved from midway through the ventricle moving upward and into the high anterolateral vicinity. When viewed from the vertical projection the high septal wall is preserved with significant loss of the mid anteroapical wall moving to the apex and in a wraparound fashion in the inferoapical wall. A limited segment of apical myocardium is still viable. No gated wall motion study was obtained. CONCLUSIONS Cardiolite perfusion findings support multivessel coronary artery disease and likely previous multivessel infarct as has been elaborated above. There is no indication for active ischemia at this time. | 33 Radiology |
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. | 5 Consult - History and Phy. |
CHIEF COMPLAINT This 3-year-old female presents today for evaluation of chronic ear infections bilateral. ASSOCIATED SIGNS AND SYMPTOMS FOR OTITIS MEDIA Associated signs and symptoms include cough fever irritability and speech and language delay. Duration ENT Duration of symptom 12 rounds of antibiotics for otitis media. Quality of ear problems Quality of the pain is throbbing. ALLERGIES No known medical allergies. MEDICATIONS None currently. PMH Past medical history is unremarkable. PSH No previous surgeries. SOCIAL HISTORY Parent admits child is in a large daycare. FAMILY HISTORY Parent admits a family history of Alzheimer s disease associated with paternal grandmother. ROS Unremarkable with exception of chief complaint. PHYSICAL EXAM Temp 99.6 Weight 38 lbs. Patient is a 3-year-old female who appears pleasant in no apparent distress her given age well developed well nourished and with good attention to hygiene and body habitus. The child is accompanied by her mother who communicates well in English. Head Face Inspection of head and face shows no abnormalities. Examination of salivary glands shows no abnormalities. Facial strength is normal. Eyes Pupil exam reveals PERRLA. ENT Otoscopic examination reveals otitis media bilateral. Hearing exam using tuning fork shows hearing to be diminished bilateral. Inspection of left ear reveals drainage of a small amount. Inspection of nasal mucosa septum and turbinates reveals no abnormalities. Frontal and maxillary sinuses all transilluminate well bilaterally. Inspection of lips teeth gums and palate reveals no gingival hypertrophy no pyorrhea healthy gums healthy teeth and no abnormalities. Inspection of the tongue reveals normal color good motility and midline position. Examination of oropharynx reveals no abnormalities. Examination of nasopharynx reveals adenoid hypertrophy. Neck Neck exam reveals no abnormalities. Lymphatic No neck or supraclavicular lymphadenopathy noted. Respiratory Chest inspection reveals chest configuration non-hyperinflated and symmetric expansion. Auscultation of lungs reveal clear lung fields and no rubs noted. Cardiovascular Heart auscultation reveals no murmurs gallop rubs or clicks. Neurological/Psychiatric Testing of cranial nerves reveals no deficits. Mood and affect normal and appropriate to situation. TEST RESULTS Audiometry test shows conductive hearing loss at 30 decibels and flat tympanogram. IMPRESSION OM suppurative without spontaneous rupture. Adenoid hyperplasia bilateral. PLAN Patient scheduled for myringotomy and tubes with adenoidectomy using general anesthesia as outpatient and scheduled for 08/07/2003. Surgery will be performed at Children s Hospital. Pre-operative consent form read and signed by parent. Common risks and side effects of the procedure and anesthesia were mentioned. Parent questions elicited and answered satisfactorily regarding planned procedure. EDUCATIONAL MATERIAL PROVIDED Hospital preregistration middle ear infection and myringtomy and tubes surgery. PRESCRIPTIONS Augmentin Dosage 400 mg-57 mg/5 ml powder for reconstitution Sig One PO Q8h Dispense 1 Refills 0 Allow Generic No | 29 Pediatrics - Neonatal |
Dear Sample Doctor Thank you for referring Mr. Sample Patient for cardiac evaluation. This is a 67-year-old obese male who has a history of therapy-controlled hypertension borderline diabetes and obesity. He has a family history of coronary heart disease but denies any symptoms of angina pectoris or effort intolerance. Specifically no chest discomfort of any kind no dyspnea on exertion unless extreme exertion is performed no orthopnea or PND. He is known to have a mother with coronary heart disease. He has never been a smoker. He has never had a syncopal episode MI or CVA. He had his gallbladder removed. No bleeding tendencies. No history of DVT or pulmonary embolism. The patient is retired rarely consumes alcohol and consumes coffee moderately. He apparently has a sleep disorder according to his wife not in the office the patient snores and stops breathing during sleep. He is allergic to codeine and aspirin angioedema . Physical exam revealed a middle-aged man weighing 283 pounds for a height of 5 feet 11 inches. His heart rate was 98 beats per minute and regular. His blood pressure was 140/80 mmHg in the right arm in a sitting position and 150/80 mmHg in a standing position. He is in no distress. Venous pressure is normal. Carotid pulsations are normal without bruits. The lungs are clear. Cardiac exam was normal. The abdomen was obese and organomegaly was not palpated. There were no pulsatile masses or bruits. The femoral pulses were 3+ in character with a symmetrical distribution and dorsalis pedis and posterior tibiales were 3+ in character. There was no peripheral edema. He had a chemistry profile which suggests diabetes mellitus with a fasting blood sugar of 136 mg/dl. Renal function was normal. His lipid profile showed a slight increase in triglycerides with normal total cholesterol and HDL and an acceptable range of LDL. His sodium was a little bit increased. His A1c hemoglobin was increased. He had a spirometry which was reported as normal. He had a resting electrocardiogram on December 20 2002 which was also normal. He had a treadmill Cardiolite which was performed only to stage 2 and was terminated by the supervising physician when the patient achieved 90 of the predicted maximum heart rate. There were no symptoms or ischemia by EKG. There was some suggestion of inferior wall ischemia with normal wall motion by Cardiolite imaging. In summary we have a 67-year-old gentleman with risk factors for coronary heart disease. I am concerned with possible diabetes and a likely metabolic syndrome of this gentleman with truncal obesity hypertension possible insulin resistance and some degree of fasting hyperglycemia as well as slight triglyceride elevation. He denies any symptoms of coronary heart disease but he probably has some degree of coronary atherosclerosis possibly affecting the inferior wall by functional testings. In view of the absence of symptoms medical therapy is indicated at the present time with very aggressive risk factor modification. I explained and discussed extensively with the patient the benefits of regular exercise and a walking program was given to the patient. He also should start aggressively losing weight. I have requested additional testing today which will include an apolipoprotein B LPa lipoprotein as well as homocystine and cardio CRP to further assess his risk of atherosclerosis. In terms of medication I have changed his verapamil for a long acting beta-blocker he should continue on an ACE inhibitor and his Plavix. The patient is allergic to aspirin. I also will probably start him on a statin if any of the studies that I have recommended come back abnormal and furthermore if he is confirmed to have diabetes. Along this line perhaps we should consider obtaining the advice of an endocrinologist to decide whether this gentleman needs treatment for diabetes which I believe he should. This however I will leave entirely up to you to decide. If indeed he is considered to be a diabetic a much more aggressive program should be entertained for reducing the risks of atherosclerosis in general and coronary artery disease in particular. I do not find an indication at this point in time to proceed with any further testing such as coronary angiography in the absence of symptoms. If you have any further questions please do not hesitate to let me know. Thank you once again for this kind referral. Sincerely Sample Doctor M.D. | 3 Cardiovascular / Pulmonary |
PROCEDURES 1. Arthroscopic rotator cuff repair. 2. Arthroscopic subacromial decompression. 3. Arthroscopic extensive debridement superior labrum anterior and posterior tear. PROCEDURE IN DETAIL After written consent was obtained from the patient the patient was brought back into the operating room and identified. The patient was placed on the operating room table in supine position and given general anesthetic. Once the patient was under general anesthetic a careful examination of the shoulder was performed. It revealed no patholigamentous laxity. The patient was then carefully positioned into a beach-chair position. We maintained the natural alignment of the head neck and thorax at all times. The shoulder and upper extremity was then prepped and draped in the usual sterile fashion. Once we fully prepped and draped we then began the surgery. We injected the glenohumeral joint with sterile saline with a spinal needle. This consisted of 60 cc of fluid. We then made a posterior incision for our portal 2 cm inferior and 2 cm medial to the posterolateral angle of the acromion. Through this incision a blunt trocar and cannula were placed in the glenohumeral joint. Through the cannula a camera was placed and the shoulder was insufflated with sterile saline through a preoperative feed. We then carefully examined the glenohumeral joint. We found the articular surface to be in good condition. There was a superior labral tear SLAP . This was extensively debrided using a shaver through an anterior portal. We also found a full thickness rotator cuff tear. We then drained the glenohumeral joint. We redirected our camera into the subacromial space. An anterolateral portal was made both superior and inferior. We then proceeded to perform a subacromial decompression using high-speed shaver. The bursa was extensively debrided. We then abraded the bone over the footprint of where the rotator cuff is usually attached. The corkscrew anchors were used to perform a rotator cuff repair. Pictures were taken. Through a separate incision an indwelling pain catheter was then placed. It was carefully positioned. Pictures were taken. We then drained the joint. All instruments were removed. The patient did receive IV antibiotic preoperatively. All portals were closed using 4-0 nylon sutures. Xeroform 4 x 4s and OpSite were applied over the pain pump. ABD tape and a sling were also applied. A Cryo/Cuff was also placed over the shoulder. The patient was taken out of the beach-chair position maintaining the neutral alignment of the head neck and thorax. The patient was extubated and brought to the recovery room in stable condition. I then went out and spoke with the family going over the case postoperative instructions and followup care. | 27 Orthopedic |
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. | 15 General Medicine |
PROCEDURE Fiberoptic bronchoscopy. PREOPERATIVE DIAGNOSIS Right lung atelectasis. POSTOPERATIVE DIAGNOSIS Extensive mucus plugging in right main stem bronchus. PROCEDURE IN DETAIL Fiberoptic bronchoscopy was carried out at the bedside in the medical ICU after Versed 0.5 mg intravenously given in 2 aliquots. The patient was breathing supplemental nasal and mask oxygen throughout the procedure. Saturations and vital signs remained stable throughout. A flexible fiberoptic bronchoscope was passed through the right naris. The vocal cords were visualized. Secretions in the larynx were as aspirated. As before he had a mucocele at the right anterior commissure that did not obstruct the glottic opening. The ports were anesthetized and the trachea entered. There was no cough reflex helping explain the propensity to aspiration and mucus plugging. Tracheal secretions were aspirated. The main carinae were sharp. However there were thick sticky grey secretions filling the right mainstem bronchus up to the level of the carina. This was gradually lavaged clear. Saline and Mucomyst solution were used to help dislodge remaining plugs. The airways appeared slightly friable but were patent after the airways were suctioned. O2 saturations remained in the mid-to-high 90s. The patient tolerated the procedure well. Specimens were submitted for microbiologic examination. Despite his frail status he tolerated bronchoscopy quite well. | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSES 1. Painful enlarged navicula right foot. 2. Osteochondroma of right fifth metatarsal. POSTOPERATIVE DIAGNOSES 1. Painful enlarged navicula right foot. 2. Osteochondroma of right fifth metatarsal. PROCEDURE PERFORMED 1. Partial tarsectomy navicula right foot. 2. Partial metatarsectomy right foot. HISTORY This 41-year-old Caucasian female who presents to ABCD General Hospital with the above chief complaint. The patient states that she has extreme pain over the navicular bone with shoe gear as well as history of multiple osteochondromas of unknown origin. She states that she has been diagnosed with hereditary osteochondromas. She has had previous dissection of osteochondromas in the past and currently has not been diagnosed in her feet as well as spine and back. The patient desires surgical treatment at this time. PROCEDURE An IV was instituted by the Department of Anesthesia in the preoperative holding area. The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap. Copious amounts of Webril were placed on the left ankle followed by a blood pressure cuff. After adequate sedation by the Department of Anesthesia a total of 5 cc of 1 1 mixture of 1 lidocaine plain and 0.5 Marcaine plain were injected in the diamond block type fashion around the navicular bone as well as the fifth metatarsal. Foot was then prepped and draped in the usual sterile orthopedic fashion. Foot was elevated from the operating table and exsanguinated with an Esmarch bandage. The pneumatic ankle tourniquet was then inflated to 250 mmHg. The foot was lowered as well as the operating table. The sterile stockinet was reflected and the foot was cleansed with wet and dry sponge. Attention was then directed to the navicular region on the right foot. The area was palpated until the bony prominence was noted. A curvilinear incision was made over the area of bony prominence. At that time a total of 10 cc with addition of 1 additional lidocaine plain was injected into the surgical site. The incision was then deepened with #15 blade. All vessels encountered were ligated for hemostasis. The dissection was carried down to the level of the capsule and periosteum. A linear incision was made over the navicular bone obliquely from proximal dorsal to distal plantar over the navicular bone. The periosteum and the capsule were then reflected from the navicular bone at this time. A bony prominence was noted both medially and plantarly to the navicular bone. An osteotome and mallet were then used to resect the enlarged portion of the navicular bone. After resection with an osteotome there was noted to be a large plantar shelf. The surrounding soft tissues were then freed from this plantar area. Care was taken to protect the attachments of the posterior tibial tendon as much as possible. Only minimal resection of its attachment to the fiber was performed in order to expose the bone. Sagittal saw was then used to resect the remaining plantar medial prominent bone. The area was then smoothed with reciprocating rasp until no sharp edges were noted. The area was flushed with copious amount of sterile saline at which time there was noted to be a palpable where the previous bony prominence had been noted. The area was then again flushed with copious amounts of sterile saline and the capsule and periosteum were then reapproximated with #3-0 Vicryl. The subcutaneous tissues were then reapproximated with #4-0 Vicryl to reduce tension from the incision and running #5-0 Vicryl subcuticular stitch was performed. Attention was then directed to the fifth metatarsal. There was noted to be a palpable bony prominence dorsally with fifth metatarsal head as well as radiographic evidence laterally of an osteochondroma at the neck of the fifth metatarsal. Approximately 7 cm incision was made dorsolaterally over the fifth metatarsal. The incision was then deepened with #15 blade. Care was taken to preserve the extensor tendon. The incision was then created over the capsule and periosteum of the fifth metatarsal head. Capsule and periosteum were reflected both dorsally laterally and plantarly. At that time there was noted to be a visible osteochondroma on the plantar lateral aspect of the fifth metatarsal neck as well as on the dorsal aspect of the head of the fifth metatarsal. A sagittal saw was used to resect both of these osteal prominences. All remaining sharp edges were then smoothed with reciprocating rasp. The area was inspected for the remaining bony prominences and none was noted. The area was flushed with copious amounts of sterile saline. The capsule and periosteum were then reapproximated with #3-0 Vicryl. Subcutaneous closure was then performed with #4-0 Vicryl in order to reduce tension around the incision line. Running #5-0 subcutaneous stitch was then performed. Steri-Strips were applied to both surgical sites. Dressings consisted of Adaptic soaked in Betadine 4x4s Kling Kerlix and Coban. The pneumatic ankle tourniquet was released and the hyperemic flush was noted to all five digits of the right foot. The patient tolerated the above procedure and anesthesia well without complications. The patient was transferred to the PACU with vital signs stable and vascular status intact. The patient was given postoperative pain prescription and instructed to be partially weightbearing with crutches as tolerated. The patient is to follow-up with Dr. X in his office as directed or sooner if any problems or questions arise. | 38 Surgery |
PREOPERATIVE DIAGNOSIS Breast mass left. POSTOPERATIVE DIAGNOSIS Breast mass left. PROCEDURE Excision of left breast mass. OPERATION After obtaining an informed consent the patient was taken to the operating room where he underwent general endotracheal anesthesia. The time-out process was followed. Preoperative antibiotic was given. The patient was prepped and draped in the usual fashion. The mass was identified adjacent to the left nipple. It was freely mobile and it did not seem to hold the skin. An elliptical skin incision was made over the mass and carried down in a pyramidal fashion towards the pectoral fascia. The whole of specimen including the skin the mass and surrounding subcutaneous tissue and fascia were excised en bloc. Hemostasis was achieved with the cautery. The specimen was sent to Pathology and the tissues were closed in layers including a subcuticular suture of Monocryl. A small pressure dressing was applied. Estimated blood loss was minimal and the patient who tolerated the procedure very well was sent to recovery room in satisfactory condition. | 38 Surgery |
PREOPERATIVE DIAGNOSES Colon cancer screening and family history of polyps. POSTOPERATIVE DIAGNOSIS Colonic polyps. PROCEDURE Colonoscopy. ANESTHESIA MAC DESCRIPTION OF PROCEDURE The Olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon into the cecum and then through the ileocecal valve into the terminal ileum. The preparation was excellent and all surfaces were well seen. The mucosa was normal throughout the colon and in the terminal ileum. Two polyps were identified and were removed. The first was a 7-mm sessile lesion in the mid transverse colon at 110 cm removed with the snare without cautery and retrieved. The second was a small 4-mm sessile lesion in the sigmoid colon at 20 cm also removed with the snare and retrieved. No other lesions were identified. Numerous diverticula were found in the sigmoid colon. A retroflex through the anorectal junction showed moderate internal hemorrhoids. The patient tolerated the procedure well and was sent to the recovery room. FINAL DIAGNOSES 1. Sigmoid diverticulosis. 2. Colonic polyps in the transverse colon and sigmoid colon benign appearance removed. 3. Internal hemorrhoids. 4. Otherwise normal colonoscopy to the terminal ileum. RECOMMENDATIONS 1. Follow up biopsy report. 2. Follow up with Dr. X as needed. 3. Screening colonoscopy in 5 years. | 14 Gastroenterology |
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 diagnosed. He had a shunt placed and was stabilized medically. He has gotten a return of function to the legs and was started on some early therapy. Significant functional limitations have been identified and ongoing by the rehab admission team. Significant functional limitations have been ongoing. He will need to be near-independent at home for periods of time and he is brought in now for rehabilitation to further address functional issues maximize skills and safety and allow a safe disposition home. PAST MEDICAL HISTORY Positive for prostate cancer intermittent urinary incontinence and left hip replacement. ALLERGIES No known drug allergies. CURRENT MEDICATIONS 1. Tylenol as needed. 2. Peri-Colace b.i.d. SOCIAL HISTORY He is a nonsmoker and nondrinker. Prior boxer. He lives in a home where he would need to be independent during the day. Family relatives intermittently available. Goal is to return home to an independent fashion to that home setting. FUNCTIONAL HISTORY Prior to admission was independent with activities of daily living and ambulatory skills. Presently he has resumed therapies and noted to have supervision levels for most activities of daily living. Memory at minimal assist. Walking at supervision. REVIEW OF SYSTEMS Negative for headaches nausea vomiting fevers chills shortness of breath or chest pain currently. He has had some dyscoordination recently and headaches on a daily basis most days although the Tylenol does seem to control that pain. PHYSICAL EXAMINATION VITAL SIGNS The patient is afebrile with vital signs stable. HEENT Oropharynx clear extraocular muscles are intact. CARDIOVASCULAR Regular rate and rhythm without murmurs rubs or gallops. LUNGS Clear to auscultation bilaterally. ABDOMEN Nontender nondistended positive bowel sounds. EXTREMITIES Without clubbing cyanosis or edema. The calves are soft and nontender bilaterally. NEUROLOGIC No focal motor or sensory losses through the lower extremities. He moves upper and lower extremities well. Bulk and tone normal in the upper and lower extremities. Cognitively showing intact with appropriate receptive and expressive skills. IMPRESSION | 30 Physical Medicine - Rehab |
PREOPERATIVE DIAGNOSIS Herniated nucleus pulposus of L5-S1 on the left. POSTOPERATIVE DIAGNOSIS Herniated nucleus pulposus of L5-S1 on the left. PROCEDURE PERFORMED Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left. ANESTHESIA General via endotracheal tube. ESTIMATED BLOOD LOSS Less than 50 cc. SPECIMENS Disc that was not sent to the lab. DRAINS None. COMPLICATIONS None. SURGICAL PROGNOSIS Remains guarded due to her ongoing pain condition and Tarlov cyst at the L5 nerve root distally. SURGICAL INDICATIONS The patient is a 51-year-old female who has had unrelenting low back pain that radiated down her left leg for the past several months. The symptoms were unrelieved by conservative modalities. The symptoms were interfering with all aspects of daily living and inability to perform any significant work endeavors. She is understanding the risks benefits potential complications as well as all treatment alternatives. She wished to proceed with the aforementioned surgery due to her persistent symptoms. Informed consent was obtained. OPERATIVE TECHNIQUE The patient was taken to OR room #5 where she was given general anesthetic by the Department of Anesthesia. She was subsequently placed on the Jackson spinal table with the Wilson attachment in the prone position. Palpation did reveal the iliac crest and suspected L5-S1 interspace. Thereafter the lumbar spine was serially prepped and draped. A midline incision was carried over the spinal process of L5 to S1. Skin and subcutaneous tissue were divided sharply. Electrocautery provided hemostasis. Electrocautery was then utilized to dissect through the subcutaneous tissues to the lumbar fascia. Lumbar fascia was identified and the decussation of fibers was identified at the L5-S1 interspace. On the left side superior aspect dissection was carried out with the Cobb elevator and electrocautery. This revealed the interspace of suspect level of L5-S1 on the left. A Kocher clamp was placed between the spinous processes of the suspect level of L5-S1. X-ray did confirm the L5-S1 interval. Angled curet was utilized to detach the ligamentum flavum from its bony attachments at the superior edge of S1 lamina and the inferior edge of the L5 lamina. Meticulous dissection was undertaken and the ligamentum flavum was removed. Laminotomy was created with Kerrison rongeur both proximally and distally. The microscope was positioned and the dura was inspected. A blunt Penfield elevator was then utilized to dissect and identify the L5-S1 nerve root on the left. It was noted to be tented over a disc extrusion. The nerve root was protected and medialized. It was retracted with a nerve root retractor. This did reveal a subligamentous disc herniation at approximately the L5-S1 disc space and neuroforaminal area. A #15 Bard-Parker blade was utilized to create an annulotomy. Medially disc material was extruding through this annulotomy. Two tier rongeur was then utilized to grasp the disc material and the disc was removed from the interspace. Additional disc material was then removed both to the right and left of the annulotomy. Up and downbiting pituitary rongeurs were utilized to remove any other loose disc pieces. Once this was completed the wound was copiously irrigated with antibiotic solution and suctioned dry. The Penfield elevator was placed in the disc space of L5-S1 and a crosstable x-ray did confirm this level. Nerve root was again expected exhibiting the foramina. A foraminotomy was created with a Kerrison rongeur. Once this was created the nerve root was again inspected and deemed free of tension. It was mobile within the neural foramina. The wound was again copiously irrigated with antibiotic solution and suctioned dry. A free fat graft was then harvested from the subcutaneous tissues and placed over the exposed dura. Lumbar fascia was then approximated with #1 Vicryl interrupted fashion subcutaneous tissue with #2-0 Vicryl interrupted fashion and #4-0 undyed Vicryl was utilized to approximate the skin. Compression dressing was applied. The patient was turned awoken and noted to be moving all four extremities without apparent deficits. She was taken to the recovery room in apparent satisfactory condition. Expected surgical prognosis remains guarded due to her ongoing pain syndrome that has been requiring significant narcotic medications. | 23 Neurosurgery |
PROCEDURE The test was performed in an observed hospital laboratory due to the evidence of obstructive sleep apnea. The patient was monitored for EEG EOG jaw and leg EMG thoracoabdominal impedance oral/nasal thermistors EKG and oximetry. CPAP TITRATION STUDY Total sleep time 425 minutes sleep onset 7.8 minutes and sleep efficiency 95 . Stage I 6 stage II 53 stage III 20 and REM stage 15 and awake 5 . Number of awakenings 6. Total arousals 36 with index 5.4 mild leg jerk movement with index 10.1. There was one apnea and 17 hypopneas with apnea/hypopnea index 2.7. The pressures required to prevent apnea/hypopnea varied between 5 and 11 cm H2O. The optimal pressure was 11 cm H2O which prevented all of the apneas/hypopneas. The patient spent all his sleeping time in supine position. Average oxygen saturation 94 with lowest oxygen saturation 89 . Only less than 0.2 minutes was spent with oxygen saturation less than 90 . SUMMARY Weight loss PFTs if not done and CPAP with nasal mask at 11 cm H2O. | 36 Sleep Medicine |
DIAGNOSIS Status post brain tumor with removal. SUBJECTIVE The patient is a 64-year-old female with previous medical history of breast cancer that has metastasized to her lung liver spleen and brain status post radiation therapy. The patient stated that on 10/24/08 she had a brain tumor removed with subsequent left-sided weakness. The patient was readmitted to ABC Hospital on 12/05/08 and was found to have massive swelling in the brain and a second surgery was performed to reduce the swelling. The patient remained at the acute rehab at ABC until she was discharged home on 01/05/09. The patient did receive skilled speech therapy while in the acute rehab which focused on higher level cognitive and linguistic skills such as attention memory mental flexibility and improvement of her executive function. The patient also complains of difficulty with word retrieval and slurring of speech. The patient denies any difficulty with swallowing at this time. OBJECTIVE Portions of the cognitive linguistic quick test was administered. An oral mechanism exam was performed. A motor speech protocol was completed. The cognitive linguistic subtests of recalling personal facts symbol cancellation confrontational naming clock drawing story retelling generative naming design and memory and completion of mazes was administered. The patient was 100 accurate with recalling personal facts completion of the symbol cancellation tasks and with confrontational naming. She had no difficulty with the clock drawing task however she has considerable hand tremors which makes writing difficult. In the storytelling task she scored within normal limits. She was also within normal limits for generative naming. She did have difficulty with the design memory and mazes subtests. She was unable to complete the second maze during the allotted time. The design generation subtest was also completed. She was able to draw four unique designs and toward the end of the tasks was no longer able to recall the stated direction. ORAL MECHANISM EXAMINATION The patient has mild left facial droop with decreased nasolabial fold. Tongue is at midline and lingual range of motion and strength are within functional limit. The patient does complain of biting her tongue on occasion but denied biting the inside of her cheeks. Her AMRs are judged to be within functional limit. Her rate of speech is decreased with a monotonous vocal quality. The decreased rate may be a compensation for decreased word retrieval ability. The patient s speech is judged to be 100 intelligible without background noise. DIAGNOSTIC IMPRESSION The patient has mild cognitive linguistic deficits in the areas of higher level cognitive function seen in mental flexibility memory and executive function. PLAN OF CARE Outpatient skilled speech therapy two times a week for four weeks to include cognitive linguistic treatment. SHORT-TERM GOALS THREE WEEKS 1. The patient will complete deductive reasoning and mental flexibility tasks with greater than 90 accuracy independently. 2. The patient will complete perspective memory test with 100 accuracy using compensatory strategy. 3. The patient will complete visual perceptual activities which focus on scanning flexibility and problem solving with greater than 90 accuracy with minimal cueing. 4. The patient will listen to and/or read a lengthy narrative and be able to recall at least 6 details after a 15-minute delay independently. PATIENT S GOAL To improve functional independence and cognitive abilities. LONG-TERM GOAL FOUR WEEKS Functional cognitive linguistic abilities to improve safety and independence at home and to decrease burden of care on caregiver. | 5 Consult - History and Phy. |
REASON FOR CONSULTATION Metastatic ovarian cancer. HISTORY OF PRESENT ILLNESS Mrs. ABCD is a very nice 66-year-old woman who is followed in clinic by Dr. X for history of renal cell cancer breast cancer as well as ovarian cancer which was initially diagnosed 10 years ago but over the last several months has recurred and is now metastatic. She last saw Dr. X in clinic towards the beginning of this month. She has been receiving gemcitabine and carboplatin and she receives three cycles of this with the last one being given on 12/15/08. She was last seen in clinic on 12/22/08 by Dr. Y. At that point her white count was 0.9 with the hemoglobin of 10.3 hematocrit of 30 and platelets of 81 000. Her ANC was 0.5. She was started on prophylactic Augmentin as well as Neupogen shots. She has also had history of recurrent pleural effusions with the knee for thoracentesis. She had two of these performed in November and the last one was done about a week ago. Over the last 2 or 3 days she states she has been getting more short of breath. Her history is somewhat limited today as she is very tired and falls asleep readily. Her history comes from herself but also from the review of the records. Overall her shortness of breath has been going on for the past few weeks related to her pleural effusions. She was seen in the emergency room this time and on chest x-ray was found to have a new right-sided pulmonic consolidative infiltrate which was felt to be possibly related to pneumonia. She specifically denied any fevers or chills. However she was complaining of chest pain. She states that the chest pain was located in the substernal area described as aching coming and going and associated with shortness of breath and cough. When she did cough it was nonproductive. While in the emergency room on examination her vital signs were stable except that she required 5 liters nasal cannula to maintain oxygen saturations. An EKG was performed which showed sinus rhythm without any evidence of Q waves or other ischemic changes. The chest x-ray described above showed a right lower lobe infiltrate. A V/Q scan was done which showed a small mismatched defect in the left upper lobe and a mass defect in the right upper lobe. The findings were compatible with an indeterminate study for a pulmonary embolism. Apparently an ultrasound of the lower extremities was done and was negative for DVT. There was apparently still some concern that this might be pulmonary embolism and she was started on Lovenox. There was also concern for pneumonia and she was started on Zosyn as well as vancomycin and admitted to the hospital. At this point we have been consulted to help follow along with this patient who is well known to our clinic. PAST MEDICAL HISTORY 1. Ovarian cancer - This was initially diagnosed about 10 years ago and treated with surgical resection including TAH and BSO. This has recurred over the last couple of months with metastatic disease. 2. History of breast cancer - She has been treated with bilateral mastectomy with the first one about 14 years and the second one about 5 years ago. She has had no recurrent disease. 3. Renal cell carcinoma - She is status post nephrectomy. 4. Hypertension. 5. Anxiety disorder. 6. Chronic pain from neuropathy secondary to chemotherapy from breast cancer treatment. 7. Ongoing tobacco use. PAST SURGICAL HISTORY 1. Recent and multiple thoracentesis as described above. 2. Bilateral mastectomies. 3. Multiple abdominal surgeries. 4. Cholecystectomy. 5. Remote right ankle fracture. ALLERGIES No known drug allergies. MEDICATIONS At home 1. Atenolol 50 mg daily 2. Ativan p.r.n. 3. Clonidine 0.1 mg nightly. 4. Compazine p.r.n. 5. Dilaudid p.r.n. 6. Gabapentin 300 mg p.o. t.i.d. 7. K-Dur 20 mEq p.o. daily. 8. Lasix unknown dose daily. 9. Norvasc 5 mg daily. 10. Zofran p.r.n. SOCIAL HISTORY She smokes about 6-7 cigarettes per day and has done so for more than 50 years. She quit smoking about 6 weeks ago. She occasionally has alcohol. She is married and has 3 children. She lives at home with her husband. She used to work as a unit clerk at XYZ Medical Center. FAMILY HISTORY Both her mother and father had a history of lung cancer and both were smokers. REVIEW OF SYSTEMS GENERAL/CONSTITUTIONAL She has not had any fever chills night sweats but has had fatigue and weight loss of unspecified amount. HEENT She has not had trouble with headaches mouth jaw or teeth pain change in vision double vision or loss of hearing or ringing in her ears. CHEST Per the HPI she has had some increasing dyspnea shortness of breath with exertion cough but no sputum production or hemoptysis. CVS She has had the episodes of chest pains as described above but has not had PND orthopnea lower extremity swelling or palpitations. GI No heartburn odynophagia dysphagia nausea vomiting diarrhea constipation blood in her stool and black tarry stools. GU No dysuria burning with urination kidney stones and difficulty voiding. MUSCULOSKELETAL No new back pain hip pain rib pain swollen joints history of gout or muscle weakness. NEUROLOGIC She has been diffusely weak but no lateralizing loss of strength or feeling. She has some chronic neuropathic pain and numbness as described above in the past medical history. She is fatigued and tired today and falls asleep while talking but is easily arousable. Some of this is related to her lack of sleep over the admission thus far. PHYSICAL EXAMINATION VITAL SIGNS Her T-max is 99.3. Her pulse is 54 her respirations is 12 and blood pressure 118/61. GENERAL Somewhat fatigued appearing but in no acute distress. HEENT NC/AT. Sclerae anicteric. Conjunctiva clear. Oropharynx is clear without any erythema exudate or discharge. NECK Supple. Nontender. No elevated JVP. No thyromegaly. No thyroid nodules. CHEST Clear to auscultation and percussion bilaterally with decreased breath sounds on the right. CVS Regular rate and rhythm. No murmurs gallops or rubs. Normal S1 and S2. No S3 or S4. ABDOMEN Soft nontender nondistended. Normoactive bowel sounds. No guarding or rebound. No hepatosplenomegaly. No masses. | 24 Obstetrics / Gynecology |
PREOPERATIVE DIAGNOSIS Degenerative arthritis of the left knee. POSTOPERATIVE DIAGNOSIS Degenerative arthritis of the left knee. PROCEDURE PERFORMED Total left knee replacement on 08/19/03. The patient also underwent a bilateral right total knee replacement in the same sitting and that will be dictated by Dr. X. TOURNIQUET TIME 76 minutes. BLOOD LOSS 150 cc. ANESTHESIA General. IMPLANT USED FOR PROCEDURE NexGen size F femur on the left with #8 size peg tibial tray a #12 mm polyethylene insert and this a cruciate retaining component. The patella on the left was not resurfaced. GROSS INTRAOPERATIVE FINDINGS Degenerative ware of three compartments of the trochlea the medial as well as the lateral femoral condyles as well was the plateau. The surface of the patella was with a minimal ware and minimal osteophytes and we decided not to resurface the patellar component. HISTORY This is a 69-year-old male with complaints of bilateral knee pain for several years and increased intensity in the past several months where it has affected his activities of daily living. He attempted conservative treatment which includes anti-inflammatory medications as well as cortisone and Synvisc. This has only provided him with temporary relief. It is for that reason he is elected to undergo the above-named procedure. All risks as well as complications were discussed with the patient which include but are not limited to infection deep vein thrombosis pulmonary embolism need for further surgery and further pain. He has agreed to undergo this procedure and a consent was obtained preoperatively. PROCEDURE The patient was wheeled back to operating room #2 at ABCD General Hospital on 08/19/03 and was placed supine on the operating room table. At this time a nonsterile tourniquet was placed on the left upper thigh but not inflated. An Esmarch was then used to exsanguinate the extremity and the left extremity was then prepped and draped in the usual sterile fashion for this procedure. The tourniquet was then inflated to 325 mmHg. At this time a standard midline incision was made towards the total knee. We did discuss preoperatively for a possible unicompartmental knee replacement for this patient but he did have radiographic evidence of chondrocalcinosis of the lateral meniscus. We did start off with a small midline skin incision in case we were going to do a unicompartmental. Once we exposed the medial parapatellar mini-arthrotomy and visualized the lateral femoral condyle we decided that this patient would not be an optimal candidate for unicompartmental knee replacement. It is for this reason that we extended the incision and underwent with the total knee replacement. Once the full medial parapatellar arthrotomy was performed with the subperiosteal dissection of the proximal tibia in order to evert the patella. Once the patella was everted we then used a drill to cannulate the distal femoral canal in order to place the intramedullary guide. A Charnley awl was then used to remove all the intramedullary contents and they were removed from the knee. At this time a femoral sizer was then placed with reference to the posterior condyles and we measured a size F. Once this was performed three degrees of external rotation was then drilled into the condyle in alignment with the epicondyles of the femur. At this time the intramedullary guide was then inserted and placed in three degrees of external rotation. Our anterior cutting guide was then placed and an anterior cut was performed with careful protection of the soft tissues. Next this was removed and the distal femoral cutting guide was then placed in five degrees of valgus. This was pinned to the distal femur and with careful protection of the collateral ligaments a distal femoral cut was performed. At this time the intramedullary guide was removed and a final cutting block was placed. This was placed in the center on the distal femur with 1 mm to 2 mm laterally translated for better patellar tracking. At this time the block was pinned and screwed in place with spring pins with careful protection of the soft tissues. An oscillating saw was then used to resect the posterior and anterior cutting blocks with anterior and posterior chamfer as well as the notch cut. Peg holes were then drilled. The block was then removed and an osteotome was then used to remove all the bony cut pieces. At this time with a better exposure of the proximal tibia we placed external tibial guide. This was placed with longitudinal axis of the tibia and carefully positioned in order to obtain an optimal cut for the proximal tibia. At this time with careful soft tissue retraction and protection an oscillating saw was used to make a proximal tibial osteotomy. Prior to the osteotomy the cut was checked with a depth gauge in order to assure appropriate bony resection. At this time a blunt Kocher and Bovie cautery were used to remove the proximal tibial cut which had soft tissue attachments. Once this was removed we then implanted our trial components of size F to the femur and a size 8 mm tibial tray with 12 mm plastic articulating surface. The knee was taken through range of motion and revealed excellent femorotibial articulation. The patella did tend to sublux somewhat laterally with extremes of flexion and it was for this reason we performed a minimal small incision lateral retinacular release. Distal lateral patella was tracked more uniformly within the patellar groove of the prosthesis. At this time an intraoperative x-ray was performed which revealed excellent alignment with no varus angulation especially of the whole femur and tibial alignment and tibial cut. At this time the prosthesis was removed. A McGill retractor was then reinserted and replaced peg tibial tray in order to peg the proximal tibia. Once the drill holes were performed we then copiously irrigated the wound and then suctioned it dry to get ready and prepped for cementation of the drilled components. At this time polymethyl methacrylate cement was then mixed. The cement was placed on the tibial surface as well as the underneath surface of the component. The component was then placed and impacted with excess cement removed. In a similar fashion the femoral component was also placed. A 12 mm plastic tray was then placed and the leg held in full extension and compression in order to obtain adequate bony cement content. Once the cement was fully hardened the knee was flexed and a small osteotome was used to remove any extruding cement from around the prosthesis of the bone. Once this was performed copious irrigation was used to irrigate the wound and the wound was then suctioned dry. The knee was again taken through range of motion with a 12 mm plastic as well as #14. The #14 appeared to be a bit too tight especially in extremes of flexion. We decided to go with a #12 mm polyethylene tray. At this time this was placed to the tibial articulation and then left in place. This was rechecked with careful attention to detail with checking no soft tissue interpositioned between the polyethylene tray and the metal tray of the tibia. The knee was again taken through range of motion and revealed excellent tracking of the patella with good femur and tibial contact. A drain was placed and cut to length. At this time the knee was irrigated and copiously suction dried. #1-0 Ethibond suture was then used to approximate the medial parapatellar arthrotomy in figure-of-eight fashion. A tight capsular closure was performed. This was reinforced with a #1-0 running Vicryl suture. At this time the knee was again taken through range of motion to assure tight capsular closure. At this time copious irrigation was used to irrigate the superficial wound. #2-0 Vicryl was used to approximate the wound with figure-of-eight inverted suture. The skin was then approximated with staples. The leg was then cleansed. Sterile dressing consisting of Adaptic 4x4 ABDs and Kerlix roll were then applied. At this time the patient was extubated and transferred to recovery in stable condition. Prognosis is good for this patient. | 27 Orthopedic |
PREOPERATIVE DIAGNOSES Epiretinal membrane right eye. CME right eye. POSTOPERATIVE DIAGNOSES Epiretinal membrane right eye. CME right eye. PROCEDURES Pars plana vitrectomy membrane peel 23-gauge right eye. PREOPERATIVE FINDINGS The patient had epiretinal membrane causing cystoid macular edema. Options were discussed with the patient stressing that the visual outcome was guarded. Especially since this membrane was of chronic duration there is no guarantee of visual outcome. DESCRIPTION OF PROCEDURE The patient was wheeled to the OR table. Local anesthesia was delivered using a retrobulbar needle in an atraumatic fashion 5 cc of Xylocaine and Marcaine was delivered to retrobulbar area and massaged and verified. Preparation was made for 23-gauge vitrectomy using the trocar inferotemporal cannula was placed 3.5 mm from the limbus and verified. The fluid was run. Then superior sclerotomies were created using the trocars and 3.5 mm from the limbus at 10 o clock and 2 o clock. Vitrectomy commenced and carried on as far anteriorly as possible using intraocular forceps ILM forceps the membrane was peeled off in its entirety. There were no complications. DVT precautions were in place. I as attending was present in the entire case. | 38 Surgery |
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 room and general endotracheal anesthesia was administered. Next the chest was prepped and draped in a standard surgical fashion. A #18-gauge spinal needle was used to aspirate blood from the subclavian vein. After aspiration of venous blood Seldinger technique was used to thread a J wire. The distal tip of the J wire was confirmed to be in adequate position with surgeon-interpreted fluoroscopy. Next a #15-blade scalpel was used to make an incision in the skin. Dissection was carried down to the level of the pectoralis muscle. A pocket was created. A dual-port Port-A-Cath was lowered into the pocket and secured with #2-0 Prolene. Both ports were flushed. The distal tip was pulled through to the wire exit site with a Kelly clamp. It was cut to the appropriate length. Next a dilator and sheath were threaded over the J wire. The J wire and dilator were removed and the distal tip of the dual-port Port-A-Cath was threaded over the sheath which was simultaneously withdrawn. Both ports of the dual-port Port-A-Cath were flushed and aspirated without difficulty. The distal tip was confirmed to be in adequate position with surgeon-interpreted fluoroscopy. The wire access site was closed with a 4-0 Monocryl. The port pocket was closed in 2 layers with 2-0 Vicryl followed by 4-0 Monocryl in a running subcuticular fashion. Sterile dressing was applied. The patient tolerated the procedure well and was transferred to the PACU in good condition | 38 Surgery |
PREOPERATIVE DIAGNOSIS Bladder tumor. POSTOPERATIVE DIAGNOSIS Bladder tumor. PROCEDURE PERFORMED Transurethral resection of a medium bladder tumor TURBT left lateral wall. ANESTHESIA Spinal. SPECIMEN TO PATHOLOGY Bladder tumor and specimen from base of bladder tumor. DRAINS A 22-French 3-way Foley catheter 30 mL balloon. ESTIMATED BLOOD LOSS Minimal. INDICATIONS FOR PROCEDURE This is a 74-year-old male who presented with microscopic and an episode of gross hematuria. He underwent an IVP which demonstrated enlarged prostate and normal upper tracts. Cystoscopy in the office demonstrated a 2.5- to 3-cm left lateral wall bladder tumor. He is brought to the operating room for transurethral resection of that bladder tumor. DESCRIPTION OF OPERATION After preoperative counseling of the patient and his wife the patient was taken to the operating room and administered a spinal anesthetic. He was placed in lithotomy position and prepped and draped in the usual fashion. Using the visual obturator the resectoscope was then inserted per urethra into the bladder. The bladder was inspected confirming previous cystoscopic findings of a 2.5- to 3-cm left lateral wall bladder tumor away from the ureteral orifice. Using the resectoscope loop the tumor was then resected down to its base in a stepwise fashion. Following completion of resection down to the base the bladder was free of tumor specimen. The resectoscope was then reinserted and the base of the bladder tumor was then resected to get the base of the bladder tumor specimen this was sent as a separate pathological specimen. Hemostasis was assured with electrocautery. The base of the tumor was then fulgurated again and into the periphery out in the normal mucosa surrounding the base of the bladder tumor. Following completion of the fulguration there was good hemostasis. The remainder of the bladder was without evidence of significant abnormality. Both ureteral orifices were visualized and noted to drain freely of clear urine. The bladder was filled and the resectoscope was removed. A 22-French 3-way Foley catheter was inserted per urethra into the bladder. The balloon was inflated to 30 mL. The catheter with sterile continuous irrigation and was noted to drain clear irrigant. The patient was then removed from lithotomy position. He was in stable condition. | 38 Surgery |
CHIEF COMPLAINT Transient visual loss lasting five minutes. HISTORY OF PRESENT ILLNESS This is a very active and pleasant 82-year-old white male with a past medical history significant for first-degree AV block status post pacemaker placement hypothyroidism secondary to hyperthyroidism and irradiation possible lumbar stenosis. He reports he experienced a single episode of his vision decreasing like it was compressed from the top down with a black sheet coming down . The episode lasted approximately five minutes and occurred three weeks ago while he was driving a car. He was able to pull the car over to the side of the road safely. During the episode he felt nauseated and possibly lightheaded. His wife was present and noted that he looked extremely pale and ashen during the episode. He went to see the Clinic at that time and received a CT scan carotid Dopplers echocardiogram and neurological evaluation all of which were unremarkable. It was suggested at that time that he get a CT angiogram since he cannot have an MRI due to his pacemaker. He has had no further similar events. He denies any lesions or other visual change focal weakness or sensory change headaches gait change or other neurological problem. He also reports that he has been diagnosed with lumbar stenosis based on some mild difficulty arising from a chair for which an outside physician ordered a CT of his L-spine that reportedly showed lumbar stenosis. The question has arisen as to whether he should have a CT myelogram to further evaluate this process. He has no back pain or pain of any type he denies bowel or bladder incontinence or frank lower extremity weakness. He is extremely active and plays tennis at least three times a week. He denies recent episodes of unexpected falls. REVIEW OF SYSTEMS He only endorses hypothyroidism the episode of visual loss described above and joint pain. He also endorses having trouble getting out of a chair but otherwise his review of systems is negative. A copy is in his clinic chart. PAST MEDICAL HISTORY As above. He has had bilateral knee replacement three years ago and experiences some pain in his knees with this. FAMILY HISTORY Noncontributory. SOCIAL HISTORY He is retired from the social security administration x 20 years. He travels a lot and is extremely active. He does not smoke. He consumes alcohol socially only. He does not use illicit drugs. He is married. MEDICATIONS The patient has recently been started on Plavix by his primary care doctor was briefly on baby aspirin 81 mg per day since the TIA-like event three weeks ago. He also takes Proscar 5 mg q.d and Synthroid 0.2 mg q.d. PHYSICAL EXAMINATION Vital Signs BP 134/80 heart rate 60 respiratory rate 16 and weight 244 pounds. He denies any pain. General This is a pleasant white male in no acute distress. HEENT He is normocephalic and atraumatic. Conjunctivae and sclerae are clear. There is no sinus tenderness. Neck Supple. Chest Clear to auscultation. Heart There are no bruits present. Extremities Extremities are warm and dry. Distal pulses are full. There is no edema. NEUROLOGIC EXAMINATION MENTAL STATUS He is alert and oriented to person place and time with good recent and long-term memory. His language is fluent. His attention and concentration are good. CRANIAL NERVES Cranial nerves II through XII are intact. VFFTC PERRL EOMI facial sensation and expression are symmetric hearing is decreased on the right hearing aid palate rises symmetrically shoulder shrug is strong tongue protrudes in the midline. MOTOR He has normal bulk and tone throughout. There is no cogwheeling. There is some minimal weakness at the iliopsoas bilaterally 4+/5 and possibly trace weakness at the quadriceps -5/5. Otherwise he is 5/5 throughout including hip adductors and abductors. SENSORY He has decreased sensation to vibration and proprioception to the middle of his feet only otherwise sensory is intact to light touch and temperature pinprick proprioception and vibration. COORDINATION There is no dysmetria or tremor noted. His Romberg is negative. Note that he cannot rise from the chair without using his arms. GAIT Upon arising he has a normal step stride and toe heel. He has difficulty with tandem and tends to fall to the left. REFLEXES 2 at biceps triceps patella and 1 at ankles. The patient provided a CT scan without contrast from his previous hospitalization three weeks ago which is normal to my inspection. He has had full labs for cholesterol and stroke for risk factors although he does not have those available here. IMPRESSION 1. TIA. The character of his brief episode of visual loss is concerning for compromise of the posterior circulation. Differential diagnoses include hypoperfusion stenosis and dissection. He is to get a CT angiogram to evaluate the integrity of the cerebrovascular system. He has recently been started on Paxil by his primary care physician and this should be continued. Other risk factors need to be evaluated however we will wait for the results to be sent from the outside hospital so that we do not have to repeat his prior workup. The patient and his wife assure me that the workup was complete and that nothing was found at that time. 2. Lumbar stenosis. His symptoms are very mild and consist mainly of some mild proximal upper extremity weakness and very mild gait instability. In the absence of motor stabilizing symptoms the patient is not interested in surgical intervention at this time. Therefore we would defer further evaluation with CT myelogram as he does not want surgery. PLAN 1. We will get a CT angiogram of the cerebral vessels. 2. Continue Plavix. 3. Obtain copies of the workup done at the outside hospital. 4. We will follow the lumbar stenosis for the time being. No further workup is planned. | 22 Neurology |
RHEUMATOID ARTHRITIS or RA is a chronic systemic condition with primary involvement of the joints. Joint inflammation is present due to an abnormal immune response in which the body attacks its own tissue. Specifically the tissues lining the joint are involved as well as cartilage and muscle and sometimes the eyes and blood vessels. The cause of rheumatoid arthritis is obscure but it is associated with a family history genetic and autoimmune problems people ages 20-60 female gender 3 1 or a Native American background. SIGNS AND SYMPTOMS Joint pain swelling redness warmth. Commonly involved joints are the small joints of the hands and feet and the ankles wrists knees shoulders and elbows. Multiple swollen joints more than 3 with simultaneous involvement of same joints on opposite side of the body. Morning stiffness that lasts longer than 30 minutes. Difficulty making a fist poor grip strength. Night pain. Feeling sick - low fever loss of appetite tiredness generalized aching and stiffness weakness. Rheumatoid nodules under the skin usually along the surface of tendons or over bony prominences. Disease may lead to deformed joints decreased vision anemia muscle weakness peripheral nerve problems pericarditis enlarged spleen increased frequency of infections. Blood tests will reveal a positive rheumatoid factor RF to be present the majority of the time. TREATMENT To diagnose RA blood studies are done to detect a substance known as rheumatoid factor and x-rays may show typical findings. Night splints for involved joints. Avoid putting a pillow under the knees as this will contribute to joint contracture. Heat helps relieve the pain hot water soaks whirlpool baths heat lamps heating pads etc. applied to affected joints 15-20 minutes 3 times per day is helpful. Sleep on a firm mattress and sleep at least 10-12 hours per night. Get rest during the day take naps. Get bed rest during an active flare-up until symptoms subside. Avoid humid weather if possible. NSAIDs non-steroidal anti-inflammatory drugs . DMARDs disease-modifying anti-rheumatic drugs - gold compounds D-penicillamine sulfasalazine methotrexate antimalarials. Immunosuppressive drugs. Acetaminophen Tylenol for pain relief only when necessary. Oral corticosteroids short term corticosteroid injection into joint can temporarily relieve pain and inflammation. Exercise as recommended by your physician. Exercise helps keep the joints limber and increases strength. Swimming and water activities are a good way to workout. Put all your joints through their full ranges of motion every day to prevent contractures. Physical therapy may be recommended. Surgical intervention. Lose excess weight as being overweight will only stress the joints further. Eat a normal well-balanced diet. | 34 Rheumatology |
PREOPERATIVE DIAGNOSES 1. Intrauterine pregnancy at 37 plus weeks nonreassuring fetal heart rate. 2. Protein S low. 3. Oligohydramnios. POSTOPERATIVE 1. Intrauterine pregnancy at 37 plus weeks nonreassuring fetal heart rate. 2. Protein S low. 3. Oligohydramnios. 4. Delivery of a viable female weight 5 pound 14 ounces. Apgars of 9 and 9 at 1 and 5 minutes respectively and cord pH is 7.314. OPERATION PERFORMED Low transverse C-section. ESTIMATED BLOOD LOSS 500 mL. DRAINS Foley. ANESTHESIA Spinal with Duramorph. HISTORY OF PRESENT ILLNESS This is a 21-year-old white female gravida 1 para 0 who had presented to the hospital at 37-3/7 weeks for induction. The patient had oligohydramnios and also when placed on the monitor had nonreassuring fetal heart rate with late deceleration. Due to the IUGR as well a decision for a C-section was made. PROCEDURE The patient was taken to the operating room and placed in a seated position with standard spinal form of anesthesia administered by the Anesthesia Department. The patient was then repositioned prepped and draped in a slight left lateral tilt. Once this was completed first knife was used to make a low transverse skin incision approximately two fingerbreadths above the pubic symphysis. This was extended down to the level of the fascia. The fascia was nicked in the center and extended in transverse fashion. Edges of the fascia were grasped with Kocher and both blunt and sharp dissection both caudally and cephalic was completed consistent with the Pfannenstiel technique. The abdominal rectus muscle was divided in the center extended in vertical fashion and the peritoneum was entered at a high point and extended in vertical fashion. Bladder blade was put in place and a bladder flap was created with the use of Metzenbaum and pickups and then bluntly dissected via cautery and reincorporated in the bladder blade. Second knife was used to make a low transverse uterine incision with care being taken to avoid the presenting part of fetus. Presenting part was vertex the head was delivered followed by the remaining portion of the body. The mouth and nose were suctioned through bulb syringe and the cord was doubly clamped and cut and then the newborn handed off to waiting nursing personnel. Cord pH blood and cord blood was obtained. The placenta was delivered manually and the uterus was externalized and the lining was cleaned off any remaining placental fragments and blood and the incisional edges were reapproximated with 0-chromic and a continuous locking stitch with a second layer used to imbricate the first. The bladder flap was re-peritonized with Gelfoam underneath and abdomen was irrigated with copious amounts of saline and the uterus was placed back in its anatomical position. The gutters were wiped clean of any remaining blood and fluid and the edges of the perineum grasped with hemostats and continuous locking stitches of 2-0 Vicryl was used to reapproximate the abdominal rectus muscle as well as the perineum. This area was then irrigated. Cautery was used for adequate hemostasis corners of the fascia grasped with hemostats and continuous locking stitch of 1-Vicryl was started at both corners and overlapped in the center. Subcutaneous tissue was irrigated with saline and reapproximated with 3-0 Vicryl. Skin edges reapproximated with sterile staples. Sterile dressing was applied. The uterus was evacuated of any remaining clots vaginally. The patient was taken to recovery room in stable condition. Instrument count needle count and sponge counts were all correct. | 38 Surgery |
HISTORY Patient is a 21-year-old white woman who presented with a chief complaint of chest pain. She had been previously diagnosed with hyperthyroidism. Upon admission she had complaints of constant left sided chest pain that radiated to her left arm. She had been experiencing palpitations and tachycardia. She had no diaphoresis no nausea vomiting or dyspnea. She had a significant TSH of 0.004 and a free T4 of 19.3. Normal ranges for TSH and free T4 are 0.5-4.7 µIU/mL and 0.8-1.8 ng/dL respectively. Her symptoms started four months into her pregnancy as tremors hot flashes agitation and emotional inconsistency. She gained 16 pounds during her pregnancy and has lost 80 pounds afterwards. She complained of sweating but has experienced no diarrhea and no change in appetite. She was given isosorbide mononitrate and IV steroids in the ER. FAMILY HISTORY Diabetes Hypertension Father had a Coronary Artery Bypass Graph CABG at age 34. SOCIAL HISTORY She had a baby five months ago. She smokes a half pack a day. She denies alcohol and drug use. MEDICATIONS Citalopram 10mg once daily for depression low dose tramadol PRN pain. PHYSICAL EXAMINATION Temperature 98.4 Pulse 123 Respiratory Rate 16 Blood Pressure 143/74. HEENT She has exophthalmos and could not close her lids completely. Cardiovascular tachycardia. Neurologic She had mild hyperreflexiveness. LAB All labs within normal limits with the exception of Sodium 133 Creatinine 0.2 TSH 0.004 Free T4 19.3 EKG showed sinus tachycardia with a rate of 122. Urine pregnancy test was negative. HOSPITAL COURSE After admission she was given propranolol at 40mg daily and continued on telemetry. On the 2nd day of treatment the patient still complained of chest pain. EKG again showed tachycardia. Propranolol was increased from 40mg daily to 60mg twice daily. A I-123 thyroid uptake scan demonstrated an increased thyroid uptake of 90 at 4 hours and 94 at 24 hours. The normal range for 4-hour uptake is 5-15 and 15-25 for 24-hour uptake. Endocrine consult recommended radioactive I-131 for treatment of Graves disease. Two days later she received 15.5mCi of I-131. She was to return home after the iodine treatment. She was instructed to avoid contact with her baby for the next week and to cease breast feeding. ASSESSMENT / PLAN 1. Treatment of hyperthyroidism. Patient underwent radioactive iodine 131 ablation therapy. 2. Management of cardiac symptoms stemming from hyperthyroidism. Patient was discharged on propranolol 60mg one tablet twice daily. 3. Monitor patient for complications of I-131 therapy such as hypothyroidism. She should return to Endocrine Clinic in six weeks to have thyroid function tests performed. Long-term follow-up includes thyroid function tests at 6-12 month intervals. 4. Prevention of pregnancy for one year post I-131 therapy. Patient was instructed to use 2 forms of birth control and was discharged an oral contraceptive taken one tablet daily. 5. Monitor ocular health. Patient was given methylcellulose ophthalmic one drop in each eye daily. She should follow up in 6 weeks with the Ophthalmology clinic. 6. Management of depression. Patient will be continued on citalopram 10 mg. | 13 Endocrinology |
Doctor s Address Dear Doctor This letter serves as a reintroduction of my patient A who will be seeing you on Thursday 06/12/2008. As you know he is an unfortunate gentleman who has reflex sympathetic dystrophy of both lower extremities. His current symptoms are more severe on the right and he has had a persisting wound that has failed to heal on his right leg. He has been through Wound Clinic to try to help heal this but was intolerant of compression dressings and was unable to get satisfactory healing of this. He has been seen by Dr. X for his pain management and was considered for the possibility of amputation being a therapeutic option to help reduce his pain. He was seen by Dr. Y at Orthopedic Associates for review of this. However in my discussion with Dr. Z and his evaluation of Mr. A it was felt that this may be an imprudent path to take given the lack of likelihood of reduction of his pain from his RST his questionable healing of his wound given noninvasive studies that did reveal tenuous oxygenation of the right lower leg and concerns of worsening of his RST symptoms on his left leg if he would have an amputation. Based on the results of his transcutaneous oxygen levels and his dramatic improvement with oxygen therapy at this test Dr. Z felt that a course of hyperbaric oxygen may be of utility to help in improving his wounds. As you may or may not know we have certainly pursued aggressive significant measures to try to improve Mr. A s pain. He has been to Cleveland Clinic for implantable stimulator which was unsuccessful at dramatically improving his pain. He currently is taking methadone up to eight tablets four times a day morphine up to 100 mg three times a day and Dilaudid two tablets by mouth every two hours to help reduce his pain. He also is currently taking Neurontin 1600 mg three times a day Effexor XR 250 mg once a day Cytomel 25 mcg once a day Seroquel 100 mg p.o. q. day levothyroxine 300 mcg p.o. q. day Prinivil 20 mg p.o. q. day and Mevacor 40 mg p.o. q day. I appreciate your assistance in determining if hyperbaric oxygen is a reasonable treatment course for this unfortunate situation. Dr. Z and I have both tried to stress the fact that amputation may be an abrupt and irreversible treatment course that may not reach any significant conclusion. He has been evaluated by Dr. X for rehab concerns to determine. He agrees that a less aggressive form of therapy may be most appropriate. I thank you kindly for your prompt evaluation of this kind gentleman in an unfortunate situation. If you have any questions regarding his care please feel free to call me at my office. Otherwise I look forward to hearing back from you shortly after your evaluation. Please feel free to call me if it is possible or if you have any questions about anything. | 22 Neurology |
CHIEF COMPLAINT This is a previously healthy 45-year-old gentleman. For the past 3 years he has had some intermittent episodes of severe nausea and abdominal pain. On the morning of this admission he had the onset of severe pain with nausea and vomiting and was seen in the emergency department where Dr. XYZ noted an incarcerated umbilical hernia. He was able to reduce this with relief of pain. He is now being admitted for definitive repair. PAST MEDICAL HISTORY Significant only for hemorrhoidectomy. He does have a history of depression and hypertension. MEDICATIONS His only medications are Ziac and Remeron. ALLERGIES No allergies. FAMILY HISTORY Negative for cancer. SOCIAL HISTORY He is single. He has 2 children. He drinks 4-8 beers per night and smokes half a pack per day for 30 years. He was born in Salt Lake City. He works in an electronic assembly for Harmony Music. He has no history of hepatitis or blood transfusions. PHYSICAL EXAMINATION GENERAL Examination shows a moderate to markedly obese gentleman in mild distress since his initial presentation to the emergency department. HEENT No scleral icterus. NECK No cervical supraclavicular or axillary adenopathy. LUNGS Clear. HEART Regular. No murmurs or gallops. ABDOMEN As noted obese with mildly visible bulging in the umbilicus at the superior position. With gentle traction we were able to feel both herniated contents which when reduced reveals an approximately 2-cm palpable defect in the umbilicus. DIAGNOSTIC STUDIES Normal sinus rhythm on EKG prolonged QT. Chest x-ray was negative. The abdominal x-rays were read as being negative. His electrolytes were normal. Creatinine was 0.9. White count was 6.5 hematocrit was 48 and platelet count was 307. ASSESSMENT AND PLAN Otherwise previously healthy gentleman who presents with an incarcerated umbilical hernia now for repair with mesh. | 15 General Medicine |
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. | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSIS Hawkins IV talus fracture. POSTOPERATIVE DIAGNOSIS Hawkins IV talus fracture. PROCEDURE PERFORMED 1. Open reduction internal fixation of the talus. 2. Medial malleolus osteotomy. 3. Repair of deltoid ligament. ANESTHESIA Spinal. TOURNIQUET TIME 90 min. BLOOD LOSS 50 cc. The patient is in the semilateral position on the beanbag. INTRAOPERATIVE FINDINGS A comminuted Hawkins IV talus fracture with an incomplete rupture of the deltoid ligament. There was no evidence of osteochondral defects of the talar dome. HISTORY This is a 50-year-old male who presented to ABCD General Hospital Emergency Department with complaints of left ankle pain and disfigurement. There was no open injury. The patient fell approximately 10 feet off his liner landing on his left foot. There was evidence of gross deformity of the ankle. An x-ray was performed in the Emergency Room which revealed a grade IV Hawkins classification talus fracture. He was distal neurovascularly intact. The patient denied any other complaints besides pain in the ankle. It was for this reason we elected to undergo the above-named procedure in order to reduce and restore the blood supply to the talus body. Because of its tenuous blood supply the patient is at risk for avascular necrosis. The patient has agreed to undergo the above-named procedure and consent was obtained. All risks as well as complications were discussed. PROCEDURE The patient was brought back to operative room #4 of ABCD General Hospital on 08/20/03. A spinal anesthetic was administered. A nonsterile tourniquet was placed on the left upper thigh but not inflated. He was then positioned on the beanbag. The extremity was then prepped and draped in the usual sterile fashion for this procedure. An Esmarch was then used to exsanguinate the extremity and the tourniquet was then inflated to 325 mmHg. At this time an anteromedial incision was made in order to perform a medial malleolus osteotomy to best localize the fracture region in order to be able to bone graft the comminuted fracture site. At this time a #15 blade was used to make approximately 10 cm incision over the medial malleolus. This was curved anteromedial along the root of the saphenous vein. The saphenous vein was located. Its tributaries going plantar were cauterized and the vein was retracted anterolaterally. At this time we identified the medial malleolus. There was evidence of approximately 80 avulsion rupture of the deltoid ligament off of the medial malleolus. This was a major blood feeder to the medial malleolus and we were concerned once we were going to do the osteotomy that this would later create healing problem. It is for this reason that the pedicle which was attached to the medial malleolus was left intact. This pedicle was the anterior portion of the deltoid ligament. At this time a MicroChoice saw was then used to make a box osteotomy of the medial malleolus. Once this was performed the medial malleolus was retracted anterolaterally with its remaining pedicle intact for later blood supply. This provided us with excellent exposure to the fracture site of the medial side. At this time any loose comminuted pieces were removed. The dome of the talus was also checked and did not reveal any osteochondral defects. There was some comminution on the dorsal aspect of the complete talus fracture and we were concerned that once we place the screw this would tend to extend the fracture site. It is for this reason we did the medial malleolar osteotomy to prevent this from happening in order to best expose the fracture site. At this time a reduction was performed. The #7-0 partially threaded cannulated screws were used in order to fix the fracture. At this time a 3.2 mm guidewire was placed going from posterolateral to anteromedial. This was placed slightly lateral to the Achilles tendon percutaneously inserted and then drilled in the according fashion across the fracture site. Once this was performed a skin knife was then used to incise over the percutaneous insertion in order to accommodate the screw going in. A depth gauze was then used to measure screw length. A cannulated drill was then used to drill across the fracture site to allow the entrance of the screw. A 55 mm partially threaded #7-0 cannulated screw was then placed with excellent compression at the fracture site. Once this was obtained we checked the reduction again using intraoperative Xi-Scan in the AP and lateral direction. This projection gave us excellent view of our screw placement and excellent compression across the fracture site. At this time we bone grafted the area of comminution using 1 cc of DynaGraft with crushed cancellous allograft. This was placed using a freer elevator into the fracture site where the comminution was. At this time we copiously irrigated the wound. The osteotomy site was then repaired first clamped using two large tenaculum reduction clamps. Two partially threaded #4-0 cannulated screws were then used to fix the osteotomy site and anatomical reduction was performed with excellent compression across the osteotomy site with the two screws. Next a #1-0 Vicryl was then used to repair the deltoid ligament which was ruptured via the injury. A tight repair was performed of the deltoid ligament. At this time again copious irrigation was used to irrigate the wound. A #2-0 Vicryl was then used to approximate the subcutaneous skin and staples for the skin incision. At this time the leg was cleansed Adaptic 4 x 4 and Kerlix roll were then applied. The patient was then placed in a plaster splint for mobilization. The tourniquet was then released. The patient was then transferred off the operating table to recovery in stable condition. The prognosis for this fracture is guarded. There is a high rate of avascular necrosis of the talar body approximately anywhere from 40-60 risk. The patient is aware of this and he will be followed as an outpatient for this problem. | 38 Surgery |
PROCEDURE Esophagogastroduodenoscopy with biopsy. PREOPERATIVE DIAGNOSIS A 1-year-10-month-old with a history of dysphagia to solids. The procedure was done to rule out organic disease. POSTOPERATIVE DIAGNOSES Loose lower esophageal sphincter and duodenal ulcers. CONSENT The consent is signed. MEDICATIONS The procedure was done under general anesthesia given by Dr. Marino Fernandez. COMPLICATIONS None. PROCEDURE IN DETAIL A history and physical examination were performed and the procedure indications potential complications including bleeding perforation the need for surgery infection adverse medical reaction risks benefits and alternatives available were explained to the parents who stated good understanding and consented to go ahead with the procedure. The opportunity for questions was provided and informed consent was obtained. Once the consent was obtained the patient was sedated with IV medications and intubated by Dr. Fernandez and placed in the supine position. Then the tip of the XP-160 videoscope was introduced into the oropharynx and under direct visualization we could advance the endoscope into the upper mid and lower esophagus. We did not find any strictures in the upper esophagus but the patient had the lower esophageal sphincter totally loose. Then the tip of the endoscope was advanced down into the stomach and guided into the pylorus and then into the first portion of the duodenum. We noticed that the patient had several ulcers in the first portion of the duodenum. Then the tip of the endoscope was advanced down into the second portion of the duodenum one biopsy was taken there and then the tip of the endoscope was brought back to the first portion and two biopsies were taken there. Then the tip of the endoscope was brought back to the antrum where two biopsies were taken and one biopsy for CLOtest. By retroflexed view at the level of the body of the stomach I could see that the patient had the lower esophageal sphincter loose. Finally the endoscope was unflexed and was brought back to the lower esophagus where two biopsies were taken. At the end air was suctioned from the stomach and the endoscope was removed out of the patient s mouth. The patient tolerated the procedure well with no complications. FINAL IMPRESSION 1. Duodenal ulcers. 2. Loose lower esophageal sphincter. PLAN 1. To start omeprazole 20 mg a day. 2. To review the biopsies. 3. To return the patient back to clinic in 1 to 2 weeks. | 38 Surgery |
PREOPERATIVE DIAGNOSIS 1. Hemoptysis. 2. History of lung cancer. POSTOPERATIVE DIAGNOSIS Tumor occluding right middle lobe with friability. PROCEDURE PERFORMED Fiberoptic bronchoscopy diagnostic. LOCATION Endoscopy suite #4. ANESTHESIA General per Anesthesia Service. ESTIMATED BLOOD LOSS Minimal. COMPLICATIONS None. INDICATIONS FOR PROCEDURE The patient presented to ABCD Hospital with a known history of lung cancer and acute hemoptysis with associated chest pain. Due to her prior history it was felt that she would benefit from diagnostic fiberoptic bronchoscopy to help determine the etiology of the hemoptysis. She was brought to endoscopy suite #4 and informed consent was obtained. PROCEDURE DETAILS The patient was placed in the supine position and intubated by the Anesthesia Service. Intravenous sedation was given as per Anesthesia. The fiberoptic scope was passed through the #8 endotracheal tube into the main trachea. The right mainstem bronchus was examined. The right upper lobe and subsegments appeared grossly within normal limits with no endobronchial lesions noted. Upon examining the right middle lobe there was a tumor noted occluding the lateral segment of the right middle lobe and a clot appreciated over the medial segment of the right middle lobe. The clot was lavaged with normal saline and there was noted to be tumor behind this clot. Tumor completely occluded both segments of the right middle lobe. Scope was then passed to the subsegments of the right lower lobe which were individually examined and noted to be grossly free of endobronchial lesions. Scope was pulled back to the level of the midtrachea passed into the left mainstem bronchus. Left upper lobe and its subsegments were examined and noted to be grossly free of endobronchial lesions. The lingula and left lower subsegments were all each individually examined and noted to be grossly free of endobronchial lesions. There were some secretions noted throughout the left lung. The scope was retracted and passed again to the right mainstem bronchus. The area of the right middle lobe was reexamined. The tumor was noted to be grossly friable with oozing noted from the tumor with minimal manipulation. It did not appear as if a scope or cannula could be passed distal to the tumor. Due to continued oozing 1 cc of epinephrine was applied topically with adequate hemostasis obtained. The area was examined for approximately one minute for assurance of adequate hemostasis. The scope was then retracted and the patient was sent to the recovery room in stable condition. She will be extubated as per the Anesthesia Service. Cytology and cultures were not sent due to the patient s known diagnosis. Further recommendations are pending at this time. | 38 Surgery |
PREOPERATIVE DIAGNOSES 1. Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy. 2. Epidural fibrosis with nerve root entrapment. POSTOPERATIVE DIAGNOSES 1. Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy. 2. Epidural fibrosis with nerve root entrapment. OPERATION PERFORMED Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection. ANESTHESIA Local/IV sedation. COMPLICATIONS None. SUMMARY The patient in the operating room status post transforaminal epidurogram see operative note for further details . Using AP and lateral fluoroscopic views to confirm the needle location the superior most being in the left L4 neural foramen and the inferior most in the left L5 neural foramen 375 units of Wydase was injected through each needle. After two minutes 3.5 cc of 0.5 Marcaine and 80 mg of Depo-Medrol was injected through each needle. These needles were removed and the patient was discharged in stable condition. | 27 Orthopedic |
PRE-OP DIAGNOSES Low back pain - 724.2 Herniated disc - 722.10 Lumbosacral Facet arthropathy - 724.4. POST-OP DIAGNOSES Low back pain - 724.2 Herniated disc - 722.10 Lumbosacral Facet arthropathy - 724.4. INTERVAL HISTORY Plans risks and options were reviewed with the patient in detail. The patient understands and agrees to proceed. ANESTHESIA General Anesthesia PROCEDURE PERFORMED Epidural steroid injection epidurogram fluroscopy. PROCEDURE After informed consent the patient was taken to the procedure room and placed in the prone position. EKG blood pressure and pulse oximetry were monitored and remained stable throughout the procedure. The area was prepped and draped in the usual sterile fashion. Local anesthetic was infiltrated at the appropriate level. Fluoroscopic guidance was used to place a #20-gauge Tuohy epidural needle gently into the epidural space at L4-L5 using a paramedian approach. No blood or CSF was obtained on aspiration. RADIOLOGY Injection of 3 cc of OMNIPAQUE showed spread of the dye into the epidural space on AP and Lateral imaging. The Needle was injected with Depo-Medrol 80 mg with Bupivacaine 1/16th 8 cc total vol. Patient tolerated procedure well and was transferred to recovery room. Patient was discharged home with escort. Discharge instructions were given. POST-OP PLAN I will see the patient back in my office in two weeks. Continue p.r.n. medications as needed. | 28 Pain Management |
PREOPERATIVE DIAGNOSIS Infected sebaceous cyst right neck. POSTOPERATIVE DIAGNOSIS Infected sebaceous cyst right neck. PROCEDURE The patient was electively taken to the operating room after obtaining an informed consent. With a combination of intravenous sedation and local infiltration anesthesia a time-out process was followed and then the patient was prepped and draped in the usual fashion. The elliptical incision was performed around the draining tract. Immediately we fell in to an abscess cavity with a lot of pus and necrotic tissue. All the necrotic tissue was excised together with an ellipse of skin. Hemostasis was achieved with a cautery. The cavity was irrigated with normal saline. At the end of procedure there was a good size around cavity that was packed with iodoform gauze. One skin suture was grazed for approximation. A bulky dressing was applied. The patient tolerated the procedure well. Estimated blood loss was negligible and the patient was sent to Same Day Surgery for recovery. | 38 Surgery |
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. | 37 Speech - Language |
PREOPERATIVE DIAGNOSIS Dental caries. POSTOPERATIVE DIAGNOSIS Dental caries. PROCEDURE Dental restorations and extractions. CLINICAL HISTORY This 23-year-old male is a client of the ABC Center because of his disability the nature of which is unclear to me at this time however he reportedly has several issues that qualify him as disabled. He has had multiple severe carious lesions that warrant multiple extractions at this time. It is also unclear to me as to how his prior or existing restorations were accomplished. In any case he has been cleared for the procedure today. He has his history and physical in the chart. PROCEDURE The patient was brought to the operating room at 11 o clock and placed in the supine position. Dr. X administered the general anesthetic after which a throat pack was placed. Available full mouth x-rays were reviewed. These x-rays were taken at another location. Teeth 2 4 10 12 13 15 18 20 27 and 31 were all in varying degrees of severe decay from complete destruction of the crowns to pulp exposures with periapical radiolucencies. All of these aforementioned teeth were extracted using combinations of forceps and elevators. Hemostasis in all of these sites was accomplished with direct pressure using gauze packs. Tooth 5 had caries in the distal surface extending to the occlusal as well as another carious lesion in the buccal. These carious lesions and his tooth were excavated and the tooth was restored with amalgam involving these surfaces. Tooth 6 had caries on the facial surface which was excavated and the tooth was restored with composite. Tooth 7 had caries involving the distal surface. Tooth 8 likewise had caries involving the distal surface and both of these distal lesions extended into incisal area. These carious lesions were excavated and both of these teeth were restored with composite. Tooth 9 had caries in a mesial surface and a buccal surface which was excavated and this tooth was restored with composite. Tooth 28 caries in the mesial surface extending to the occlusal which was excavated and the tooth was restored with amalgam and tooth 30 had carries in the buccal surface which was excavated and the tooth was restored with amalgam. A prophylaxis was done primarily using a rotating rubber cup and some minor scaling and the mouth was irrigated and suctioned thoroughly. The throat pack was removed and the patient was awakened and brought to the recovery room in good condition at 1330 hours. There was negligible blood loss. | 7 Dentistry |
HISTORY The patient is a 53-year-old male who was seen for evaluation at the request of Dr. X regarding recurrent jaw pain. This patient has been having what he described as numbness and tingling along the jaw teeth and tongue. This numbness has been present for approximately two months. It seems to be there all the time. He was seen by his dentist and after dental evaluation was noted to be okay. He had been diagnosed with a throat infection about a week ago and is finishing a course of Avelox at this time. He has been taking cough drops and trying to increase his fluids. He has recently stopped tobacco. He has been chewing tobacco for about 30 years. Again there is concern regarding the numbness he has been having. He has had a loss of sensation of taste as well. Numbness seems to be limited just to the left lateral tongue and the jaw region and extends from the angle of the jaw to the lip. He does report he has had about a 20-pound of weight gain over the winter but notes he has had this in the past just simply from decreased activity. He has had no trauma to the face. He does note a history of headaches. These are occasional and he gets these within the neck area when they do flare up. The headaches are noted to be less than one or two times per month. The patient does note he has a history of anxiety disorder as well. He has tried to eliminate his amount of tobacco and he is actually taking Nicorette gum at this time. He denies any fever or chills. He is not having any dental pain with biting down. He has had no jaw popping and no trismus noted. The patient is concerned regarding this numbness and presents today for further workup evaluation and treatment. REVIEW OF SYSTEMS Other than those listed above were otherwise negative. PAST SURGICAL HISTORY Pertinent for hernia repair. FAMILY HISTORY Pertinent for hypertension. CURRENT MEDICATIONS Tylenol. He is on Nicorette gum. ALLERGIES He is allergic to codeine unknown reaction. SOCIAL HISTORY The patient is single self-employed carpenter. He chews tobacco or having chewing tobacco for 30 years about half a can per day but notes he has been recently off and he does note occasional moderate alcohol use. PHYSICAL EXAMINATION VITAL SIGNS Blood pressure is 138/82 pulse 64 and regular temperature 98.3 and weight is 191 pounds. GENERAL The patient is an alert cooperative obese 53-year-old male with a normal-sounding voice and good memory. HEAD FACE Inspected with no scars lesions or masses noted. Sinuses palpated and are normal. Salivary glands also palpated and are normal with no masses noted. The patient also has full facial function. CARDIOVASCULAR Heart regular rate and rhythm without murmur. RESPIRATORY Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort. EYES Extraocular muscles were tested and within normal limits. EARS Both ears external ears are normal. The ear canals are clean and dry. The drums are intact and mobile. He does have moderate tympanosclerosis noted no erythema. Weber exam is midline. Hearing is grossly intact and normal. NASAL Reveals a deviated nasal septum to the left moderate clear drainage and no erythema. ORAL Oral cavity is normal with good moisture. Lips teeth and gums are normal. Evaluation of the oropharynx reveals normal mucosa normal palates and posterior oropharynx. Examination of the larynx with a mirror reveals normal epiglottis false and true vocal cords with good mobility of the cords. The nasopharynx was briefly examined by mirror with normal appearing mucosa posterior choanae and eustachian tubes. NECK The neck was examined with normal appearance. Trachea in the midline. The thyroid was normal nontender with no palpable masses or adenopathy noted. NEUROLOGIC He does have slightly decreased sensation to the left jaw. He is able to feel pressure on touch. This extends also on to the left lateral tongue and the left intrabuccal mucosa. DERMATOLOGIC Evaluation reveals no masses or lesions. Skin turgor is normal. PROCEDURE A fiberoptic nasopharyngoscopy was also performed. See separate operative report in chart. This does reveal a moderately deviated nasal septum to the left large inferior turbinates no mass or neoplasm noted. IMPRESSION 1. Persistent paresthesia of the left manual teeth and tongue consider possible neoplasm within the mandible. 2. History of tobacco use. 3. Hypogeusia with loss of taste. 4. Headaches. 5. Xerostomia. RECOMMENDATIONS I have ordered a CT of the head. This includes sinuses and mandible. This is primarily to evaluate and make sure there is not a neoplasm as the source of this numbness that he has had. On the mucosal surface I do not see any evidence of malignancy and no visible or palpable masses were noted. I did recommend he increase his fluid intake. He is to remain off the tobacco. I have scheduled a recheck with me in the next two to three weeks to make further recommendations at that time. | 5 Consult - History and Phy. |
PHYSICAL EXAMINATION GENERAL The patient is awake and alert in no apparent distress appropriate pleasant and cooperative. No dysarthria is noted. No discomfort on presentation is noted. HEAD Atraumatic normocephalic. Pupils are equal round and reactive to light. Extraocular muscles are intact. Sclerae are white without injection or icterus. Fundi are without papilledema hemorrhages or exudates with normal vessels. EARS The ear canals are patent without edema exudate or drainage. Tympanic membranes are intact with a normal cone of light. No bulging or erythema to indicate infection is present. There is no hemotympanum. Hearing is grossly intact. NOSE Without deformity bleeding or discharge. No septal hematoma is noted. ORAL CAVITY No swelling or abnormality to the lip or teeth. Oral mucosa is pink and moist. No swelling to the palate or pharynx. Uvula is midline. The pharynx is without exudate or erythema. No edema is seen of the tonsils. The airway is completely patent. The voice is normal. No stridor is heard. NECK No signs of meningismus. No Brudzinski or Kernig sign is present. No adenopathy is noted. No JVD is seen. No bruits are auscultated. Trachea is midline. CHEST Symmetrical with equal breath sounds. Equal excursion. No hyperresonance or dullness to percussion is noted. There is no tenderness on palpation of the chest. LUNGS Clear to auscultation bilaterally. No rales rhonchi or wheezes are appreciated. Good air movement is auscultated in all 4 lung fields. HEART Regular rate and rhythm. No murmur. No S3 S4 or rub is auscultated. Point of maximal impulse is strong and in normal position. Abdominal aorta is not palpable. The carotid upstroke is normal. ABDOMEN Soft nontender and nondistended. Normal bowel sounds are auscultated. No organomegaly is appreciated. No masses are palpated. No tympany is noted on percussion. No guarding rigidity or rebound tenderness is seen on exam. Murphy and McBurney sign is negative. There is no Rovsing obturator or psoas sign present. No hepatosplenomegaly and no hernias are noted. RECTAL Normal tone. No masses. Soft brown stool in the vault. Guaiac negative. GENITOURINARY External genitalia without erythema exudate or discharge. Vaginal vault is without discharge. Cervix is of normal color without lesion. The os is closed. There is no bleeding noted. Uterus is noted to be of normal size and nontender. No cervical motion tenderness is seen. No masses are palpated. The adnexa are without masses or tenderness. EXTREMITIES No clubbing cyanosis or edema. Pulses are strong and equal in the femoral and dorsalis pedis arteries bounding and equal. No deformity or signs of trauma. All joints are stable without laxity. There is good range of motion of all joints without tenderness or discomfort. Homan sign is negative. No atrophy or contractures are noted. SKIN No rashes. No jaundice. Pink and warm with good turgor. Good color. No erythema or nodules noted. No petechia bulla or ecchymosis. NEUROLOGIC Cranial nerves II through XII are grossly intact. Muscle strength is graded 5/5 in the upper and lower extremities bilaterally. Deep tendon reflexes are symmetrical in the upper and lower extremities bilaterally. Babinski is downgoing bilaterally. Sensation is intact to light touch and vibration. Gait is normal. Romberg finger-to-nose rapid alternating movements and heel-to-shin are all normal. There is no ataxia seen on gait testing. Tone is normal. No pronator drift is seen. PSYCHIATRIC The patient is oriented x4. Mood and affect are appropriate. Memory is intact with good short- and long-term memory recall. No dysarthria is noted. Remote memory is intact. Judgment and insight appear normal. | 15 General Medicine |
HISTORY OF PRESENT ILLNESS The patient is a 26-year-old gravida 2 para 1-0-0-1 at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so. She states that she has not voided in the last 24 hours as well due to pain. She denies any leaking of fluid vaginal bleeding or uterine contractions. She reports good fetal movement. She denies any fevers chills or burning with urination. REVIEW OF SYSTEMS Positive for back pain in her lower back only. Her mother reports that she has been eating food without difficulty and that the current nausea and vomiting is much less than when she is not pregnant. She continues to yell out for requesting pain medication and about how much it hurts. PAST MEDICAL HISTORY 1. Irritable bowel syndrome. 2. Urinary tract infections times three. The patient is unsure if pyelo is present or not. PAST SURGICAL HISTORY Denies. ALLERGIES No known drug allergies. MEDICATIONS Phenergan and Zofran twice a day. Macrobid questionable. GYN History of an abnormal Pap group B within normal limits. Denies any sexually transmitted diseases. OB HISTORY G1 is a term spontaneous vaginal delivery without complications now a 6-year-old. G2 is current. Gets her care at Lyndhurst. SOCIAL HISTORY Denies tobacco and alcohol use. She endorses marijuana use and a history of cocaine use five years ago. Upon review of the Baptist lab systems the patient has had multiple positive urine drug screens and as recently as February 2008 had a urine drug screen that was positive for benzodiazepines barbiturates opiates and marijuana and as recently as 2005 with cocaine present as well. PHYSICAL EXAM VITAL SIGNS Blood pressure 139/82 pulse 89 respirations 20 98 on room air 96 degrees Fahrenheit. Fetal heart tones are 130s with moderate long-term variability. No paper is available for the fetal heart monitor due to the misorder and audibly sounds reassuring. GENERAL Appears sedated trashing intermittently and then falling asleep in mid sentence. CARDIOVASCULAR Regular rate and rhythm. PULMONARY Clear to auscultation bilaterally. BACK Tender to palpation in her lower back bilaterally but no CVA tenderness. ABDOMEN Tender to palpation in left lower quadrant. No guarding or rebound. Normal bowel sounds. EXTREMITIES Scar track marks from bilateral arms. PELVIC External vaginal exam is closed long high and posterior. Stool was felt in the rectum. LABS White count is 11.1 hemoglobin is 13.5 platelets are 279. CMP is within normal limits with an AST of 17 ALT of 11 and creatinine of 0.6. Urinalysis which is supposedly a cath specimen shows a specific gravity of 1.024 greater than 88 ketones many bacteria but no white blood cells or nitrites. ASSESSMENT AND PLAN The patient is a 26-year-old gravida 2 para 1-0-0-1 at 28-1 weeks with left lower quadrant pain and likely constipation. I spoke with Dr. X who is the physician on-call tonight and he requests that she be transferred for continued fetal monitoring and further evaluation of this abdominal pain to Labor and Delivery. Plans are made for transfer at this time. This was discussed with Dr. Y who is in agreement with the plan. | 12 Emergency Room Reports |
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. | 3 Cardiovascular / Pulmonary |
PROCEDURE Gastroscopy. PREOPERATIVE DIAGNOSIS Dysphagia and globus. POSTOPERATIVE DIAGNOSIS Normal. MEDICATIONS MAC. DESCRIPTION OF PROCEDURE The Olympus gastroscope was introduced through the oropharynx and passed carefully through the esophagus and stomach and then through the gastrojejunal anastomosis into the efferent jejunal loop. The preparation was good and all surfaces were well seen. The hypopharynx was normal with no evidence of inflammation. The esophagus had a normal contour and normal mucosa throughout with no sign of stricturing or inflammation or exudate. The GE junction was located at 39 cm from the incisors and appeared normal with no evidence of reflux damage or Barrett s. Below this there was a small gastric pouch measuring 6 cm with intact mucosa and no retained food. The gastrojejunal anastomosis was patent measuring about 12 mm with no inflammation or ulceration. Beyond this there was a side-to-side gastrojejunal anastomosis with a short afferent blind end and a normal efferent end with no sign of obstruction or inflammation. The scope was withdrawn and the patient was sent to recovery room. She tolerated the procedure well. FINAL DIAGNOSES 1. Normal post-gastric bypass anatomy. 2. No evidence of inflammation or narrowing to explain her symptoms. | 38 Surgery |
PREOPERATIVE DIAGNOSES Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea. POSTOPERATIVE DIAGNOSES Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea. OPERATION PERFORMED Neck exploration tracheostomy urgent flexible bronchoscopy via tracheostomy site removal of foreign body tracheal metallic stent material dilation distal trachea placement of #8 Shiley single cannula tracheostomy tube. INDICATIONS FOR SURGERY The patient is a 50-year-old white male with history of progressive tracheomalacia treated in the National Tennessee and several years ago he had a tracheal metallic stent placed with some temporary improvement. However developed progressive problems and he had two additional stents placed with some initial improvement. Subsequently he developed progressive airway obstruction and came into the ABC Hospital critical airway service for further evaluation and was admitted on Month DD YYYY. He underwent bronchoscopy by Dr. W and found to have an extensive subglottic upper tracheal and distal tracheal stenosis secondary to metallic stent extensive granulation and inflammatory tissue changes. The patient had some debridement and then was hospitalized and Laryngology and Thoracic Surgery services were consulted for further management. Exploration of trachea removal of foreign body stents constricting his airway dilation and stabilization of his trachea were offered to the patient. Nature of the proposed procedure including risks and complications of bleeding infection alteration of voice speech swallowing voice changes permanently possibility of tracheotomy temporarily or permanently to maintain his airway loss of voice cardiac risk factors anesthetic risks recurrence of problems upon surgical intervention were all discussed at length. The patient stated that he understood and wished to proceed. DESCRIPTION OF PROCEDURE The patient was taken to the operating room placed in the supine position. Following adequate monitoring by Anesthesia Service to maintain sedation the patient s neck was prepped and draped in the sterile fashion. The neck was then infiltrated with 1 Xylocaine and 1000 epinephrine. A collar incision approximately 1 fingerbreadth above the clavicle this was an outline incision was carried out. The skin subcutaneous tissue platysma subplatysmal flaps elevated superiorly and inferiorly. Strap muscles were separated in the midline dissection carried down to visceral fascia. Beneath the strap muscles there was dense inflammation scarring obscuring palpable landmarks. There appeared to be significant scarring fusion of soft tissue at the perichondrium and cartilage of the cricoid making the cricoid easily definable. There was a markedly enlarged thyroid isthmus. Thyroid isthmus was divided and dense inflammation attachment of the thyroid isthmus fusion of the thyroid gland to the capsule to the pretracheal fascia requiring extensive blunt sharp dissection. Trachea was exposed from the cricoid to the fourth ring which entered down into the chest. The trachea was incised between the second and third ring inferior limb in the midline and excision of small ridge of cartilage on each side sent for pathologic evaluation. The tracheal cartilage externally had marked thickening and significant stiffness calcification and the tracheal wall from the outside of the trachea to the mucosa measured 3 to 4 mm in thickness. The trachea was entered and visualized with thickening of the mucosa and submucosa was noted. The patient however was able to ventilate at this point a #6 Endo Tube was inserted and general anesthesia administered. Once the airway was secured we then proceeded working around the #6 Endo Tube as well as with the tube intake and out to explore the trachea with ridged fiberoptic scopes as well as flexible fiberoptic bronchoscopy to the trach site. Examination revealed extrusion of metallic fragments from stent and multiple metallic fragments were removed from the stent in the upper trachea. A careful examination of the subglottic area showed inflamed and thickened mucosa but patent subglottis. After removal of the stents and granulation tissue the upper trachea was widely patent. The mid trachea had some marked narrowing secondary to granulation. Stent material was removed from this area as well. In the distal third of the trachea a third stent was embedded within the mucosa not encroaching on the lumen without significant obstruction distally and this was not disturbed at this time. All visible stent material in the upper and mid trachea were removed. Initial attempt to place a #16 Montgomery T tube showed the distal lumen of the T tube to be too short to stent the granulation narrowing of the trachea at the junction of the anterior two thirds and the distal third. Also this was removed and a #8 Shiley single cannula tracheostomy tube was placed after removal of the endotracheal tube. A good ventilation was confirmed and the position of the tube confirmed it to be at the level just above the metallic stent which was embedded in the mucosa. The distal trachea and mainstem bronchi were widely patent. This secured his airway and no further manipulation felt to be needed at this time. Neck wound was thoroughly irrigated and strap muscles were closed with interrupted 3-0 Vicryl. The skin laterally to the trach site was closed with running 2-0 Prolene. Tracheostomy tube was secured with interrupted 2-0 silk sutures and the patient was taken back to the Intensive Care Unit in satisfactory condition. The patient tolerated the procedure well without complication. | 38 Surgery |
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