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ADENOIDECTOMY PROCEDURE The patient was brought into the operating room suite anesthesia administered via endotracheal tube. Following this the patient was draped in standard fashion. The Crowe-Davis mouth gag was inserted in the oral cavity. The palate and tonsils were inspected the palate was suspended with a... | 11 ENT - Otolaryngology |
PREOPERATIVE DIAGNOSIS Left communicating hydrocele. POSTOPERATIVE DIAGNOSIS Left communicating hydrocele. ANESTHESIA General. PROCEDURE Left inguinal hernia and hydrocele repair. INDICATIONS The patient is a 5-year-old young man with fluid collection in the tunica vaginalis and peritesticular space on t... | 29 Pediatrics - Neonatal |
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... | 14 Gastroenterology |
EXAM MRI-UP EXT JOINT LEFT SHOULDER CLINICAL Left shoulder pain. Evaluate for rotator cuff tear. FINDINGS Multiple T1 and gradient echo axial images were obtained as well as T1 and fat suppressed T2-weighted coronal images. The rotator cuff appears intact and unremarkable. There is no significant effusion seen. O... | 33 Radiology |
PREOPERATIVE DIAGNOSES 1. Herniated nucleus pulposus C5-C6 greater than C6-C7 and C4-C5 with left radiculopathy. 2. Cervical stenosis with cord compression C5-C6 723.0 . POSTOPERATIVE DIAGNOSES 1. Herniated nucleus pulposus C5-C6 greater than C6-C7 and C4-C5 with left radiculopathy. 2. Cervical stenosis... | 38 Surgery |
OPERATION Insertion of a #8 Shiley tracheostomy tube. ANESTHESIA General endotracheal anesthesia. OPERATIVE PROCEDURE IN DETAIL After obtaining informed consent from the patient s family including a thorough explanation of the risks and benefits of the aforementioned procedure the patient was taken to the op... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Right renal mass. POSTOPERATIVE DIAGNOSIS Right renal mass. PROCEDURE PERFORMED Laparoscopic right partial nephrectomy. ESTIMATED BLOOD LOSS 250 mL. X-RAYS None. SPECIMENS Included right renal mass as well as biopsies from the base of the resection. ANESTHESIA General endotra... | 21 Nephrology |
PROCEDURE Colonoscopy. PREOPERATIVE DIAGNOSES The patient is a 56-year-old female. She was referred for a screening colonoscopy. The patient has bowel movements every other day. There is no blood in the stool no abdominal pain. She has hypertension dyslipidemia and gastroesophageal reflux disease. She has... | 14 Gastroenterology |
CT ABDOMEN WITHOUT CONTRAST AND CT PELVIS WITHOUT CONTRAST REASON FOR EXAM Evaluate for retroperitoneal hematoma the patient has been following is currently on Coumadin. CT ABDOMEN There is no evidence for a retroperitoneal hematoma. The liver spleen adrenal glands and pancreas are unremarkable. Within the ... | 21 Nephrology |
TITLE OF OPERATION Youngswick osteotomy with internal screw fixation of the first right metatarsophalangeal joint of the right foot. PREOPERATIVE DIAGNOSIS Hallux limitus deformity of the right foot. POSTOPERATIVE DIAGNOSIS Hallux limitus deformity of the right foot. ANESTHESIA Monitored anesthesia care wit... | 38 Surgery |
The patient and his wife had the opportunity to ask questions all of which were answered for them and the patient stated in a clear competent and coherent fashion that he wished to go forward with cardiac catheterization which I felt was appropriate. PROCEDURE NOTE The patient was brought to the Cardiac Catheteriz... | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSES Right lumbosacral radiculopathy secondary to lumbar spondylolysis. POSTOPERATIVE DIAGNOSES Right lumbosacral radiculopathy secondary to lumbar spondylolysis. OPERATION PERFORMED 1. Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots. 2. Right L4-L5 and righ... | 38 Surgery |
HISTORY This 15-day-old female presents to Children s Hospital and transferred from Hospital Emergency Department for further evaluation. Information is obtained in discussion with the mother and the grandmother in review of previous medical records. This patient had the onset on the day of presentation of a jelly... | 38 Surgery |
DIAGNOSES 1. Cervical dystonia. 2. Post cervical laminectomy pain syndrome. Ms. XYZ states that the pain has now shifted to the left side. She has noticed a marked improvement on the right side which was subject to a botulinum toxin injection about two weeks ago. She did not have any side effects on the Botox inj... | 28 Pain Management |
EXAM CT KUB. REASON FOR EXAM Flank pain. TECHNIQUE Noncontrast CT abdomen and pelvis per renal stone protocol. Correlation is made with the prior examination dated 01/16/09. FINDINGS There is no intrarenal stone or obstruction bilaterally. There is no hydronephrosis ureteral dilatation. There are calcifi... | 21 Nephrology |
EXAM Renal ultrasound. HISTORY Renal failure neurogenic bladder status-post cystectomy. TECHNIQUE Multiple ultrasonographic images of the kidneys were obtained in the transverse and longitudinal planes. COMPARISON Most recently obtained mm/dd/yy. FINDINGS The right kidney measures 12 x 5.2 x 4.6 cm and... | 33 Radiology |
PROCEDURE Colonoscopy. INDICATIONS Hematochezia Personal history of colonic polyps. MEDICATIONS Midazolam 2 mg IV Fentanyl 100 mcg IV PROCEDURE A History and Physical has been performed and patient medication allergies have been reviewed. The patient s tolerance of previous anesthesia has been reviewed.... | 14 Gastroenterology |
EXAM Skull complete five images HISTORY Plagiocephaly. TECHNIQUE Multiple images of the skull were evaluated. There are no priors for comparison. FINDINGS Multiple images of the skull were evaluated and they reveal radiographic visualization of the cranial sutures without evidence of closure. There is n... | 33 Radiology |
PREOPERATIVE DIAGNOSES 1. Herniated nucleus pulposus C2-C3. 2. Spinal stenosis C3-C4. POSTOPERATIVE DIAGNOSES 1. Herniated nucleus pulposus C2-C3. 2. Spinal stenosis C3-C4. PROCEDURES 1. Anterior cervical discectomy C3-C4 C2-C3. 2. Anterior cervical fusion C2-C3 C3-C4. 3. Removal of old instrumentation C4-C... | 23 Neurosurgery |
PREOPERATIVE DIAGNOSIS Cataract to right eye. POSTOPERATIVE DIAGNOSIS Cataract to right eye. PROCEDURE PERFORMED Cataract extraction with intraocular lens implant of the right eye anterior vitrectomy of the right eye. LENS IMPLANT USED See below. COMPLICATIONS Posterior capsular hole vitreous prolapse.... | 26 Ophthalmology |
CHIEF COMPLAINT / REASON FOR THE VISIT Patient has been diagnosed to have breast cancer. BREAST CANCER HISTORY Patient presented with the following complaints Lump in the upper outer quadrant of the right breast that has been present for the last 4 weeks. The lump is painless and the skin over the lump is normal. ... | 5 Consult - History and Phy. |
SUBJECTIVE This is a 1-year-old male who comes in with a cough and congestion for the past two to three weeks. Started off as a congestion but then he started coughing about a week ago. Cough has gotten worsen. Mother was also worried. He had Pop Can just three days ago and she never found the top of that and wa... | 15 General Medicine |
PREOPERATIVE DIAGNOSIS Left undescended testis. POSTOPERATIVE DIAGNOSIS Left undescended testis plus left inguinal hernia. PROCEDURES Left inguinal hernia repair left orchiopexy with 0.25 Marcaine ilioinguinal nerve block and wound block at 0.5 Marcaine plain. ABNORMAL FINDINGS A high left undescended t... | 39 Urology |
PROBLEM Prescription evaluation for Crohn s disease. HISTORY This is a 46-year-old male who is here for a refill of Imuran. He is taking it at a dose of 100 mg per day. He is status post resection of the terminal ileum and has experienced intermittent obstructive symptoms for the past several years. In fact ... | 14 Gastroenterology |
PREOPERATIVE DIAGNOSES 1. Enlarging skin neoplasm actinic neoplasm left upper cheek measures 1 cm x 1.5 cm. 2. Enlarging 0.5 cm x 1 cm nevus of the left lower cheek neck region. 3. A 1 cm x 1 cm seborrheic keratosis of the mid neck. 4. A 1 cm x 1.5 cm verrucous seborrheic keratosis of the right auricular rim. 5... | 38 Surgery |
HOSPITAL COURSE The patient is an 1812 g baby boy born by vaginal delivery to a 32-year-old gravida 3 para 2 at 34 weeks of gestation. Mother had two previous C-sections. Baby was born at 5 57 on 07/30/2006. Mother received ampicillin 2 g 4 hours prior to delivery. Mother came with preterm contractions with pr... | 10 Discharge Summary |
EXAM CT head. REASON FOR EXAM Seizure disorder. TECHNIQUE Noncontrast CT head. FINDINGS There is no evidence of an acute intracranial hemorrhage or infarction. There is no midline shift intracranial mass or mass effect. There is no extra-axial fluid collection or hydrocephalus. Visualized portions of t... | 22 Neurology |
INDICATIONS Predominant rhythm is sinus. Heart rate varied between 56-128 beats per minute average heart rate of 75 beats per minute. Minimum heart rate of 50 beats per minute. 640 ventricular ectopic isolated beats noted. Rare isolated APCs and supraventricular couplets. One supraventricular triplet reported. T... | 3 Cardiovascular / Pulmonary |
REASON FOR CONSULTATION New-onset seizure. HISTORY OF PRESENT ILLNESS The patient is a 2-1/2-year-old female with a history of known febrile seizures who was placed on Keppra oral solution at 150 mg b.i.d. to help prevent febrile seizures. Although this has been a very successful treatment in terms of her febri... | 22 Neurology |
DATE OF ADMISSION MM/DD/YYYY. DATE OF DISCHARGE MM/DD/YYYY. REFERRING PHYSICIAN AB CD M.D. ATTENDING PHYSICIAN AT DISCHARGE X Y M.D. ADMITTING DIAGNOSES 1. Ewing sarcoma. 2. Anemia. 3. Hypertension. 4. Hyperkalemia. PROCEDURES DURING HOSPITALIZATION Cycle seven Ifosfamide mesna and VP-16 chemoth... | 10 Discharge Summary |
PREOPERATIVE DIAGNOSIS Positive peptic ulcer disease. POSTOPERATIVE DIAGNOSIS Gastritis. PROCEDURE PERFORMED Esophagogastroduodenoscopy with photography and biopsy. GROSS FINDINGS The patient had a history of peptic ulcer disease epigastric abdominal pain x2 months being evaluated at this time for ulcer d... | 38 Surgery |
SUBJECTIVE The patient presents with Mom and Dad for her 1-year well child check. The family has no concerns stating the patient has been doing well overall since the last visit taking in a well-balanced diet consisting of formula transitioning to whole milk fruits vegetables proteins and grains. Normal voiding... | 5 Consult - History and Phy. |
FEMALE REVIEW OF SYSTEMS Constitutional Patient denies fevers chills sweats and weight changes. Eyes Patient denies any visual symptoms. Ears Nose and Throat No difficulties with hearing. No symptoms of rhinitis or sore throat. Cardiovascular Patient denies chest pains palpitations orthopnea and paroxys... | 15 General Medicine |
PREOPERATIVE DIAGNOSES 1. Intrauterine pregnancy at 38 weeks. 2. Malpresentation. POSTOPERATIVE DIAGNOSES 1. Intrauterine pregnancy at 38 weeks. 2. Malpresentation. 3. Delivery of a viable male neonate. PROCEDURE PERFORMED Primary low transverse cervical cesarean section. ANESTHESIA Spinal with Astramorph.... | 24 Obstetrics / Gynecology |
SUBJECTIVE The patient is keeping a food journal that she brought in. She is counting calorie points which ranged 26 to 30 per day. She is exercising pretty regularly. She attends Overeaters Anonymous and her sponsor is helping her and told her to get some ideas on how to plan snacks to prevent hypoglycemia. Th... | 9 Diets and Nutritions |
SUBJECTIVE The patient was seen and examined. He feels much better today improved weakness and decreased muscular pain. No other complaints. PHYSICAL EXAMINATION GENERAL Not in acute distress awake alert and oriented x3. VITAL SIGNS Blood pressure 147/68 heart rate 82 respiratory rate 20 temperature 97.... | 15 General Medicine |
CHIEF COMPLAINT Left knee pain and stiffness. HISTORY OF PRESENT ILLNESS The patient is a 57-year-old with severe bilateral knee DJD left greater than right with significant pain and limitations because of both. He is able to walk approximately a 1/2-mile a day but is limited because of his knees. Stairs are ... | 27 Orthopedic |
PREOPERATIVE DIAGNOSIS Nonpalpable neoplasm right breast. POSTOPERATIVE DIAGNOSIS Deferred for Pathology. PROCEDURE PERFORMED Needle localized wide excision of nonpalpable neoplasm right breast. SPECIMEN Mammography. GROSS FINDINGS This 53-year-old Caucasian female who had a nonpalpable neoplasm detect... | 24 Obstetrics / Gynecology |
PROCEDURE Urgent cardiac catheterization with coronary angiogram. PROCEDURE IN DETAIL The patient was brought urgently to the cardiac cath lab from the emergency room with the patient being intubated with an abnormal EKG and a cardiac arrest. The right groin was prepped and draped in usual manner. Under 2 lido... | 12 Emergency Room Reports |
Patient was informed by Dr. ABC that he does not need sleep study as per patient. PHYSICAL EXAMINATION General Pleasant brighter. Vital signs 117/78 12 56. Abdomen Soft nontender. Bowel sounds normal. ASSESSMENT AND PLAN 1. Constipation. Milk of Magnesia 30 mL daily p.r.n. Dulcolax suppository twice a w... | 14 Gastroenterology |
PREOPERATIVE DIAGNOSES Cervical spondylosis status post complex anterior cervical discectomy corpectomy decompression and fusion. POSTOPERATIVE DIAGNOSES Cervical spondylosis status post complex anterior cervical discectomy corpectomy decompression and fusion and potentially unstable cervical spine. OPERAT... | 23 Neurosurgery |
EXAM MRI of the brain without contrast. HISTORY Daily headaches for 6 months in a 57-year-old. TECHNIQUE Noncontrast axial and sagittal images were acquired through the brain in varying degrees of fat and water weighting. FINDINGS The brain is normal in signal intensity and morphology for age. There are no... | 22 Neurology |
CHIEF COMPLAINT Blood-borne pathogen exposure. HISTORY OF PRESENT ILLNESS The patient is a 54-year-old right-handed male who works as a phlebotomist and respiratory therapist at Hospital. The patient states that he was attempting to do a blood gas. He had his finger of the left hand over the pulse and was inserti... | 5 Consult - History and Phy. |
REASON FOR EXAM Atrial flutter/cardioversion. PROCEDURE IN DETAIL The procedure was explained to the patient with risks and benefits. The patient agreed and signed the consent form. The patient received sedation prior to the cardioversion with a transesophageal echo as dictated earlier with a total of 50 mcg of... | 38 Surgery |
FINAL DIAGNOSES 1. Morbid obesity status post laparoscopic Roux-en-Y gastric bypass. 2. Hypertension. 3. Obstructive sleep apnea on CPAP. OPERATION AND PROCEDURE Laparoscopic Roux-en-Y gastric bypass. BRIEF HOSPITAL COURSE SUMMARY This is a 30-year-old male who presented recently to the Bariatric Center f... | 2 Bariatrics |
PROCEDURES 1. Left heart catheterization. 2. Coronary angiography. 3. Left ventriculogram. PREPROCEDURE DIAGNOSIS Atypical chest pain. POSTPROCEDURE DIAGNOSES 1. No angiographic evidence of coronary artery disease. 2. Normal left ventricular systolic function. 3. Normal left ventricular end diastolic pressure.... | 38 Surgery |
INDICATIONS FOR PROCEDURE Impending open heart surgery for closure of ventricular septal defect in a 4-month-old girl. Procedures were done under general anesthesia. The patient was already in the operating room under general anesthesia. Antibiotic prophylaxis with cefazolin and gentamicin was already given prior ... | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSIS Left cervical radiculopathy. POSTOPERATIVE DIAGNOSIS Left cervical radiculopathy. PROCEDURES PERFORMED 1. C5-C6 anterior cervical discectomy. 2. Bone bank allograft. 3. Anterior cervical plate. TUBES AND DRAINS LEFT IN PLACE None. COMPLICATIONS None. SPECIMEN SENT TO PATHOLOGY ... | 23 Neurosurgery |
REASON FOR EVALUATION The patient is a 37-year-old white single male admitted to the hospital through the emergency room. I had seen him the day before in my office and recommended him to go into the hospital. He had just come from a trip to Taho in Nevada and he became homicidal while there. He started having th... | 22 Neurology |
HISTORY AND REASON FOR CONSULTATION For evaluation of this patient for colon cancer screening. HISTORY OF PRESENT ILLNESS Mr. A is a 53-year-old gentleman who was referred for colon cancer screening. The patient said that he occasionally gets some loose stools. Other than that there are no other medical problems... | 5 Consult - History and Phy. |
PREOPERATIVE DIAGNOSIS Low back pain. POSTOPERATIVE DIAGNOSIS Low back pain. PROCEDURE PERFORMED 1. Lumbar discogram L2-3. 2. Lumbar discogram L3-4. 3. Lumbar discogram L4-5. 4. Lumbar discogram L5-S1. ANESTHESIA IV sedation. PROCEDURE IN DETAIL The patient was brought to the Radiology Suite and placed... | 33 Radiology |
PREOPERATIVE DIAGNOSIS Epigastric hernia. POSTOPERATIVE DIAGNOSIS Epigastric hernia. OPERATIONS Epigastric herniorrhaphy. ANESTHESIA General inhalation. PROCEDURE Following attainment of satisfactory anesthesia the patient s abdomen was prepped with Hibiclens and draped sterilely. The hernia mass had b... | 14 Gastroenterology |
MULTISYSTEM EXAM CONSTITUTIONAL The vital signs showed that the patient was afebrile blood pressure and heart rate were within normal limits. The patient appeared alert. EYES The conjunctiva was clear. The pupil was equal and reactive. There was no ptosis. The irides appeared normal. EARS NOSE AND THROAT ... | 15 General Medicine |
SUBJECTIVE I am asked to see the patient today with ongoing issues around her diabetic control. We have been fairly aggressively downwardly adjusting her insulins both the Lantus insulin which we had been giving at night as well as her sliding scale Humalog insulin prior to meals. Despite frequent decreases in ... | 35 SOAP / Chart / Progress Notes |
CHIEF COMPLAINT Pressure decubitus right hip. HISTORY OF PRESENT ILLNESS This is a 30-year-old female patient presenting with the above chief complaint. She has a history of having had a similar problem last year which resolved in about three treatments. She appears to have residual from spina bifida thus spendin... | 15 General Medicine |
PREOPERATIVE DIAGNOSIS 1. Right cubital tunnel syndrome. 2. Right carpal tunnel syndrome. 3. Right olecranon bursitis. POSTOPERATIVE DIAGNOSIS 1. Right cubital tunnel syndrome. 2. Right carpal tunnel syndrome. 3. Right olecranon bursitis. PROCEDURES 1. Right ulnar nerve transposition. 2. Right carpal... | 38 Surgery |
PREOPERATIVE DIAGNOSES 1. Nasal obstruction secondary to deviated nasal septum. 2. Bilateral turbinate hypertrophy. PROCEDURE Cosmetic rhinoplasty. Request for cosmetic change in the external appearance of the nose. ANESTHESIA General via endotracheal tube. INDICATIONS FOR OPERATION The patient is a 26-yea... | 38 Surgery |
SUBJECTIVE He is a 24-year-old male who said that he had gotten into some poison ivy this weekend while he was fishing. He has had several cases of this in the past and he says that is usually takes quite awhile for him to get over it he said that the last time he was here he got a steroid injection by Dr. Blackma... | 35 SOAP / Chart / Progress Notes |
PREOPERATIVE DIAGNOSIS Blood loss anemia. POSTOPERATIVE DIAGNOSES 1. Normal colon with no evidence of bleeding. 2. Hiatal hernia. 3. Fundal gastritis with polyps. 4. Antral mass. ANESTHESIA Conscious sedation with Demerol and Versed. SPECIMEN Antrum and fundal polyps. HISTORY The patient is a 66-year-o... | 38 Surgery |
PRIMARY DIAGNOSIS Esophageal foreign body no associated comorbidities are noted. PROCEDURE Esophagoscopy with removal of foreign body. CPT CODE 43215. PRINCIPAL DIAGNOSIS Esophageal foreign body ICD-9 code 935.1. DESCRIPTION OF PROCEDURE Under general anesthesia flexible EGD was performed. Esophagus ... | 14 Gastroenterology |
PREOPERATIVE DIAGNOSIS Bilateral open mandible fracture open left angle and open symphysis fracture. POSTOPERATIVE DIAGNOSIS Bilateral open mandible fracture open left angle and open symphysis fracture. PROCEDURE Closed reduction of mandible fracture with MMF. ANESTHESIA General anesthesia via nasal endot... | 7 Dentistry |
PROCEDURES 1. Robotic-assisted pyeloplasty. 2. Anterograde right ureteral stent placement. 3. Transposition of anterior crossing vessels on the right. 4. Nephrolithotomy. DIAGNOSIS Right ureteropelvic junction obstruction. DRAINS 1. Jackson-Pratt drain times one from the right flank. 2. Foley catheter times ... | 39 Urology |
SUBJECTIVE The patient is a 20-year-old Caucasian male admitted via ABCD Hospital Emergency Department for evaluation of hydrocarbon aspiration. The patient ingested tiki oil kerosene liquid paraffin citronella oil approximately two days prior to admission. He subsequently developed progressive symptoms of d... | 12 Emergency Room Reports |
PREOPERATIVE DIAGNOSES 1. Radiation cystitis. 2. Refractory voiding dysfunction. 3. Status post radical retropubic prostatectomy and subsequent salvage radiation therapy. POSTOPERATIVE DIAGNOSES 1. Radiation cystitis. 2. Refractory voiding dysfunction. 3. Status post radical retropubic prostatectomy and subsequ... | 38 Surgery |
OPERATIVE NOTE The patient was taken to the operating room and was placed in the supine position on the operating room table. A general inhalation anesthetic was administered. The patient was prepped and draped in the usual sterile fashion. The urethral meatus was calibrated with a small mosquito hemostat and was... | 38 Surgery |
PREOPERATIVE DIAGNOSES 1. protein-calorie malnutrition. 2. Intractable nausea vomiting and dysphagia. POSTOPERATIVE DIAGNOSES 1. Protein-calorie malnutrition. 2. Intractable nausea vomiting and dysphagia. 3. Enterogastritis. PROCEDURE PERFORMED EGD with PEG tube placement using Russell technique. ANESTHES... | 38 Surgery |
EXAM CT KUB. REASON FOR EXAM Flank pain. TECHNIQUE Noncontrast CT abdomen and pelvis per renal stone protocol. Correlation is made with the prior examination dated 01/16/09. FINDINGS There is no intrarenal stone or obstruction bilaterally. There is no hydronephrosis ureteral dilatation. There are calcifi... | 33 Radiology |
FINDINGS Axial scans were performed from L1 to S2 and reformatted images were obtained in the sagittal and coronal planes. Preliminary scout film demonstrates anterior end plate spondylosis at T11-12 and T12-L1. L1-2 There is normal disc height anterior end plate spondylosis very minimal vacuum change with no poste... | 27 Orthopedic |
HISTORY OF PRESENT ILLNESS The patient is a 60-year-old female patient who off and on for the past 10 to 12 months has had almost daily diarrhea nausea inability to eat. She had an EGD and colonoscopy with Dr. ABC a few days prior to this admission. Colonoscopy did reveal diverticulosis and EGD showed retained b... | 10 Discharge Summary |
PREOPERATIVE DIAGNOSIS Brain tumor left temporal lobe. POSTOPERATIVE DIAGNOSIS Brain tumor left temporal lobe - glioblastoma multiforme. OPERATIVE PROCEDURE 1. Left temporal craniotomy. 2. Removal of brain tumor. OPERATING MICROSCOPE Stealth. PROCEDURE The patient was placed in the supine position shoul... | 22 Neurology |
REASON FOR CONSULTATION Lightheaded dizziness and palpitation. HISTORY OF PRESENT ILLNESS The patient is a 50-year-old female who came to the Emergency Room. This morning the patient experienced symptoms of lightheaded dizziness felt like passing out however there was no actual syncope. During the episod... | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSIS Left inguinal hernia. POSTOPERATIVE DIAGNOSIS Left indirect inguinal hernia. PROCEDURE PERFORMED Repair of left inguinal hernia indirect. ANESTHESIA Spinal with local. COMPLICATIONS None. DISPOSITION The patient tolerated the procedure well was transferred to recovery in stable c... | 39 Urology |
EXAM Single frontal view of the chest. HISTORY Respiratory distress. The patient has a history of malrotation. The patient is back for a re-anastomosis of the bowel with no acute distress. TECHNIQUE Single frontal view of the chest was evaluated and correlated with the prior film dated MM/DD/YY. FINDINGS ... | 29 Pediatrics - Neonatal |
PREOPERATIVE DIAGNOSIS Residual stone status post right percutaneous nephrolithotomy. POSTOPERATIVE DIAGNOSES Residual stone status post right percutaneous nephrolithotomy attempted second-look nephrolithotomy cysto with insertion of 6-French variable length double-J stent. ANESTHESIA General via endotrache... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Right distal both-bone forearm fracture. POSTOPERATIVE DIAGNOSIS Right distal both-bone forearm fracture. INDICATIONS Mr. ABC is a 10-year-old boy who suffered a fall resulting in a right distal both-bone forearm fracture. Upon evaluation by Orthopedic Surgery team in the emergency depa... | 27 Orthopedic |
SUBJECTIVE The patient is in with several medical problems. He complains his mouth being sore since last week and also some trouble with my eyes. He states that they feel funny but he is seeing okay. He denies any more diarrhea or abdominal pain. Bowels are working okay. He denies nausea or diarrhea. Eatin... | 35 SOAP / Chart / Progress Notes |
SUBJECTIVE The patient is a 20-year-old Caucasian male admitted via ABCD Hospital Emergency Department for evaluation of hydrocarbon aspiration. The patient ingested tiki oil kerosene liquid paraffin citronella oil approximately two days prior to admission. He subsequently developed progressive symptoms of d... | 15 General Medicine |
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... | 24 Obstetrics / Gynecology |
EXAM Echocardiogram. INDICATION Aortic stenosis. INTERPRETATION Transthoracic echocardiogram was performed of adequate technical quality. Left ventricle reveals concentric hypertrophy with normal size and dimensions and normal function. Ejection fraction is 60 without any obvious wall motion abnormality. L... | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSIS Acute infected olecranon bursitis left elbow. POSTOPERATIVE DIAGNOSIS Infection left olecranon bursitis. PROCEDURE PERFORMED 1. Incision and drainage left elbow. 2. Excision of the olecranon bursa left elbow. ANESTHESIA Local with sedation. COMPLICATIONS None. NEEDLE AND SPONGE... | 27 Orthopedic |
EXAM CTA chest pulmonary angio. REASON FOR EXAM Evaluate for pulmonary embolism. TECHNIQUE Postcontrast CT chest pulmonary embolism protocol 100 mL of Isovue-300 contrast is utilized. FINDINGS There are no filling defects in the main or main right or left pulmonary arteries. No central embolism. The prox... | 33 Radiology |
PROCEDURE Diagnostic fiberoptic bronchoscopy. ANESTHESIA Plain lidocaine 2 was given intrabronchially for local anesthesia. PREOPERATIVE MEDICATIONS 1. Lortab 10 mg plus Phenergan 25 mg p.o. 1 hour before the procedure. 2. Versed a total of 5 mg given IV push during the procedure. INDICATIONS | 3 Cardiovascular / Pulmonary |
SUBJECTIVE The patient returns to the Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema. She was last seen in the clinic in March 2004. Since that time she has been hospitalized for psychiatric problems and now is in a nursing facility. She is very frustrated with her living situation and w... | 35 SOAP / Chart / Progress Notes |
PAST MEDICAL HISTORY Include 1. Type II diabetes mellitus. 2. Hypertension. 3. Hyperlipidemia. 4. Gastroesophageal reflux disease. 5. Renal insufficiency. 6. Degenerative joint disease status post bilateral hip and bilateral knee replacements. 7. Enterocutaneous fistula. 8. Respiratory failure. 9. History ... | 15 General Medicine |
NAME OF PROCEDURE Left heart catheterization with ventriculography selective coronary angiography. INDICATIONS Acute coronary syndrome. TECHNIQUE OF PROCEDURE Standard Judkins right groin. Catheters used were a 6 French pigtail 6 French JL4 6 French JR4. ANTICOAGULATION The patient was on heparin at ... | 3 Cardiovascular / Pulmonary |
EXAM Magnified airway. CLINICAL HISTORY An 11-month-old female with episodes of difficulty in breathing cough. TECHNIQUE Multiple fluoroscopic spot images of the pharyngeal airway trachea and mainstem bronchi were performed in various phases of respiration. FINDINGS The airway is patent throughout its co... | 33 Radiology |
REASON FOR CONSULTATION Thrombocytopenia. HISTORY OF PRESENT ILLNESS Mrs. XXX is a 17-year-old lady who is going to be 18 in about 3 weeks. She has been referred for the further evaluation of her thrombocytopenia. This thrombocytopenia was detected on a routine blood test performed on the 10th of June 2006. He... | 5 Consult - History and Phy. |
SUBJECTIVE This patient presents to the office today for a checkup. He has several things to go over and discuss. First he is sick. He has been sick for a month intermittently but over the last couple of weeks it is worse. He is having a lot of yellow phlegm when he coughs. It feels likes it is in his chest. ... | 35 SOAP / Chart / Progress Notes |
REVIEW OF SYSTEMS There was no weight loss fevers chills sweats. There is no blurring of the vision itching throat or neck pain or neck fullness. There is no vertigo or hoarseness or painful swallowing. There is no chest pain shortness of breath paroxysmal nocturnal dyspnea or chest pain with exertion. The... | 15 General Medicine |
PREOPERATIVE DIAGNOSIS Cervical spondylosis at C3-C4 with cervical radiculopathy and spinal cord compression. POSTOPERATIVE DIAGNOSIS Cervical spondylosis at C3-C4 with cervical radiculopathy and spinal cord compression. OPERATION PERFORMED 1. Anterior cervical discectomy of C3-C4. 2. Removal of herniated disc ... | 38 Surgery |
REASON FOR CONSULTATION Ventricular ectopy and coronary artery disease. HISTORY OF PRESENT ILLNESS I am seeing the patient upon the request of Dr. Y. The patient is a very well known to me. He is a 69-year-old gentleman with established history coronary artery disease and peripheral vascular disease with prior ... | 3 Cardiovascular / Pulmonary |
TITLE OF OPERATION Austin bunionectomy with internal screw fixation first metatarsal left foot. PREOPERATIVE DIAGNOSIS Bunion deformity left foot. POSTOPERATIVE DIAGNOSIS Bunion deformity left foot. ANESTHESIA Monitored anesthesia care with 15 mL of 1 1 mixture of 0.5 Marcaine and 1 lidocaine plain. H... | 27 Orthopedic |
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 subseque... | 37 Speech - Language |
TITLE OF OPERATION 1. Removal of painful hardware first left metatarsal. 2. Excision of nonunion first left metatarsal. 3. Incorporation of corticocancellous bone graft with internal fixation consisting of screws and plates of the first left metatarsal. PREOPERATIVE DIAGNOSES 1. Nonunion of fractured first left... | 27 Orthopedic |
PROCEDURE Colonoscopy. INDICATIONS Hematochezia Personal history of colonic polyps. MEDICATIONS Midazolam 2 mg IV Fentanyl 100 mcg IV PROCEDURE A History and Physical has been performed and patient medication allergies have been reviewed. The patient s tolerance of previous anesthesia has been reviewed.... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Large juxtarenal abdominal aortic aneurysm. POSTOPERATIVE DIAGNOSIS Large juxtarenal abdominal aortic aneurysm. ANESTHESIA General endotracheal anesthesia. OPERATIVE TIME Three hours. ANESTHESIA TIME Four hours. DESCRIPTION OF PROCEDURE After thorough preoperative evaluation the pati... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Left patellar chondromalacia. POSTOPERATIVE DIAGNOSIS Left patellar chondromalacia with tight lateral structures. PROCEDURE Left knee arthroscopy with lateral capsular release. ANESTHESIA Surgery performed under general anesthesia. TOURNIQUET TIME 47 minutes. MEDICATION The pati... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Epistaxis and chronic dysphonia. POSTOPERATIVE DIAGNOSES 1. Atrophic dry nasal mucosa. 2. Epistaxis. 3. Atrophic laryngeal changes secondary to inhaled steroid use. PROCEDURE PERFORMED 1. Cauterization of epistaxis left nasal septum. 2. Fiberoptic nasal laryngoscopy. ANESTHESIA Neo-... | 38 Surgery |
CHIEF COMPLAINT Iron deficiency anemia. HISTORY OF PRESENT ILLNESS This is a very pleasant 19-year-old woman who was recently hospitalized with iron deficiency anemia. She was seen in consultation by Dr. X. She underwent a bone marrow biopsy on 07/21/10 which showed a normal cellular marrow with trilineage he... | 16 Hematology - Oncology |
INDICATION FOR STUDY Elevated cardiac enzymes fullness in chest abnormal EKG and risk factors. MEDICATIONS Femara verapamil Dyazide Hyzaar glyburide and metformin. BASELINE EKG Sinus rhythm at 84 beats per minute poor anteroseptal R-wave progression mild lateral ST abnormalities. EXERCISE RESULTS 1.... | 3 Cardiovascular / Pulmonary |
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