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PROCEDURE IN DETAIL While in the holding area the patient received a peripheral IV from the nursing staff. In addition pilocarpine 1 was placed into the operative eye two times separated by 10 minutes. The patient was wheeled to the operating suite where the anesthesia team established peripheral monitoring l... | 38 Surgery |
PREOPERATIVE DIAGNOSES 1. Blepharochalasia. 2. Lower lid large primary and secondary bagging. POSTOPERATIVE DIAGNOSES 1. Blepharochalasia. 2. Lower lid large primary and secondary bagging. PROCEDURE Quad blepharoplasty. ANESTHESIA General. ESTIMATED BLOOD LOSS Minimal. CONDITION The patient did well. ... | 26 Ophthalmology |
PREOPERATIVE DIAGNOSIS Acute abdominal pain rule out appendicitis versus other. POSTOPERATIVE DIAGNOSIS Acute pelvic inflammatory disease and periappendicitis. PROCEDURE PERFORMED Diagnostic laparoscopy. COMPLICATIONS None. CULTURES Intra-abdominally are done. HISTORY The patient is a 31-year-old Afr... | 24 Obstetrics / Gynecology |
PROCEDURES PERFORMED 1. Left heart catheterization with coronary angiography and left ventricular pressure measurement. 2. Left ventricular angiography was not performed. 3. Right posterior descending artery percutaneous transluminal coronary angioplasty followed by stenting. 4. Right femoral artery angiography. 5. Pe... | 38 Surgery |
EXAM CT scan of the abdomen and pelvis without and with intravenous contrast. CLINICAL INDICATION Left lower quadrant abdominal pain. COMPARISON None. FINDINGS CT scan of the abdomen and pelvis was performed without and with intravenous contrast. Total of 100 mL of Isovue was administered intravenously. O... | 14 Gastroenterology |
PREOPERATIVE DIAGNOSES 1. Spondylosis with cervical stenosis C5-C6 greater than C4-C5 C6-C7 721.0 723.0 . 2. Neck pain with left radiculopathy progressive 723.1/723.4 . 3. Headaches progressive 784.0 . POSTOPERATIVE DIAGNOSES 1. Spondylosis with cervical stenosis C5-C6 greater than C4-C5 C6-C7 72... | 23 Neurosurgery |
1. Odynophagia. 2. Dysphagia. 3. Gastroesophageal reflux disease rule out stricture. POSTOPERATIVE DIAGNOSES 1. Antral gastritis. 2. Hiatal hernia. PROCEDURE PERFORMED EGD with photos and biopsies. GROSS FINDINGS This is a 75-year-old female who presents with difficulty swallowing occasional choking and ody... | 14 Gastroenterology |
PREOPERATIVE DIAGNOSIS Recurrent right upper quadrant pain with failure of antacid medical therapy. POSTOPERATIVE DIAGNOSIS Normal esophageal gastroduodenoscopy. PROCEDURE PERFORMED Esophagogastroduodenoscopy with bile aspirate. ANESTHESIA IV Demerol and Versed in titrated fashion. INDICATIONS This 41-ye... | 38 Surgery |
DIAGNOSES PROBLEMS 1. Orthostatic hypotension. 2. Bradycardia. 3. Diabetes. 4. Status post renal transplant secondary polycystic kidney disease in 1995. 5. Hypertension. 6. History of basal cell ganglia cerebrovascular event in 2004 with left residual. 7. History of renal osteodystrophy. 8. Iron deficiency ane... | 3 Cardiovascular / Pulmonary |
REASON FOR CONSULTATION Azotemia. HISTORY OF PRESENT ILLNESS The patient is a 36-year-old gentleman admitted to the hospital because he passed out at home. Over the past week he has been noticing increasing shortness of breath. He also started having some abdominal pain however he continued about his regular ... | 21 Nephrology |
PREOPERATIVE DIAGNOSIS Acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip. POSTOPERATIVE DIAGNOSIS Acetabular fracture on the left posterior column/transverse posterior wall variety with an acc... | 38 Surgery |
CHIEF COMPLAINT Low back pain and right lower extremity pain. The encounter reason for today s consultation is for a second opinion regarding evaluation and treatment of the aforementioned symptoms. HPI - LUMBAR SPINE The patient is a male and 39 years old. The current problem began on or about 3 months ago. The sy... | 5 Consult - History and Phy. |
PREOPERATIVE DIAGNOSIS Abdominal mass. POSTOPERATIVE DIAGNOSIS Abdominal mass. PROCEDURE Paracentesis. DESCRIPTION OF PROCEDURE This 64-year-old female has stage II endometrial carcinoma which had been resected before and treated with chemotherapy and radiation. At the present time the patient is under r... | 38 Surgery |
PREOPERATIVE DIAGNOSES 1. XXX upper lid laceration. 2. XXX upper lid canalicular laceration. POSTOPERATIVE DIAGNOSES 1. XXX upper lid laceration. 2. XXX upper lid canalicular laceration. PROCEDURES 1. Repair of XXX upper lid laceration. 2. Repair of XXX upper lid canalicular laceration. ANESTHESIA General SPECIMEN... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Radioactive plaque macular edema. POSTOPERATIVE DIAGNOSIS Radioactive plaque macular edema. TITLE OF OPERATION Removal of radioactive plaque right eye with lateral canthotomy. OPERATIVE PROCEDURE IN DETAIL The patient was prepped and draped in the usual manner for a local eye procedu... | 26 Ophthalmology |
REASON FOR CONSULTATION Loculated left effusion multilobar pneumonia. | 5 Consult - History and Phy. |
HISTORY This 61-year-old retailer who presents with acute shortness of breath hypertension found to be in acute pulmonary edema. No confirmed prior history of heart attack myocardial infarction heart failure. History dates back to about six months of intermittent shortness of breath intermittent very slight e... | 3 Cardiovascular / Pulmonary |
ADMISSION DIAGNOSIS Left hip fracture. CHIEF COMPLAINT Diminished function secondary to the above. HISTORY This pleasant 70-year-old gentleman had a ground-level fall at home on 05/05/03 and was brought into ABCD Medical Center evaluated by Dr. X and brought in for orthopedic stay. He had left hip fracture ... | 27 Orthopedic |
REASON FOR RETURN VISIT Followup of left hand discomfort and systemic lupus erythematosus. HISTORY OF PRESENT ILLNESS The patient is a 56-year-old female with a history of systemic lupus erythematosus who was last seen in rheumatology clinic approximately 4 months ago for bilateral hand discomfort left greater ... | 35 SOAP / Chart / Progress Notes |
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... | 38 Surgery |
HISTORY OF PRESENT ILLNESS This is a 76-year-old female that was admitted with fever chills and left pelvic pain. The patient was well visiting in ABC with her daughter that evening. She had pain in her left posterior pelvic and low back region. They came back to XYZ the following day. By the time they got he... | 15 General Medicine |
INDICATION Iron deficiency anemia. PROCEDURE Colonoscopy with terminal ileum examination. POSTOPERATIVE DIAGNOSIS Normal examination. WITHDRAWAL TIME 15 minutes. SCOPE CF-H180AL. MEDICATIONS Fentanyl 100 mcg and versed 10 mg. PROCEDURE DETAIL Following the preprocedure patient assessment the proced... | 14 Gastroenterology |
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 ... | 5 Consult - History and Phy. |
PREOPERATIVE DIAGNOSIS Umbilical hernia. POSTOPERATIVE DIAGNOSIS Umbilical hernia. PROCEDURE PERFORMED Repair of umbilical hernia. ANESTHESIA General. COMPLICATIONS None. ESTIMATED BLOOD LOSS Minimal. PROCEDURE IN DETAIL The patient was prepped and draped in the sterile fashion. An infraumbilical ... | 14 Gastroenterology |
PREOPERATIVE DIAGNOSIS Right hand Dupuytren disease to the little finger. POSTOPERATIVE DIAGNOSIS Right hand Dupuytren disease to the little finger. PROCEDURE PERFORMED Excision of Dupuytren disease of the right hand extending out to the proximal interphalangeal joint of the little finger. COMPLICATIONS Non... | 27 Orthopedic |
CHIEF COMPLAINT Lump in the chest wall. HISTORY OF PRESENT ILLNESS This is a 56-year-old white male who has been complaining of having had a lump in the chest for the past year or so and it has been getting larger and tender according to the patient. It is tender on palpation and also he feels like when he take... | 5 Consult - History and Phy. |
CHIEF COMPLAINT Multiple problems main one is chest pain at night. HISTORY OF PRESENT ILLNESS This is a 60-year-old female with multiple problems as numbered below 1. She reports that she has chest pain at night. This happened last year exactly the same. She went to see Dr. Murphy and he did a treadmill and... | 15 General Medicine |
PREOPERATIVE DIAGNOSIS Bunion right foot. POSTOPERATIVE DIAGNOSIS Bunion right foot. PROCEDURE PERFORMED Austin/akin bunionectomy right foot. HISTORY This 77-year-old African-American female presents to ABCD General Hospital with the above chief complaint. The patient states she has had a bunion deformi... | 27 Orthopedic |
REASON FOR CONSULT Evaluation of alcohol withdrawal and dependance as well as evaluation of anxiety. HISTORY OF PRESENT ILLNESS This is a 50-year-old male who was transferred from Sugar Land ER to ABCD Hospital for admission to the MICU for acute alcohol withdrawal. The patient had been on a drinking binge for t... | 5 Consult - History and Phy. |
ADMISSION DIAGNOSES Hyperglycemia cholelithiasis obstructive sleep apnea diabetes mellitus and hypertension. DISCHARGE DIAGNOSES Hyperglycemia cholelithiasis obstructive sleep apnea diabetes mellitus hypertension and cholecystitis. PROCEDURE Laparoscopic cholecystectomy. SERVICE Surgery. HISTORY OF... | 10 Discharge Summary |
PREOPERATIVE DIAGNOSIS Cervical lymphadenopathy. POSTOPERATIVE DIAGNOSIS Cervical lymphadenopathy. PROCEDURE Excisional biopsy of right cervical lymph node. ANESTHESIA General endotracheal anesthesia. SPECIMEN Right cervical lymph node. EBL 10 cc. COMPLICATIONS None. FINDINGS Enlarged level 2 ly... | 38 Surgery |
TITLE OF OPERATION Ligation clip interruption of patent ductus arteriosus. INDICATION FOR SURGERY This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-si... | 38 Surgery |
EXAM Thoracic Spine. REASON FOR EXAM Injury. INTERPRETATION The thoracic spine was examined in the AP lateral and swimmer s projections. There is mild chronic-appearing anterior wedging of what is believed to represent T11 and 12 vertebral bodies. A mild amount of anterior osteophytic lipping is seen involv... | 22 Neurology |
PREOPERATIVE DIAGNOSIS Left mesothelioma focal. POSTOPERATIVE DIAGNOSIS Left pleural-based nodule. PROCEDURES PERFORMED 1. Left thoracoscopy. 2. Left mini thoracotomy with resection of left pleural-based mass. FINDINGS Left anterior pleural-based nodule which was on a thin pleural pedicle with no invasion... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Prior history of neoplastic polyps. POSTOPERATIVE DIAGNOSIS Small rectal polyps/removed and fulgurated. PREMEDICATIONS Prior to the colonoscopy the patient complained of a sever headache and she was concerned that she might become ill. I asked the nurse to give her 25 mg of Demerol IV.... | 14 Gastroenterology |
REASON FOR VISIT Six-month follow-up visit for paroxysmal atrial fibrillation PAF . She reports that she is getting occasional chest pains with activity. Sometimes she feels that at night when she is lying in bed and it concerns her. She is frustrated by her inability to lose weight even though she is hyperthyroid... | 35 SOAP / Chart / Progress Notes |
PROCEDURE Cardiac catheterization by a. Left heart catheterization. b. Left ventriculography. c. Selective coronary angiography. d. Right femoral artery approach. COMPLICATIONS None. MEDICATIONS 1. IV Versed. 2. IV fentanyl. 3. Intravenous fluid administration. 4. Heparin 3000 units IV. INDICATIONS Th... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Malignant mass of the left neck. POSTOPERATIVE DIAGNOSIS Malignant mass of the left neck squamous cell carcinoma. PROCEDURES 1. Left neck mass biopsy. 2. Selective surgical neck dissection left. DESCRIPTION OF PROCEDURE After obtaining an informed the patient was taken to the operat... | 16 Hematology - Oncology |
PREOPERATIVE DIAGNOSIS Soft tissue mass right knee. POSTOPERATIVE DIAGNOSES 1. Soft tissue mass right knee. 2. Osteophyte lateral femoral condyle right knee. PROCEDURES PERFORMED Excision of capsular mass and arthrotomy with ostectomy of lateral femoral condyle right knee. SPECIFICATION The entire operati... | 27 Orthopedic |
PREOPERATIVE DIAGNOSIS Prior history of polyps. POSTOPERATIVE DIAGNOSIS Small polyps no evidence of residual or recurrent polyp in the cecum. PREMEDICATIONS Versed 5 mg Demerol 100 mg IV. REPORTED PROCEDURE The rectal chamber revealed no external lesions. Prostate was normal in size and consistency. The ... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Grade 1 compound fracture right mid-shaft radius and ulna with complete displacement and shortening. POSTOPERATIVE DIAGNOSIS Grade 1 compound fracture right mid-shaft radius and ulna with complete displacement and shortening. OPERATIONS 1. Irrigation and debridement of skin subcutaneous... | 27 Orthopedic |
Chief Complaint Dark urine and generalized weakness. History of Present Illness 40 year old Hispanic male presented to the emergency room complaining of generalized weakness fatigue and dark urine for one week. In addition he stated that his family had noticed yellowing of his skin and eyes though he himself had ... | 15 General Medicine |
CHIEF COMPLAINT Nausea. PRESENT ILLNESS The patient is a 28-year-old who is status post gastric bypass surgery nearly one year ago. He has lost about 200 pounds and was otherwise doing well until yesterday evening around 7 00-8 00 when he developed nausea and right upper quadrant pain which apparently wrapped ... | 5 Consult - History and Phy. |
PREOPERATIVE DIAGNOSIS Tremor dystonic form. POSTOPERATIVE DIAGNOSIS Tremor dystonic form. COMPLICATIONS None. ESTIMATED BLOOD LOSS Less than 100 mL. ANESTHESIA MAC monitored anesthesia care with local anesthesia. TITLE OF PROCEDURES 1. Left frontal craniotomy for placement of deep brain stimulator... | 38 Surgery |
HISTORY OF PRESENT ILLNESS This is a 58-year-old male who reports a six to eight-week history of balance problems with fatigue and weakness. He has had several falls recently. He apparently had pneumonia 10 days prior to the onset of the symptoms. He took a course of amoxicillin for this. He complained of increased s... | 22 Neurology |
PREOPERATIVE DIAGNOSES 1. Hallux abductovalgus right foot. 2. Hammertoe bilateral third fourth and fifth toes. POSTOPERATIVE DIAGNOSES 1. Hallux abductovalgus right foot. 2. Hammertoe bilateral third fourth and fifth toes. PROCEDURE PERFORMED 1. Bunionectomy with distal first metatarsal osteotomy and in... | 27 Orthopedic |
SUBJECTIVE The patient states that she feels better. She is on IV amiodarone the dosage pattern is appropriate for ventricular tachycardia. Researching the available records I find only an EMS verbal statement that tachycardia of wide complex was seen. There is no strip for me to review all available EKG tracin... | 15 General Medicine |
PREOPERATIVE DIAGNOSES 1. Extruded herniated disc left L5-S1. 2. Left S1 radiculopathy acute . 3. Morbid obesity. POSTOPERATIVE DIAGNOSES 1. Extruded herniated disc left L5-S1. 2. Left S1 radiculopathy acute . 3. Morbid obesity. PROCEDURE PERFORMED Microscopic lumbar discectomy left L5-S1. ANESTHESIA ... | 27 Orthopedic |
CC Weakness. HX This 30 y/o RHM was in good health until 7/93 when he began experiencing RUE weakness and neck pain. He was initially treated by a chiropractor and after an unspecified length of time developed atrophy and contractures of his right hand. He then went to a local neurosurgeon and a cervical spine C... | 33 Radiology |
PREOPERATIVE DIAGNOSIS Refractory priapism. POSTOPERATIVE DIAGNOSIS Refractory priapism. PROCEDURE PERFORMED Cavernosaphenous shunt. ANESTHESIA General. ESTIMATED BLOOD LOSS 400 cc. FLUIDS IV fluids 1600 crystalloids one liter packed red blood cells. INDICATIONS FOR PROCEDURE This is a 34-year-old... | 39 Urology |
SUBJECTIVE The patient is here for a follow-up. The patient has a history of lupus currently on Plaquenil 200-mg b.i.d. Eye report was noted and appreciated. The patient states that she is having some aches and pains of the hands and elbows that started recently a few weeks ago. She denied having any trauma. S... | 35 SOAP / Chart / Progress Notes |
HISTORY OF PRESENT ILLNESS The patient presents today as a consultation from Dr. ABC s office regarding the above. He has history of neurogenic bladder and on intermittent self-catheterization 3 times a day. However June 24 2008 he was seen in the ER and with fever weakness possible urosepsis. He had a blo... | 5 Consult - History and Phy. |
S ABC is in today for a followup of her atrial fibrillation. They have misplaced the Cardizem. She is not on this and her heart rate is up just a little bit today. She does complain of feeling dizziness some vertigo some lightheadedness and has attributed this to the Coumadin therapy. She is very adamant that... | 35 SOAP / Chart / Progress Notes |
PROGRESS NOTES 4/16/01 Patient in respiratory failure on ventilator Request airline placement Airline tracing good 4/17/01 S Sedated intubated in NAD O Lungs Increased bibasilar crackles A/P Respiratory arrest pneumonia COPD exacerbation Replete K+ continue IVABX start TPN decrease TV review ABGs 4/18/01 ... | 35 SOAP / Chart / Progress Notes |
HISTORY OF PRESENT ILLNESS The patient is a 48-year-old man who has had abdominal pain since October of last year associated with a 30-pound weight loss and then developed jaundice. He had epigastric pain and was admitted to the hospital. A thin-slice CT scan was performed which revealed a 4 x 3 x 2 cm pancreati... | 14 Gastroenterology |
DIAGNOSIS Possible cerebrovascular accident. DESCRIPTION The EEG was obtained using 21 electrodes placed in scalp-to-scalp and scalp-to-vertex montages. The background activity appears to consist of fairly organized somewhat pleomorphic low to occasional medium amplitude of 7-8 cycle per second activity and was ... | 33 Radiology |
PREOPERATIVE DIAGNOSIS Ovarian cancer. POSTOPERATIVE DIAGNOSIS Ovarian cancer. OPERATION PERFORMED Insertion of a Port-A-Catheter via the left subclavian vein approach under fluoroscopic guidance. DETAILED OPERATIVE NOTE The patient was placed on the operating table and placed under LMA general anesthesia i... | 38 Surgery |
HISTORY OF PRESENT ILLNESS The patient is a 71-year-old Caucasian female with a history of diabetes osteoarthritis atrial fibrillation hypertension asthma obstructive sleep apnea on CPAP diabetic foot ulcer anemia and left lower extremity cellulitis. She was brought in by the EMS service to Erlanger emergency ... | 5 Consult - History and Phy. |
PREOPERATIVE DIAGNOSIS Cleft soft palate. POSTOPERATIVE DIAGNOSIS Cleft soft palate. PROCEDURES 1. Repair of cleft soft palate CPT 42200. 2. Excise accessory ear tag right ear. ANESTHESIA General. DESCRIPTION OF PROCEDURE The patient was placed supine on the operating room table. After anesthesia was ... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Empyema. POSTOPERATIVE DIAGNOSIS Empyema. PROCEDURE PERFORMED 1. Right thoracotomy total decortication. 2. Intraoperative bronchoscopy. ANESTHESIA General. COMPLICATIONS None. ESTIMATED BLOOD LOSS 300 cc. FLUIDS 2600 cc IV crystalloid. URINE 300 cc intraoperatively. INDIC... | 3 Cardiovascular / Pulmonary |
DOBUTAMINE STRESS ECHOCARDIOGRAM REASON FOR EXAM Chest discomfort evaluation for coronary artery disease. PROCEDURE IN DETAIL The patient was brought to the cardiac center. Cardiac images at rest were obtained in the parasternal long and short axis apical four and apical two views followed by starting with a d... | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSES 1. Entropion left upper lid. 2. Entropion and some blepharon right lower lid. TITLE OF OPERATION 1. Repair of entropion left upper lid with excision of anterior lamella and cryotherapy. 2. Repairs of blepharon entropion right lower lid with mucous membrane graft. PROCEDURE IN DETAIL ... | 38 Surgery |
SUBJECTIVE The patient returns to the Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis. She was last seen in the Pulmonary Medicine Clinic in January 2004. Since that time her respiratory status has been quite good. She has had no major respiratory difficul... | 35 SOAP / Chart / Progress Notes |
SUBJECTIVE The patient is a 33-year-old black male who comes in to the office today main complaint of sexual dysfunction. Patient reports that he would like to try Cialis to see if it will improve his erectile performance. Patient states that he did a quiz on-line at the Cialis web site and did not score in the no... | 35 SOAP / Chart / Progress Notes |
REASON FOR VISIT Followup left-sided rotator cuff tear and cervical spinal stenosis. HISTORY OF PRESENT ILLNESS Ms. ABC returns today for followup regarding her left shoulder pain and left upper extremity C6 radiculopathy. I had last seen her on 06/21/07. At that time she had been referred to me Dr. X and Dr. Y... | 27 Orthopedic |
PROCEDURE Flexible sigmoidoscopy. PREOPERATIVE DIAGNOSIS Rectal bleeding. POSTOPERATIVE DIAGNOSIS Diverticulosis. MEDICATIONS None. DESCRIPTION OF PROCEDURE The Olympus gastroscope was introduced through the rectum and advanced carefully through the colon for a distance of 90 cm reaching the proximal de... | 38 Surgery |
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... | 3 Cardiovascular / Pulmonary |
TITLE OF OPERATION Lateral and plantar condylectomy fifth left metatarsal. PREOPERATIVE DIAGNOSIS Prominent lateral and plantar condyle hypertrophy fifth left metatarsal. POSTOPERATIVE DIAGNOSIS Prominent lateral and plantar condyle hypertrophy fifth left metatarsal. ANESTHESIA Monitored anesthesia c... | 27 Orthopedic |
CHIEF COMPLAINT Arm and leg jerking. HISTORY OF PRESENT ILLNESS The patient is a 10-day-old Caucasian female here for approximately 1 minute bilateral arm and leg jerks which started at day of life 1 and have occurred 6 total times since then. Mom denies any apnea perioral cyanosis or color changes. These mo... | 15 General Medicine |
PREOPERATIVE DIAGNOSIS Right carpal tunnel syndrome. POSTOPERATIVE DIAGNOSIS Right carpal tunnel syndrome. PROCEDURE PERFORMED Right carpal tunnel release. PROCEDURE NOTE The right upper extremity was prepped and draped in the usual fashion. IV sedation was supplied by the anesthesiologist. A local block ... | 27 Orthopedic |
HISTORY OF PRESENT ILLNESS This is the initial clinic visit for a 29-year-old man who is seen for new onset of right shoulder pain. He states that this began approximately one week ago when he was lifting stacks of cardboard. The motion that he describes is essentially picking up a stack of cardboard at his waist l... | 5 Consult - History and Phy. |
REASON FOR EXAM 1. Angina. 2. Coronary artery disease. INTERPRETATION This is a technically acceptable study. DIMENSIONS Anterior septal wall 1.2 posterior wall 1.2 left ventricular end diastolic 6.0 end systolic 4.7. The left atrium is 3.9. FINDINGS Left atrium was mildly to moderately dilated. No m... | 33 Radiology |
PROCEDURE Thoracic epidural steroid injection without fluoroscopy. ANESTHESIA Local sedation. VITAL SIGNS See nurse s notes. COMPLICATIONS None. DETAILS OF PROCEDURE INT was placed. The patient was in the sitting position and the back was prepped with Betadine. Lidocaine 1.5 was used for skin wheal ma... | 28 Pain Management |
HISTORY OF PRESENT ILLNESS The patient is an 84-year-old woman with a history of hypertension severe tricuspid regurgitation with mild pulmonary hypertension mild aortic stenosis and previously moderate mitral regurgitation although not seen recently and I was asked to perform cardiology consultation for her beca... | 3 Cardiovascular / Pulmonary |
CHIEF COMPLAINT Right shoulder pain. HISTORY The patient is a pleasant 31-year-old right-handed white female who injured her shoulder while transferring a patient back on 01/01/02. She formerly worked for Veteran s Home as a CNA. She has had a long drawn out course of treatment for this shoulder. She tried ... | 22 Neurology |
PREOPERATIVE DIAGNOSIS Secondary capsular membrane right eye. POSTOPERATIVE DIAGNOSIS Secondary capsular membrane right eye. PROCEDURE PERFORMED YAG laser capsulotomy right eye. INDICATIONS This patient has undergone cataract surgery and vision is reduced in the operated eye due to presence of a seconda... | 38 Surgery |
FEMALE PHYSICAL EXAMINATION HEENT Pupils equal round and reactive to light and accommodation. Extraocular movements are intact. Sclerae are anicteric. TMs are clear bilaterally. Oropharynx is clear without erythema or exudate. Neck Supple without lymphadenopathy or thyromegaly. Carotids are silent. There is ... | 15 General Medicine |
NERVE CONDUCTION TESTING AND EMG EVALUATION 1. Right median sensory response 3.0 amplitude 2.5 distance 100. 2. Right ulnar sensory response 2.1 amplitude 1 distance 90. 3. Left median sensory response 3.0 amplitude 1.2 distance 100. 4. Left median motor response distal 4.2 proximal 9 amplitude 2.2 distanc... | 30 Physical Medicine - Rehab |
REASON FOR REFERRAL Ms. A is a 60-year-old African-American female with 12 years of education who was referred for neuropsychological evaluation by Dr. X after she demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment with him for stroke in July. A comprehen... | 32 Psychiatry / Psychology |
PREOPERATIVE DX 1. Menorrhagia 2. Desires permanent sterilization. POSTOPERATIVE DX 1. Menorrhagia 2. Desires permanent sterilization. OPERATIVE PROCEDURE Hysteroscopy Essure tubal occlusion and ThermaChoice endometrial ablation. ANESTHESIA General with paracervical block. ESTIMATED BLOOD LOSS Minimal... | 38 Surgery |
PROBLEM Rectal bleeding positive celiac sprue panel. HISTORY The patient is a 19-year-old Irish-Greek female who ever since elementary school has noted diarrhea constipation cramping nausea vomiting bloating belching abdominal discomfort change in bowel habits. She noted that her symptoms were getting i... | 14 Gastroenterology |
ADMITTING DIAGNOSES 1. Vomiting probably secondary to gastroenteritis. 2. Goldenhar syndrome. 3. Severe gastroesophageal reflux. 4. Past history of aspiration and aspiration pneumonia. DISCHARGE DIAGNOSES 1. Gastroenteritis versus bowel obstruction. 2. Gastroesophageal reflux. 3. Goldenhar syndrome. 4. Anemia ... | 29 Pediatrics - Neonatal |
HISTORY The patient is a 34-year-old right-handed female who states her symptoms first started after a motor vehicle accident in September 2005. She may have had a brief loss of consciousness at the time of the accident since shortly thereafter she had some blurred vision which lasted about a week and then resolve... | 30 Physical Medicine - Rehab |
INDICATIONS This is a 55-year-old female who is having a colonoscopy to screen for colon cancer. There is no family history of colon cancer and there has been no blood in the stool. PROCEDURE PERFORMED Colonoscopy. PREP Fentanyl 100 mcg IV and 3 mg Versed IV. PROCEDURE The tip of the endoscope was introduc... | 14 Gastroenterology |
CHIEF COMPLAINT Followup on hypertension and hypercholesterolemia. SUBJECTIVE This is a 78-year-old male who recently had his right knee replaced and also back surgery about a year and a half ago. He has done well with that. He does most of the things that he wants to do. He travels at every chance he has and... | 15 General Medicine |
CHIEF COMPLAINT Foot pain. HISTORY OF PRESENT ILLNESS This is a 17-year-old high school athlete who swims for the swimming team. He was playing water polo with some of his teammates when he dropped a weight on the dorsal aspects of his feet. He was barefoot at that time. He had been in the pool practicing an h... | 12 Emergency Room Reports |
CHIEF COMPLAINT Followup on diabetes mellitus hypercholesterolemia and sinusitis. SUBJECTIVE A 70-year-old female who was diagnosed with diabetes mellitus last fall. She has been checking her Accu-Cheks generally once a day and they range from 82 to a high of 132. She feels well. She walks 1-2 miles most da... | 35 SOAP / Chart / Progress Notes |
HISTORY This 57-year-old female who presented today for evaluation and recommendations regarding facial rhytids. In summary the patient is a healthy 57-year-old female nonsmoker with no history of skin disease who has predominant fullness in the submandibular region and mid face region and prominent nasolabial f... | 35 SOAP / Chart / Progress Notes |
REFERRING DIAGNOSIS Motor neuron disease. PERTINENT HISTORY AND EXAMINATION Briefly the patient is an 83-year-old woman with a history of progression of dysphagia for the past year dysarthria weakness of her right arm cramps in her legs and now with progressive weakness in her upper extremities. SUMMARY T... | 30 Physical Medicine - Rehab |
EXAM Two views of the pelvis. HISTORY This is a patient post-surgery 2-1/2 months. The patient has a history of slipped capital femoral epiphysis SCFE bilaterally. TECHNIQUE Frontal and lateral views of the hip and pelvis were evaluated and correlated with the prior film dated MM/DD/YYYY. Lateral view of ... | 27 Orthopedic |
PREOPERATIVE DIAGNOSES Left elbow fracture dislocation with incarceration of the medial epicondyle with ulnar nerve paresthesias status post closed reduction attempts 2 right radial shaft fracture with volar apex angulation. POSTOPERATIVE DIAGNOSES Left elbow fracture dislocation with incarceration of the media... | 38 Surgery |
CC Intermittent binocular horizontal vertical and torsional diplopia. HX 70y/o RHM referred by Neuro-ophthalmology for evaluation of neuromuscular disease. In 7/91 he began experiencing intermittent binocular horizontal vertical and torsional diplopia which was worse and frequent at the end of the day and was ... | 33 Radiology |
PREOPERATIVE DIAGNOSIS Ganglion of the left wrist. POSTOPERATIVE DIAGNOSIS Ganglion of the left wrist. OPERATION Excision of ganglion. ANESTHESIA General. ESTIMATED BLOOD LOSS Less than 5 mL. OPERATION After a successful anesthetic the patient was positioned on the operating table. A tourniquet appl... | 38 Surgery |
CHIEF COMPLAINT 1/1 This 59 year old female presents today complaining that her toenails are discolored thickened and painful. Duration Condition has existed for 6 months. Severity Severity of condition is worsening. ALLERGIES Patient admits allergies to dairy products penicillin. MEDICATION HISTORY None. ... | 5 Consult - History and Phy. |
REASON FOR VISIT The patient is a 76-year-old man referred for neurological consultation by Dr. X. The patient is companied to clinic today by his wife and daughter. He provides a small portion of his history however his family provides virtually all of it. HISTORY OF PRESENT ILLNESS He has trouble with walki... | 5 Consult - History and Phy. |
PREOPERATIVE DIAGNOSIS Left axillary adenopathy. POSTOPERATIVE DIAGNOSIS Left axillary adenopathy. PROCEDURE Left axillary lymph node excisional biopsy. ANESTHESIA LMA. INDICATIONS Patient is a very pleasant woman who in 2006 had breast conservation therapy with radiation only. Note she refused her CMF... | 16 Hematology - Oncology |
REFERRAL INDICATION AND PREPROCEDURE DIAGNOSES 1. Dilated cardiomyopathy. 2. Ejection fraction less than 10 . 3. Ventricular tachycardia. 4. Bradycardia with likely high degree of pacing. PROCEDURES PLANNED AND PERFORMED 1. Implantation of biventricular automatic implantable cardioverter defibrillator. 2. Fluoros... | 38 Surgery |
SUBJECTIVE The patient is a 68-year-old white female who presents for complete physical Pap and breast exam. Her last Pap smear was 05/02/2002. Her only complaint is that she has had some occasional episodes of some midchest pain that seems to go to her back usually occurs at rest. Has awakened her at night on ... | 24 Obstetrics / Gynecology |
PROCEDURES Esophagogastroduodenoscopy and colonoscopy with biopsy and polypectomy. REASON FOR PROCEDURE Child with abdominal pain and rectal bleeding. Rule out inflammatory bowel disease allergic enterocolitis rectal polyps and rectal vascular malformations. CONSENT History and physical examination was per... | 14 Gastroenterology |
EXAM MRI OF THE LEFT KNEE WITHOUT CONTRAST CLINICAL Left knee pain. Twisting injury. FINDINGS The images reveal a sizable joint effusion. The joint effusion appears to be complex with mixed signal intensity material within. The patella is slightly laterally tilted towards the left. The mid portion of the patella car... | 33 Radiology |
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