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PREOPERATIVE DIAGNOSES 1. Term pregnancy. 2. Desires permanent sterilization. POSTOPERATIVE DIAGNOSES 1. Term pregnancy. 2. Desires permanent sterilization. PROCEDURE 1. Repeat low-transverse cesarean section. 2. Bilateral tubal ligation. 3. Extensive anterior abdominal wall/uterine/bladder adhesiolysis. ANES... | 24 Obstetrics / Gynecology |
PREOPERATIVE DIAGNOSES Vault prolapse and rectocele. POSTOPERATIVE DIAGNOSES Vault prolapse and rectocele. OPERATION Colpocleisis and rectocele repair. ANESTHESIA Spinal. ESTIMATED BLOOD LOSS Minimal. FLUIDS Crystalloid. BRIEF HISTORY OF THE PATIENT This is an 85-year-old female who presented to us... | 38 Surgery |
ADMISSION DIAGNOSIS ES 1. Chronic obstructive pulmonary disease. 2. Pneumonia. 3. Congestive heart failure. 4. Diabetes mellitus. 5. Neuropathy. 6. Anxiety. 7. Hypothyroidism. 8. Depression. 9. Hypertension. DISCHARGE DIAGNOSIS ES 1. Severe chronic obstructive pulmonary disease. 2. Diabetes mellitus. 3. Hypothyro... | 15 General Medicine |
GENERAL Alert well developed in no acute distress. MENTAL STATUS Judgment and insight appropriate for age. Oriented to time place and person. No recent loss of memory. Affect appropriate for age. EYES Pupils are equal and reactive to light. No hemorrhages or exudates. Extraocular muscles intact. EAR N... | 5 Consult - History and Phy. |
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 anastomosi... | 14 Gastroenterology |
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... | 31 Podiatry |
PREOPERATIVE DIAGNOSIS Metastatic glossal carcinoma needing chemotherapy and a port. POSTOPERATIVE DIAGNOSIS Metastatic glossal carcinoma needing chemotherapy and a port. PROCEDURES 1. Open exploration of the left subclavian/axillary vein. 2. Insertion of a double lumen port through the left femoral vein rad... | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSIS ES Recurrent herniation L4-5 disk with left radiculopathy. POSTOPERATIVE DIAGNOSIS ES Recurrent herniation L4-5 disk with left radiculopathy. PROCEDURE Redo L4-5 diskectomy left. COMPLICATIONS None. ANTIBIOTIC S Vancomycin given preoperatively. ANESTHESIA General endotracheal. E... | 27 Orthopedic |
PROCEDURE PERFORMED 1. Left heart catheterization left ventriculogram aortogram coronary angiogram. 2. PCI of the LAD and left main coronary artery with Impella assist device. INDICATIONS FOR PROCEDURE Unstable angina and congestive heart failure with impaired LV function. TECHNIQUE OF PROCEDURE After obtai... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Bladder cancer. POSTOPERATIVE DIAGNOSIS Bladder cancer. OPERATION Transurethral resection of the bladder tumor TURBT large. ANESTHESIA General endotracheal. ESTIMATED BLOOD LOSS Minimal. FLUIDS Crystalloid. BRIEF HISTORY The patient is an 82-year-old male who presented to ... | 39 Urology |
PREOPERATIVE DIAGNOSIS Left acoustic neuroma. POSTOPERATIVE DIAGNOSIS Left acoustic neuroma. PROCEDURE PERFORMED Left retrosigmoid craniotomy and excision of acoustic neuroma. ANESTHESIA General. OPERATIVE FINDINGS This patient had a 3-cm acoustic neuroma. The tumor was incompletely excised leaving a re... | 22 Neurology |
PREOPERATIVE DIAGNOSES 1. Cervical spinal stenosis C3-c4 and C4-C5. 2. Cervical spondylotic myelopathy. POSTOPERATIVE DIAGNOSES 1. Cervical spinal stenosis C3-C4 and C4-C5. 2. Cervical spondylotic myelopathy. OPERATIVE PROCEDURES 1. Radical anterior discectomy C3-C4 with removal of posterior osteophytes forami... | 23 Neurosurgery |
REASON FOR VISIT Lap band adjustment. HISTORY OF PRESENT ILLNESS Ms. A is status post lap band placement back in 01/09 and she is here on a band adjustment. Apparently she had some problems previously with her adjustments and apparently she has been under a lot of stress. She was in a car accident a couple of ... | 38 Surgery |
HISTORY OF PRESENT ILLNESS The patient is a 44-year-old man who was seen for complaints of low back and right thigh pain. He attributes this to an incident in which he was injured in 1994. I do not have any paperwork authenticating his claim that there is an open claim. Most recently he was working at Taco Bell ... | 35 SOAP / Chart / Progress Notes |
A 1 cm infraumbilical skin incision was made. Through this a Veress needle was inserted into the abdominal cavity. The abdomen was filled with approximately 2 liters of CO2 gas. The Veress needle was withdrawn. A trocar sleeve was placed through the incision into the abdominal cavity. The trocar was withdrawn and ... | 38 Surgery |
EXAM CT examination of the abdomen and pelvis with intravenous contrast. INDICATIONS Abdominal pain. TECHNIQUE CT examination of the abdomen and pelvis was performed after 100 mL of intravenous Isovue-300 contrast administration. Oral contrast was not administered. There was no comparison of studies. FINDING... | 24 Obstetrics / Gynecology |
DIAGNOSIS Left knee osteoarthritis. HISTORY The patient is a 58-year-old female referred to therapy due to left knee osteoarthritis. The patient states that approximately 2 years ago she fell to the ground and thereafter had blood clots in the knee area. The patient was transferred from the hospital to a nurs... | 27 Orthopedic |
FINDINGS There is a lobulated mass lesion of the epiglottis measuring approximately 22 x 16 x 30 mm mediolateral x AP x craniocaudal in size. There is slightly greater involvement on the right side however there is bilateral involvement of the aryepiglottic folds. There is marked enlargement of the bilateral aryepig... | 33 Radiology |
HISTORY OF PRESENT ILLNESS This 59-year-old white male is seen for comprehensive annual health maintenance examination on 02/19/08 although this patient is in excellent overall health. Medical problems include chronic tinnitus in the left ear with moderate hearing loss for many years without any recent change dys... | 5 Consult - History and Phy. |
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 RE... | 39 Urology |
PREOPERATIVE DIAGNOSIS Sterilization candidate. POSTOPERATIVE DIAGNOSIS Sterilization candidate. PROCEDURE PERFORMED 1. Cervical dilatation. 2. Laparoscopic bilateral partial salpingectomy. ANESTHESIA General endotracheal. COMPLICATIONS None. ESTIMATED BLOOD LOSS Less than 50 cc. SPECIMEN Portions ... | 38 Surgery |
PREOPERATIVE DIAGNOSES 1. Cervical spondylosis C5-C6 greater than C6-C7 721.0 . 2. Neck pain progressive 723.1 with right greater than left radiculopathy 723.4 . POSTOPERATIVE DIAGNOSES 1. Cervical spondylosis C5-C6 greater than C6-C7 721.0 . 2. Neck pain progressive 723.1 with right greater than lef... | 27 Orthopedic |
PREOPERATIVE DIAGNOSIS Endometrial carcinoma. POSTOPERATIVE DIAGNOSIS Endometrial carcinoma. PROCEDURE PERFORMED Total laparoscopic hysterectomy with laparoscopic staging including paraaortic lymphadenectomy bilateral pelvic and obturator lymphadenectomy and washings. ANESTHESIA General endotracheal tub... | 38 Surgery |
PREOPERATIVE DIAGNOSES Bladder laceration. POSTOPERATIVE DIAGNOSES Bladder laceration. NAME OF OPERATION Closure of bladder laceration. FINDINGS The patient was undergoing a cesarean section for twins. During the course of the procedure a bladder laceration was notices and urology was consulted. Findings... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Sebaceous cyst right lateral eyebrow. POSTOPERATIVE DIAGNOSIS Sebaceous cyst right lateral eyebrow. PROCEDURE PERFORMED Excision of sebaceous cyst right lateral eyebrow. ASSISTANT None. ESTIMATED BLOOD LOSS Minimal. COMPLICATIONS None. ANESTHESIA General endotracheal anest... | 38 Surgery |
EXAM Ultrasound examination of the scrotum. REASON FOR EXAM Scrotal pain. FINDINGS Duplex and color flow imaging as well as real time gray-scale imaging of the scrotum and testicles was performed. The left testicle measures 5.1 x 2.8 x 3.0 cm. There is no evidence of intratesticular masses. There is normal ... | 33 Radiology |
HISTORY OF PRESENT ILLNESS This is a 91-year-old male with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung. The patient also has a positive history of smoking in the past. At the present time he is admitted for continued manag... | 5 Consult - History and Phy. |
REASON FOR EXAM Right-sided abdominal pain with nausea and fever. TECHNIQUE Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300. CT ABDOMEN The liver spleen pancreas gallbladder adrenal glands and kidney are unremarkable. CT PELVIS Within the right lower quadrant the... | 33 Radiology |
PREOPERATIVE DIAGNOSIS ES Left supracondylar intercondylar distal femur fracture. POSTOPERATIVE DIAGNOSIS ES Left supracondylar intercondylar distal femur fracture. PROCEDURE Open reduction internal fixation of the left supracondylar intercondylar distal femur fracture 27513 . OPERATIVE FINDINGS He had ... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Left supraorbital deep complex facial laceration measuring 6x2 cm. POSTOPERATIVE DIAGNOSIS Left supraorbital deep complex facial laceration measuring 6x2 cm. PROCEDURE PERFORMED Plastic closure of deep complex facial laceration measuring 6x2 cm. ANESTHESIA Local anesthesia with 1 lid... | 38 Surgery |
PROCEDURES 1. Placement of SynchroMed infusion pump. 2. Tunneling of SynchroMed infusion pump catheter 3. Anchoring of the intrathecal catheter and connecting of the right lower quadrant SynchroMed pump catheter to the intrathecal catheter. DESCRIPTION OF PROCEDURE Under general endotracheal anesthesia the pati... | 28 Pain Management |
CC Left third digit numbness and wrist pain. HX This 44 y/o LHM presented with a one month history of numbness and pain of the left middle finger and wrist. The numbness began in the left middle finger and gradually progressed over the course of a day to involve his wrist as well. Within a few days he developed pai... | 22 Neurology |
S - An 84-year-old diabetic female 5 7-1/2 tall 148 pounds history of hypertension and diabetes. She presents today with complaint of a very painful left foot because of the lesions on the bottom of the foot. She also has a left great toenail that is giving her problems as well. O - Plantar to the left first me... | 38 Surgery |
HISTORY OF PRESENT ILLNESS The patient is a 71-year-old woman with history of coronary artery disease for which she has had coronary artery bypass grafting x2 and percutaneous coronary intervention with stenting x1. She also has a significant history of chronic renal insufficiency and severe COPD. The patient and ... | 3 Cardiovascular / Pulmonary |
EXAM AP abdomen and ultrasound of kidney. HISTORY Ureteral stricture. AP ABDOMEN FINDINGS Comparison is made to study from Month DD YYYY. There is a left lower quadrant ostomy. There are no dilated bowel loops suggesting obstruction. There is a double-J right ureteral stent which appears in place. There... | 33 Radiology |
CC Motor vehicle-bicycle collision. HX A 5 y/o boy admitted 10/17/92. He was struck while riding his bicycle by a motor vehicle traveling at a high rate of speed. First responders found him unconscious with left pupil 6 mm and unreactive and the right pupil 3 mm and reactive. He had bilateral decorticate posturing ... | 33 Radiology |
PREOPERATIVE DIAGNOSIS Possible inflammatory bowel disease. POSTOPERATIVE DIAGNOSIS Polyp of the sigmoid colon. PROCEDURE PERFORMED Total colonoscopy with photography and polypectomy. GROSS FINDINGS The patient had a history of ischiorectal abscess. He has been evaluated now for inflammatory bowel disease.... | 14 Gastroenterology |
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 ... | 38 Surgery |
BILATERAL SCROTAL ORCHECTOMY PROCEDURE The patient is placed in the supine position prepped and draped in the usual manner. Under satisfactory general anesthesia the scrotum was approached and through a transverse mid scrotal incision the right testicle was delivered through the incision. Hemostasis was obtain... | 38 Surgery |
REASON FOR CONSULTATION I was asked by Dr. X to see the patient in regard to his likely recurrent brain tumor. HISTORY OF PRESENT ILLNESS The patient was admitted for symptoms that sounded like postictal state. He was initially taken to Hospital. CT showed edema and slight midline shift and therefore he was tr... | 5 Consult - History and Phy. |
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... | 38 Surgery |
SUBJECTIVE She is here for a followup on her weight loss on phentermine. She has gained another pound since she was here last. We talked at length about the continued plateau she has had with her weight. She gained a pound the month before and really has not been able to get her weight any farther down than she h... | 35 SOAP / Chart / Progress Notes |
SUMMARY OF CLINICAL HISTORY The patient was a 35-year-old African-American male with no significant past medical history who called EMS with shortness of breath and chest pain. Upon EMS arrival patient was tachypneic at 40 breaths per minute with oxygen saturation of 90 . At the scene EMS administered breathing ... | 1 Autopsy |
REASON FOR CONSULTATION This 92-year-old female states that last night she had a transient episode of slurred speech and numbness of her left cheek for a few hours. However the chart indicates that she had recurrent TIAs x3 yesterday each lasting about 5 minutes with facial drooping and some mental confusion. Sh... | 22 Neurology |
HISTORY OF PRESENT ILLNESS I have seen ABC today for her preoperative visit for weight management. I have explained to her the need for Optifast for weight loss prior to these procedures to make it safer because of the large size of her liver. She understands this. IMPRESSION/PLAN We are going to put her on two w... | 2 Bariatrics |
PREOPERATIVE DIAGNOSIS Left thyroid mass. POSTOPERATIVE DIAGNOSIS Left thyroid mass. PROCEDURE PERFORMED Left total thyroid lumpectomy. ANESTHESIA General endotracheal. ESTIMATED BLOOD LOSS Less than 50 cc. COMPLICATIONS None. INDICATIONS FOR PROCEDURE The patient is a 76-year-old Caucasian female ... | 38 Surgery |
HISTORY The patient is a 5-1/2-year-old who recently presented with a cardiac murmur diagnosed due to a patent ductus arteriosus. An echocardiogram from 09/13/2007 demonstrated a 3.8-mm patent ductus arteriosus with restrictive left-to-right shunt. There is mild left atrial chamber enlargement with an LA/AO ratio... | 3 Cardiovascular / Pulmonary |
HISTORY OF INJURY AND PRESENT COMPLAINTS The patient is a 59-year-old gentleman. He is complaining chiefly of persistent lower back pain. He states the pain is of a rather constant nature. He describes it as a rather constant dull ache sometimes rather sharp and stabbing in nature most localized to the right si... | 18 IME-QME-Work Comp etc. |
PREOPERATIVE DIAGNOSES Bilateral chronic otitis media POSTOPERATIVE DIAGNOSES Bilateral chronic otitis media ANESTHESIA General mask NAME OF OPERATION Bilateral Myringotomy with placement of PE tubes PROCEDURE The patient was taken to the operating room and placed in the supine position. After adequate ... | 38 Surgery |
TITLE OF OPERATION Bilateral endoscopic proximal shunt revision and a distal shunt revision. INDICATIONS FOR OPERATION Headaches full subtemporal site. PREOPERATIVE DIAGNOSIS Slit ventricle syndrome. POSTOPERATIVE DIAGNOSIS Slit ventricle syndrome. FINDINGS Coaptation of ventricles against proximal end ... | 38 Surgery |
PAST MEDICAL HISTORY She had a negative stress test four to five years ago. She gets short of breath in walking about 30 steps. She has had non-insulin dependent diabetes for about eight years now. She has a left knee arthritis and history of hemorrhoids. PAST SURGICAL HISTORY Pertinent for laparoscopic cholec... | 5 Consult - History and Phy. |
Her evaluation today reveals restriction in the range of motion of the cervical and lumbar region with tenderness and spasms of the paraspinal musculature. Motor strength was 5/5 on the MRC scale. Reflexes were 2+ and symmetrical. Palpable trigger points were noted bilaterally in the trapezius and lumbar paraspinal ... | 27 Orthopedic |
PREOPERATIVE DIAGNOSIS Urinary hesitancy and weak stream. POSTOPERATIVE DIAGNOSES 1. Urinary hesitancy and weak stream. 2. Urethral narrowing. 3. Mild posterior wall erythema. PROCEDURE PERFORMED 1. Cystourethroscopy. 2. Urethral dilation. 3. Bladder biopsy and fulguration. ANESTHESIA General. SPECIMEN ... | 39 Urology |
CHIEF COMPLAINT Recurrent bladder tumor. HISTORY OF PRESENT ILLNESS The patient is a 79-year-old woman the patient of Dr. X who on recent followup cystoscopy for transitional cell carcinomas of the bladder neck was found to have a 5-cm area of papillomatosis just above the left ureteric orifice. The patient un... | 39 Urology |
REASON FOR CT SCAN The patient is a 79-year-old man with adult hydrocephalus who was found to have large bilateral effusions on a CT scan performed on January 16 2008. I changed the shunt setting from 1.5 to 2.0 on February 12 2008 and his family obtained this repeat CT scan to determine whether his subdural effu... | 22 Neurology |
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 a... | 11 ENT - Otolaryngology |
DIAGNOSIS Polycythemia vera with secondary myelofibrosis. REASON FOR VISIT Followup of the above condition. CHIEF COMPLAINT Left shin pain. HISTORY OF PRESENT ILLNESS A 55-year-old white male who carries a diagnosis of polycythemia vera with secondary myelofibrosis. Diagnosis was made some time in 2005/2006... | 35 SOAP / Chart / Progress Notes |
CHIEF COMPLAINT Cut on foot. HISTORY OF PRESENT ILLNESS This is a 32-year-old male who had a piece of glass fall on to his right foot today. The patient was concerned because of the amount of bleeding that occurred with it. The bleeding has been stopped and the patient does not have any pain. The patient has n... | 15 General Medicine |
PREOPERATIVE DIAGNOSIS Colovesical fistula. POSTOPERATIVE DIAGNOSES 1. Colovesical fistula. 2. Intraperitoneal abscess. PROCEDURE PERFORMED 1. Exploratory laparotomy. 2. Low anterior colon resection. 3. Flexible colonoscopy. 4. Transverse loop colostomy and JP placement. ANESTHESIA General. HISTORY Thi... | 38 Surgery |
PREOPERATIVE DIAGNOSES 1. Enlarged fibroid uterus. 2. Blood loss anemia. POSTOPERATIVE DIAGNOSES 1. Enlarged fibroid uterus. 2. Blood loss anemia. PROCEDURE PERFORMED 1. Laparotomy. 2. Myomectomy. ANESTHESIA General. ESTIMATED BLOOD LOSS Less than a 100 cc. URINE OUTPUT 110 cc clear at the end of the... | 38 Surgery |
OPERATIVE PROCEDURE 1. Redo coronary bypass grafting x3 right and left internal mammary left anterior descending reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery. Total cardiopulmonary bypass cold-blood potassium cardioplegia antegrade f... | 38 Surgery |
PREOPERATIVE DIAGNOSES Nonhealing decubitus ulcer left ischial region Osteomyelitis paraplegia and history of spina bifida. POSTOPERATIVE DIAGNOSES Nonhealing decubitus ulcer left ischial region Osteomyelitis paraplegia and history of spina bifida. PROCEDURE PERFORMED Debridement left ischial ulcer. AN... | 38 Surgery |
DELIVERY NOTE The patient came in around 0330 hours in the morning on this date 12/30/08 in early labor and from a closed cervix very posterior yesterday she was 3 cm dilated. Membranes ruptured this morning by me with some meconium. An IUPC was placed. Some Pitocin was started because the contractions were very... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Osteomyelitis right hallux. POSTOPERATIVE DIAGNOSIS Osteomyelitis right hallux. PROCEDURE PERFORMED Amputation distal phalanx and partial proximal phalanx right hallux. ANESTHESIA TIVA/local. HISTORY This 44-year-old male patient was admitted to ABCD General Hospital on 09/02/20... | 27 Orthopedic |
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... | 14 Gastroenterology |
PREOPERATIVE DIAGNOSIS Left pleural effusion parapneumonic loculated. POSTOPERATIVE DIAGNOSIS Left pleural effusion parapneumonic loculated. OPERATION Left chest tube placement. IV SEDATION 5 mg of Versed total given under pulse ox monitoring 1 lidocaine local infiltration. PROCEDURE With the patie... | 38 Surgery |
CHIEF COMPLAINT Chronic otitis media. HISTORY OF PRESENT ILLNESS This is a 14-month-old with history of chronic recurrent episodes of otitis media totalling 6 bouts requiring antibiotics since birth. There is also associated chronic nasal congestion. There had been no bouts of spontaneous tympanic membrane pe... | 11 ENT - Otolaryngology |
IMPRESSION EEG during wakefulness drowsiness and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity. | 22 Neurology |
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. ... | 38 Surgery |
HISTORY OF PRESENT ILLNESS The patient is known to me secondary to atrial fibrillation with slow ventricular response partially due to medications at least when I first saw him in the office on 01/11/06. He is now 77 years old. He is being seen on the Seventh Floor. The patient is in Room 7607. The patient has a hi... | 5 Consult - History and Phy. |
PAST MEDICAL/SURGICAL HISTORY Briefly his past medical history is significant for hypertension of more than 5 years asthma and he has been on Advair and albuterol. He was diagnosed with renal disease in 02/2008 and has since been on hemodialysis since 02/2008. His past surgical history is only significant for l... | 21 Nephrology |
CHIEF COMPLAINT Patient AF is a 50-year-old hepatitis C positive African-American man presenting with a 2-day history of abdominal pain and distention with nausea and vomiting. HISTORY OF PRESENT ILLNESS AF s symptoms began 2 days ago and he has not passed gas or had any bowel movements. He has not eaten anythi... | 14 Gastroenterology |
REASON FOR REFERRAL Evaluation for right L4 selective nerve root block. CHIEF COMPLAINT | 27 Orthopedic |
PROCEDURE PERFORMED Endotracheal intubation. INDICATION FOR PROCEDURE The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather. PCO2 was 29 and pO2 was 66 on the 15 liters. NARRATIVE OF PROCEDURE The patient was given a total... | 38 Surgery |
REASON FOR CONSULTATION Newly diagnosed cholangiocarcinoma. HISTORY OF PRESENT ILLNESS The patient is a very pleasant 77-year-old female who is noted to have an increase in her liver function tests on routine blood work in December 2009. Ultrasound of the abdomen showed gallbladder sludge and gallbladder finding... | 14 Gastroenterology |
PREOPERATIVE DIAGNOSIS Left carpal tunnel syndrome. POSTOPERATIVE DIAGNOSIS Left carpal tunnel syndrome. OPERATIVE PROCEDURE 1. Left endoscopic carpal tunnel release. 2. Endotracheal fasciotomy. ANESTHESIA General. COMPLICATIONS None. INDICATION The patient is a 62-year-old lady with the aforementione... | 27 Orthopedic |
PREOPERATIVE DIAGNOSIS Esophageal rupture. POSTOPERATIVE DIAGNOSIS Esophageal rupture. OPERATION PERFORMED 1. Left thoracotomy with drainage of pleural fluid collection. 2. Esophageal exploration and repair of esophageal perforation. 3. Diagnostic laparoscopy and gastrostomy. 4. Radiographic gastrostomy tube ... | 14 Gastroenterology |
CHIEF COMPLAINT 1. Stage IIIC endometrial cancer. 2. Adjuvant chemotherapy with cisplatin Adriamycin and Abraxane. HISTORY OF PRESENT ILLNESS The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009. In March 2010 she had an abnormal endometrial ultrasound with t... | 24 Obstetrics / Gynecology |
PREOPERATIVE DIAGNOSIS Refractory dyspepsia. POSTOPERATIVE DIAGNOSIS 1. Hiatal hernia. 2. Reflux esophagitis. PROCEDURE PERFORMED Esophagogastroduodenoscopy with pseudo and esophageal biopsy. ANESTHESIA Conscious sedation with Demerol and Versed. SPECIMEN Esophageal biopsy. COMPLICATIONS None. HISTORY... | 14 Gastroenterology |
CHIEF COMPLAINT Buttock abscess. HISTORY OF PRESENT ILLNESS This patient is a 24-year-old African-American female who presented to the hospital with buttock pain. She started off with a little pimple on the buttock. She was soaking it at home without any improvement. She came to the hospital on the first. The... | 15 General Medicine |
SUBJECTIVE The patient is not in acute distress. PHYSICAL EXAMINATION VITAL SIGNS Blood pressure of 121/63 pulse is 75 and O2 saturation is 94 on room air. HEAD AND NECK Face is symmetrical. Cranial nerves are intact. CHEST There is prolonged expiration. CARDIOVASCULAR First and second heart sounds are ... | 35 SOAP / Chart / Progress Notes |
PREOPERATIVE DIAGNOSES 1. Chronic cholecystitis. 2. Cholelithiasis. POSTOPERATIVE DIAGNOSES 1. Chronic cholecystitis. 2. Cholelithiasis. 3. Liver cyst. PROCEDURES PERFORMED 1. Laparoscopic cholecystectomy. 2. Excision of liver cyst. ANESTHESIA General endotracheal and injectable 0.25 Marcaine with 1 lido... | 38 Surgery |
PREOPERATIVE DIAGNOSES Left calcaneal valgus split. POSTOPERATIVE DIAGNOSES Left calcaneal valgus split. PROCEDURES 1. Left calcaneal lengthening osteotomy with allograft. 2. Partial plantar fasciotomy. 3. Posterior subtalar and tibiotalar capsulotomy. 4. Short leg cast placed. ANESTHESIA Surgery perfor... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Pelvic pain. POSTOPERATIVE DIAGNOSES 1. Pelvic pain. 2. Pelvic endometriosis. 3. Pelvic adhesions. PROCEDURE PERFORMED 1. Laparoscopy. 2. Harmonic scalpel ablation of endometriosis. 3. Lysis of adhesions. 4. Cervical dilation. ANESTHESIA General. SPECIMEN Peritoneal biopsy. ESTI... | 24 Obstetrics / Gynecology |
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 ... | 27 Orthopedic |
PAST MEDICAL HISTORY Unremarkable except for diabetes and atherosclerotic vascular disease. ALLERGIES PENICILLIN. CURRENT MEDICATIONS Include Glucovance Seroquel Flomax and Nexium. PAST SURGICAL HISTORY Appendectomy and exploratory laparotomy. FAMILY HISTORY Noncontributory. SOCIAL HISTORY The pat... | 3 Cardiovascular / Pulmonary |
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... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Recurrent bladder tumors. POSTOPERATIVE DIAGNOSIS Recurrent bladder tumors. OPERATION Cystoscopy TUR and electrofulguration of recurrent bladder tumors. ANESTHESIA General. INDICATIONS A 79-year-old woman with recurrent bladder tumors of the bladder neck. DESCRIPTION OF PROCEDURE... | 39 Urology |
NAME OF PROCEDURE Left heart catheterization with ventriculography selective coronary arteriographies successful stenting of the left anterior descending diagonal. INDICATION Recurrent angina. History of coronary disease. TECHNICAL PROCEDURE Standard Judkins right groin. CATHETERS USED 6-French pigtail ... | 3 Cardiovascular / Pulmonary |
PROCEDURE Colonoscopy. PREOPERATIVE DIAGNOSES Change in bowel habits and rectal prolapse. POSTOPERATIVE DIAGNOSIS Normal colonoscopy. PROCEDURE The Olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve... | 14 Gastroenterology |
REASON FOR VISIT Mr. ABC is a 30-year-old man who returns in followup of his still moderate-to-severe sleep apnea. He returns today to review his response to CPAP. HISTORY OF PRESENT ILLNESS The patient initially presented with loud obnoxious snoring that disrupted the sleep of his bed partner. He was found to ... | 36 Sleep Medicine |
PREOPERATIVE DIAGNOSIS Patellar tendon retinaculum ruptures right knee. POSTOPERATIVE DIAGNOSIS Patellar tendon retinaculum ruptures right knee. PROCEDURE PERFORMED Patellar tendon and medial and lateral retinaculum repair right knee. SPECIFICATIONS Intraoperative procedure done at Inpatient Operative S... | 27 Orthopedic |
INDICATION Paroxysmal atrial fibrillation. HISTORY OF PRESENT ILLNESS The patient is a pleasant 55-year-old white female with multiple myeloma. She is status post chemotherapy and autologous stem cell transplant. Latter occurred on 02/05/2007. At that time she was on telemetry monitor and noticed to be in nor... | 3 Cardiovascular / Pulmonary |
DIAGNOSIS 1. Broad-based endocervical poly. 2. Broad- based pigmented raised nevus right thigh. OPERATION 1. LEEP procedure of endocervical polyp. 2. Electrical excision of pigmented mole of inner right thigh. FINDINGS There was a 1.5 x 1.5 cm broad-based pigmented nevus on the inner thigh that was excised w... | 24 Obstetrics / Gynecology |
PRIMARY DISCHARGE DIAGNOSES 1. Urinary tract infection. 2. Gastroenteritis with nausea and vomiting. 3. Upper gastrointestinal bleed likely secondary to gastritis. 4. Right hip osteoarthritic pain. SECONDARY DISCHARGE DIAGNOSES 1. Hypertension. 2. Gastroesophageal reflux disease. 3. Chronic atrial fibrillation... | 10 Discharge Summary |
TITLE OF OPERATION 1. Pars plana vitrectomy. 2. Pars plana lensectomy. 3. Exploration of exit wound. 4. Closure of perforating corneal scleral laceration involving uveal tissue. 5. Air-fluid exchange. 6. C3F8 gas. 7. Scleral buckling right eye. INDICATION FOR SURGERY The patient was hammering and a piece of... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Herniated nucleus pulposus T8-T9. POSTOPERATIVE DIAGNOSIS Herniated nucleus pulposus T8-T9. OPERATION PERFORMED Thoracic right-sided discectomy at T8-T9. BRIEF HISTORY AND INDICATION FOR OPERATION The patient is a 53-year-old female with a history of right thoracic rib pain related to... | 23 Neurosurgery |
PREOPERATIVE DIAGNOSIS Degenerative osteoarthritis right knee. POSTOPERATIVE DIAGNOSIS Degenerative osteoarthritis right knee. PROCEDURE PERFORMED Right knee total arthroplasty. ANESTHESIA The procedure was done under a subarachnoid block anesthetic in the supine position with a tourniquet utilized. TOTAL ... | 38 Surgery |
CC Five years ago I stopped drinking and since that time I have had severe depression. I was doing okay when I stopped my medications in April for a few weeks but then I got depressed again. I started lithium three weeks ago. HPI The patient is a 45-year-old married white female without children currently ... | 5 Consult - History and Phy. |
MEDICATIONS 1. Versed intravenously. 2. Demerol intravenously. DESCRIPTION OF THE PROCEDURE After informed consent the patient was placed in the left lateral decubitus position and Cetacaine spray was applied to the posterior pharynx. The patient was sedated with the above medications. The Olympus video panend... | 38 Surgery |
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