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PREOPERATIVE DIAGNOSIS Cervical spondylosis and herniated nucleus pulposus of C4-C5. POSTOPERATIVE DIAGNOSIS Cervical spondylosis and herniated nucleus pulposus of C4-C5. TITLE OF OPERATION Anterior cervical discectomy C4-C5 arthrodesis with 8 mm lordotic ACF spacer corticocancellous and stabilization with S... | 27 Orthopedic |
PREOPERATIVE DIAGNOSES Empyema of the left chest and consolidation of the left lung. POSTOPERATIVE DIAGNOSES Empyema of the left chest consolidation of the left lung lung abscesses of the left upper lobe and left lower lobe. OPERATIVE PROCEDURE Left thoracoscopy and left thoracotomy with declaudication and d... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Aortic stenosis. POSTOPERATIVE DIAGNOSIS Aortic stenosis. PROCEDURES PERFORMED 1. Insertion of a -mm Toronto stentless porcine valve. 2. Cardiopulmonary bypass. 3. Cold cardioplegia arrest of the heart. ANESTHESIA General endotracheal anesthesia. ESTIMATED BLOOD LOSS 300 cc. INT... | 38 Surgery |
CLEAR CORNEAL TEMPORAL INCISION NO STITCHES DESCRIPTION OF OPERATION Under satisfactory local anesthesia the patient was appropriately prepped and draped. A lid speculum was placed in the fissure of the right eye. The secondary incision was then made through clear cornea using 1-mm diamond keratome at surgeon s ... | 26 Ophthalmology |
PROCEDURE Left heart catheterization left ventriculography coronary angiography and successful stenting of tight lesion in the distal circumflex and moderately tight lesion in the mid right coronary artery. This gentleman has had a non-Q-wave troponin-positive myocardial infarction complicated by ventricular f... | 38 Surgery |
PREOPERATIVE DIAGNOSES 1. Recurrent tonsillitis. 2. Deeply cryptic hypertrophic tonsils with numerous tonsillolith. 3. Residual adenoid hypertrophy and recurrent epistaxis. POSTOPERATIVE DIAGNOSES 1. Recurrent tonsillitis. 2. Deeply cryptic hypertrophic tonsils with numerous tonsillolith. 3. Residual adenoid hype... | 38 Surgery |
PROCEDURE Bronchoscopy right upper lobe biopsies and right upper lobe bronchial washing as well as precarinal transbronchial needle aspiration. DETAILS OF THE PROCEDURE The risks alternatives and benefits of the procedure were explained to the patient as well as conscious sedation and she agrees to proceed. T... | 38 Surgery |
PREOPERATIVE DIAGNOSES 1. Pelvic pain. 2. Hypermenorrhea. POSTOPERATIVE DIAGNOSES 1. Pelvic pain. 2. Hypermenorrhea. 3. Mild pelvic endometriosis. PROCEDURE PERFORMED 1. Dilatation and curettage D C . 2. Laparoscopic ablation of endometrial implants. ANESTHESIA General endotracheal. COMPLICATIONS None.... | 24 Obstetrics / Gynecology |
CHIEF COMPLAINT Worker’s compensation injury. HISTORY OF PRESENT ILLNESS The patient is a 21-year-old Hispanic female. She comes in today with her boyfriend. The patient speaks English fairly well but her primary language is Spanish. Her boyfriend does help to make sure that she understands what we are talkin... | 5 Consult - History and Phy. |
PREOPERATIVE DIAGNOSIS Stage IV necrotic sacral decubitus. POSTOPERATIVE DIAGNOSIS Stage IV necrotic sacral decubitus. PROCEDURE PERFORMED Debridement of stage IV necrotic sacral decubitus. GROSS FINDINGS This is a 92-year-old African-American female who was brought into the office 48 hours earlier with a c... | 38 Surgery |
PREOPERATIVE DIAGNOSES 1. Right renal mass. 2. Hematuria. POSTOPERATIVE DIAGNOSES 1. Right renal mass. 2. Right ureteropelvic junction obstruction. PROCEDURES PERFORMED 1. Cystourethroscopy. 2. Right retrograde pyelogram. 3. Right ureteral pyeloscopy. 4. Right renal biopsy. 5. Right double-J 4.5 x 26 mm ure... | 39 Urology |
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... | 21 Nephrology |
TITLE OF OPERATION Endoscopic and microsurgical transnasal resection of cystic suprasellar tumor. INDICATION FOR SURGERY She is a 3-year-old girl who is known to have a head injury and CT in 2005 was normal presented with headache. All endocrine labs were normal. Surgery was recommended. PREOP DIAGNOSIS Cys... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Gangrene osteomyelitis right second toe. POSTOPERATIVE DIAGNOSIS Gangrene osteomyelitis right second toe. OPERATIVE REPORT The patient is a 58-year-old female with poorly controlled diabetes with severe lower extremity lymphedema. The patient has history of previous right foot infecti... | 31 Podiatry |
PREOPERATIVE DIAGNOSIS Rejection of renal transplant. POSTOPERATIVE DIAGNOSIS Rejection of renal transplant. OPERATIVE PROCEDURE Transplant nephrectomy. DESCRIPTION OF PROCEDURE The patient has had rapid deterioration of her kidney function since her transplant at ABCD one year ago. The patient was recentl... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Traumatic injury to bilateral upper extremities. POSTOPERATIVE DIAGNOSIS Traumatic injury to bilateral upper extremities. PROCEDURE Dressing change under anesthesia. PREOPERATIVE INDICATIONS This 6 year old was involved in a traumatic accident. She presents today for evaluation and d... | 38 Surgery |
HISTORY OF PRESENT ILLNESS A 67-year-old gentleman who presented to the emergency room with chest pain cough hemoptysis shortness of breath and recent 30-pound weight loss. He had a CT scan done of the chest there which demonstrated bilateral hilar adenopathy with extension to the subcarinal space as well as a ... | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSIS Adenocarcinoma of the prostate. POSTOPERATIVE DIAGNOSIS Adenocarcinoma of the prostate. TITLE OF OPERATION Mini-laparotomy radical retropubic prostatectomy with bilateral pelvic lymph node dissection with Cavermap. ANESTHESIA General by intubation. Informed consent was obtained for th... | 39 Urology |
CT ANGIOGRAPHY CHEST WITH CONTRAST REASON FOR EXAM Chest pain shortness of breath and cough evaluate for pulmonary arterial embolism. TECHNIQUE Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300. FINDINGS There is no evidence for pulmonary arterial embol... | 3 Cardiovascular / Pulmonary |
SUBJECTIVE The patient is a 78-year-old female who returns for recheck. She has hypertension. She denies difficulty with chest pain palpations orthopnea nocturnal dyspnea or edema. PAST MEDICAL HISTORY / SURGERY / HOSPITALIZATIONS Reviewed and unchanged from the dictation on 12/03/2003. MEDICATIONS Ateno... | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSIS 1. Aortoiliac occlusive disease bilaterally. 2. Dementia. POSTOPERATIVE DIAGNOSIS 1. Aortoiliac occlusive disease bilaterally. 2. Dementia. OPERATION Aortobifemoral bypass surgery utilizing a bifurcated Hemashield graft. ANESTHESIA General endotracheal ESTIMATED BLOOD LOSS 300 cc INT... | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSES 1. Ventilator-dependent respiratory failure. 2. Laryngeal edema. POSTOPERATIVE DIAGNOSES 1. Ventilator-dependent respiratory failure. 2. Laryngeal edema. PROCEDURE PERFORMED Tracheostomy change. A #6 Shiley with proximal extension was changed to a #6 Shiley with proximal extension. INDI... | 38 Surgery |
REASON FOR VISIT Syncope. HISTORY The patient is a 75-year-old lady who had a syncopal episode last night. She went to her room with a bowl of cereal and then blacked out for a few seconds and then when she woke up the cereal was on the floor. She did not have any residual deficit. She had a headache at that ... | 12 Emergency Room Reports |
PROCEDURES PERFORMED 1. Functional endoscopic sinus surgery. 2. Bilateral maxillary antrostomy. 3. Bilateral total ethmoidectomy. 4. Bilateral nasal polypectomy. 5. Right middle turbinate reduction. ANESTHESIA General endotracheal tube. BLOOD LOSS Approximately 50 cc. INDICATION This is a 48-year-old fem... | 11 ENT - Otolaryngology |
PHYSICAL EXAMINATION GENERAL APPEARANCE Well developed well nourished in no acute distress. VITAL SIGNS SKIN Inspection of the skin reveals no rashes ulcerations or petechiae. HEENT The sclerae were anicteric and conjunctivae were pink and moist. Extraocular movements were intact and pupils were equ... | 15 General Medicine |
PROCEDURE Subcutaneous ulnar nerve transposition. PROCEDURE IN DETAIL After administering appropriate antibiotics and MAC anesthesia the upper extremity was prepped and draped in the usual standard fashion. The arm was exsanguinated with Esmarch and the tourniquet inflated to 250 mmHg. A curvilinear incision w... | 27 Orthopedic |
PREOPERATIVE DIAGNOSES 1. Nonfunctioning inflatable penile prosthesis. 2. Peyronie s disease. POSTOPERATIVE DIAGNOSES 1. Nonfunctioning inflatable penile prosthesis. 2. Peyronie s disease. PROCEDURE PERFORMED Ex-plantation of inflatable penile prosthesis and then placement of second inflatable penile prosthesi... | 39 Urology |
PREOPERATIVE DIAGNOSES 1. Metatarsus primus varus with bunion deformity right foot. 2. Hallux abductovalgus with angulation deformity right foot. POSTOPERATIVE DIAGNOSES 1. Metatarsus primus varus with bunion deformity right foot. 2. Hallux abductovalgus with angulation deformity right foot. PROCEDURES 1. D... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Right renal mass. POSTOPERATIVE DIAGNOSIS Right renal mass. PROCEDURE Right radical nephrectomy and assisted laparoscopic approach. ANESTHESIA General. PROCEDURE IN DETAIL The patient underwent general anesthesia with endotracheal intubation. An orogastric was placed and a Foley c... | 21 Nephrology |
CARDIAC CT INCLUDING CORONARY CT ANGIOGRAPHY PROCEDURE Breath hold cardiac CT was performed using a 64-channel CT scanner with a 0.5-second rotation time. Contrast injection was timed using a 10 mL bolus of Ultravist 370 IV. Then the patient received 75 mL of Ultravist 370 at a rate of 5 mL/sec. Retrospective ECG ... | 3 Cardiovascular / Pulmonary |
REASON FOR EXAM Followup for fetal growth. INTERPRETATION Real-time exam demonstrates a single intrauterine fetus in cephalic presentation with a regular cardiac rate of 147 beats per minute documented. FETAL BIOMETRY BPD = 8.3 cm = 33 weeks 4 days HC = 30.2 cm = 33 weeks 4 days AC = 27.9 cm = 32 weeks ... | 24 Obstetrics / Gynecology |
PROCEDURE Bilateral L5 dorsal ramus block and bilateral S1 S2 and S3 lateral branch block. INDICATION Sacroiliac joint pain. INFORMED CONSENT The risks benefits and alternatives of the procedure were discussed with the patient. The patient was given opportunity to ask questions regarding the procedure its... | 27 Orthopedic |
PREOPERATIVE DIAGNOSES 1. Intrauterine pregnancy at 39 weeks. 2. History of previous cesarean section x2. The patient desires a repeat section. 3. Chronic hypertension. 4. Undesired future fertility. The patient desires permanent sterilization. POSTOPERATIVE DIAGNOSES 1. Intrauterine pregnancy at 39 weeks. 2. ... | 24 Obstetrics / Gynecology |
PREOPERATIVE DIAGNOSIS Left hemothorax rule out empyema. POSTOPERATIVE DIAGNOSIS Left hemothorax rule out empyema. PROCEDURE Insertion of a 12-French pigtail catheter in the left pleural space. PROCEDURE DETAIL After obtaining informed consent the patient was taken to the minor OR in the Same Day Surgery ... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Acute left subdural hematoma. POSTOPERATIVE DIAGNOSIS Acute left subdural hematoma. PROCEDURE Left frontal temporal craniotomy for evacuation of acute subdural hematoma. DESCRIPTION OF PROCEDURE This is a 76-year-old man who has a history of acute leukemia. He is currently in the pha... | 38 Surgery |
SUBJECTIVE The patient is in with several medical problems. She complains of numbness tingling and a pain in the toes primarily of her right foot described as a moderate pain. She initially describes it as a sharp quality pain but is unable to characterize it more fully. She has had it for about a year but se... | 15 General Medicine |
PREOPERATIVE DIAGNOSIS Prostate cancer. POSTOPERATIVE DIAGNOSIS Prostate cancer. OPERATION Cystoscopy and removal of foreign objects from the urethra. BRACHYTHERAPY Iodine 125. ANESTHESIA General endotracheal. The patient was given Levaquin 500 mg IV preoperatively. Total seeds were 59. Activity of 0.4... | 39 Urology |
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... | 29 Pediatrics - Neonatal |
OPERATION PERFORMED Ligament reconstruction and tendon interposition arthroplasty of right wrist. DESCRIPTION OF PROCEDURE With the patient under adequate anesthesia the right upper extremity was prepped and draped in a sterile manner. Attention was turned to the base of the thumb where a longitudinal incision w... | 38 Surgery |
HISTORY OF PRESENT ILLNESS See chart attached. MEDICATIONS Tramadol 50 mg every 4 to 6 hours p.r.n. hydrocodone 7.5 mg/500 mg every 6 hours p.r.n. zolpidem 10 mg at bedtime triamterene 37.5 mg atenolol 50 mg vitamin D TriCor 145 mg simvastatin 20 mg ibuprofen 600 mg t.i.d. and Lyrica 75 mg. FAMILY HISTOR... | 14 Gastroenterology |
HISTORY OF PRESENT ILLNESS Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain. She has had a dry cough and a fever as high as 100 but this has not been since the first day. She denies any vomiting o... | 11 ENT - Otolaryngology |
EXAM Ultrasound abdomen complete. HISTORY 38-year-old male admitted from the emergency room 04/18/2009 decreased mental status and right upper lobe pneumonia. The patient has diffuse abdominal pain. There is a history of AIDS. TECHNIQUE An ultrasound examination of the abdomen was performed. FINDINGS Th... | 14 Gastroenterology |
CHIEF COMPLAINT Congestion and cough. HISTORY OF PRESENT ILLNESS The patient is a 5-month-old infant who presented initially on Monday with a cold cough and runny nose for 2 days. Mom states she had no fever. Her appetite was good but she was spitting up a lot. She had no difficulty breathing and her cough w... | 29 Pediatrics - Neonatal |
REPORT This is an 18-channel recording obtained using the standard scalp and referential electrodes observing the 10/20 international system. The patient was reported to be cooperative and was awake throughout the recording. CLINICAL NOTE This is a 51-year-old male who is being evaluated for dizziness. Spontan... | 22 Neurology |
PREOPERATIVE DIAGNOSIS Acute cholecystitis. POSTOPERATIVE DIAGNOSIS Acute gangrenous cholecystitis with cholelithiasis. OPERATION PERFORMED Laparoscopic cholecystectomy with cholangiogram. FINDINGS The patient had essentially a dead gallbladder with stones and positive wide bile/pus coming from the gallblad... | 38 Surgery |
PROCEDURE CODES 64640 times two 64614 time two 95873 times two 29405 times two. PREOPERATIVE DIAGNOSIS Spastic diplegic cerebral palsy 343.0. POSTOPERATIVE DIAGNOSIS Spastic diplegic cerebral palsy 343.0. ANESTHESIA MAC. COMPLICATIONS None. DESCRIPTION OF TECHNIQUE Informed consent was obtained from th... | 38 Surgery |
HISTORY OF PRESENT ILLNESS The patient is a 53-year-old right-handed gentleman who presents to the clinic for further evaluation of diplopia. He states that he was in his usual state of health when he awoke one morning in January 2009. He had double vision. He states when he closed each eye the double vision dis... | 5 Consult - History and Phy. |
FINDINGS There is a well demarcated mass lesion of the deep lobe of the left parotid gland measuring approximately 2.4 X 3.9 X 3.0cm AP X transverse X craniocaudal in size. The lesion is well demarcated. There is a solid peripheral rim with a mean attenuation coefficient of 56.3. There is a central cystic appearing ... | 27 Orthopedic |
PREOPERATIVE DIAGNOSIS Acquired nasal septal deformity. POSTOPERATIVE DIAGNOSIS Acquired nasal septal deformity. PROCEDURES 1. Open septorhinoplasty with placement of bilateral spreader grafts. 2. Placement of a radiated rib tip graft. 3. Placement of a morcellized autogenous cartilage dorsal onlay graft. 4. ... | 11 ENT - Otolaryngology |
HISTORY OF PRESENT ILLNESS Hospitalist followup is required for continuing issues with atrial flutter with rapid ventricular response which was resistant to treatment with diltiazem and amiodarone being followed by Dr. X of cardiology through most of the day. This afternoon when I am seeing the patient nursing ... | 3 Cardiovascular / Pulmonary |
PROBLEM LIST 1. Type 1 diabetes mellitus insulin pump. 2. Hypertension. 3. Hyperlipidemia. HISTORY OF PRESENT ILLNESS The patient is a 39-year-old woman returns for followup management of type 1 diabetes mellitus. Her last visit was approximately 4 months ago. Since that time the patient states her health ha... | 13 Endocrinology |
PROCEDURE Bilateral L5 S1 S2 and S3 radiofrequency ablation. INDICATION Sacroiliac joint pain. INFORMED CONSENT The risks benefits and alternatives of the procedure were discussed with the patient. The patient was given opportunity to ask questions regarding the procedure its indications and the associat... | 38 Surgery |
NASAL EXAM The nose is grossly in the midline with no evidence of fractures or dislocations. The nasal septum is roughly in the midline with pale boggy mucosa and moderately enlarged inferior turbinates. There is no pus or polyps in the nose on anterior rhinoscopy. The airway appears adequate. No external valve ... | 11 ENT - Otolaryngology |
SUBJECTIVE This patient presents to the office today because he has not been feeling well. He was in for a complete physical on 05/02/2008. According to the chart the patient gives a history of feeling bad for about two weeks. At first he thought it was stress and anxiety and then he became worried it was someth... | 15 General Medicine |
TITLE OF OPERATION Completion thyroidectomy with limited right paratracheal node dissection. INDICATION FOR SURGERY A 49-year-old woman with a history of a left dominant nodule in her thyroid gland who subsequently underwent left thyroid lobectomy and isthmusectomy was found to have multifocal papillary thyroid... | 13 Endocrinology |
CC BLE weakness. HX This 82y/o RHM was referred to the Neurology service by the Neurosurgery service for evaluation of acute onset paraplegia. He was in his usual state of health until 5 30PM on 4/6/95 when he developed sudden pressure-like epigastric discomfort associated with bilateral lower extremity weakness... | 27 Orthopedic |
CHIEF COMPLAINT Septal irritation. HISTORY OF PRESENT ILLNESS The patient is a 39-year-old African-American female status post repair of septal deviation but unfortunately ultimately ended with a large septal perforation. The patient has been using saline nasal wash 2-3 times daily however she states that she... | 11 ENT - Otolaryngology |
PREOPERATIVE DIAGNOSIS Carpal tunnel syndrome. POSTOPERATIVE DIAGNOSIS Carpal tunnel syndrome. TITLE OF PROCEDURE Endoscopic carpal tunnel release. ANESTHESIA MAC PROCEDURE After administering appropriate antibiotics and MAC anesthesia the upper extremity was prepped and draped in the usual standard fas... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Bilateral chronic serous otitis media. POSTOPERATIVE DIAGNOSIS Bilateral chronic serous otitis media. OPERATION PERFORMED 1. Bilateral myringotomies. 2. Insertion of Shepard grommet draining tubes. ANESTHESIA General by mask. ESTIMATED BLOOD LOSS Less than 1 mL. COMPLICATIONS N... | 38 Surgery |
PROCEDURE Belly button piercing for insertion of belly button ring. DESCRIPTION OF PROCEDURE The patient was prepped after informed consent was given of risk of infection and foreign body reaction. The area was marked by the patient and then prepped. The area was injected with 2 Xylocaine 1 100 000 epinephrine... | 38 Surgery |
REASON FOR VISIT This is an 83-year-old woman referred for diagnostic lumbar puncture for possible malignancy by Dr. X. She is accompanied by her daughter. HISTORY OF PRESENT ILLNESS The patient daughter tells me that over the last month the patient has gradually stopped walking even with her walker and her left... | 23 Neurosurgery |
PREOPERATIVE DIAGNOSES 1. Metatarsus primus varus with bunion deformity right foot. 2. Hallux abductovalgus with angulation deformity right foot. POSTOPERATIVE DIAGNOSES 1. Metatarsus primus varus with bunion deformity right foot. 2. Hallux abductovalgus with angulation deformity right foot. PROCEDURES 1. D... | 27 Orthopedic |
PREOPERATIVE DIAGNOSIS Stenosing tendinosis right thumb trigger finger . POSTOPERATIVE DIAGNOSIS Stenosing tendinosis right thumb trigger finger . PROCEDURE PERFORMED Release of A1 pulley right thumb. ANESTHESIA IV regional with sedation. COMPLICATIONS None. ESTIMATED BLOOD LOSS Minimal. TOURNIQU... | 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... | 38 Surgery |
PROCEDURES PERFORMED Endoscopy. INDICATIONS Dysphagia. POSTOPERATIVE DIAGNOSIS Esophageal ring and active reflux esophagitis. PROCEDURE Informed consent was obtained prior to the procedure from the parents and patient. The oral cavity is sprayed with lidocaine spray. A bite block is placed. Versed IV 5 m... | 14 Gastroenterology |
CHIEF COMPLAINT Left elbow pain. HISTORY OF PRESENT ILLNESS This 17-year-old male was fighting with some other kids in Juvenile Hall when he felt some pain in his left elbow causing sudden pain. He also has pain in his left ankle but he is able to walk normally. He has had previous pain in his left knee. He ... | 27 Orthopedic |
EXAM CT chest with contrast. REASON FOR EXAM Pneumonia chest pain short of breath and coughing up blood. TECHNIQUE Postcontrast CT chest 100 mL of Isovue-300 contrast. FINDINGS This study demonstrates a small region of coalescent infiltrates/consolidation in the anterior right upper lobe. There are line... | 3 Cardiovascular / Pulmonary |
IDENTIFYING DATA This is a 26-year-old Caucasian male of unknown employment who has been living with his father. CHIEF COMPLAINT AND/OR REACTION TO HOSPITALIZATION The patient is unresponsive. HISTORY OF PRESENT ILLNESS The patient was found by outpatient case manager to be unresponsive and incontinent of uri... | 32 Psychiatry / Psychology |
TIME SEEN 0734 hours and 1034 hours. TOTAL RECORDING TIME 27 hours 4 minutes. PATIENT HISTORY This is a 43-year-old female with a history of events concerning for seizures. Video EEG monitoring is performed to capture events and/or identify etiology. VIDEO EEG DIAGNOSES 1. AWAKE Normal. 2. SLEEP No acti... | 22 Neurology |
PREOPERATIVE DIAGNOSIS Cervical myelopathy secondary to very large disc herniations at C4-C5 and C5-C6. POSTOPERATIVE DIAGNOSIS Cervical myelopathy secondary to very large disc herniations at C4-C5 and C5-C6. PROCEDURE PERFORMED 1. Anterior cervical discectomy C4-C5 and C5-C6. 2. Arthrodesis C4-C5 and C5-C6.... | 38 Surgery |
MALE 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 no... | 25 Office Notes |
ADMISSION DIAGNOSES 1. Syncope. 2. End-stage renal disease requiring hemodialysis. 3. Congestive heart failure. 4. Hypertension. DISCHARGE DIAGNOSES 1. Syncope. 2. End-stage renal disease requiring hemodialysis. 3. Congestive heart failure. 4. Hypertension. CONDITION ON DISCHARGE Stable. PROCEDURE PERFORME... | 10 Discharge Summary |
HISTORY OF PRESENT ILLNESS The patient comes in today because of feeling lightheaded and difficulty keeping his balance. He denies this as a spinning sensation that he had had in the past with vertigo. He just describes as feeling very lightheaded. It usually occurs with position changes such as when he stands up... | 5 Consult - History and Phy. |
REASON FOR CONSULTATION Left flank pain ureteral stone. BRIEF HISTORY The patient is a 76-year-old female who was referred to us from Dr. X for left flank pain. The patient was found to have a left ureteral stone measuring about 1.3 cm in size per the patient s history. The patient has had pain in the abdomen ... | 39 Urology |
PREOPERATIVE DIAGNOSES 1. Basal cell nevus syndrome. 2. Cystic lesion left posterior mandible. 3. Corrected dentition. 4. Impacted teeth 1 and 16. 5. Maxillary transverse hyperplasia. POSTOPERATIVE DIAGNOSES 1. Basal cell nevus syndrome. 2. Cystic lesion left posterior mandible. 3. Corrected dentition. 4. Im... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Left renal mass 5 cm in diameter. POSTOPERATIVE DIAGNOSIS Left renal mass 5 cm in diameter. OPERATION PERFORMED Left partial nephrectomy. ANESTHESIA General with epidural. COMPLICATIONS None. ESTIMATED BLOOD LOSS About 350 mL. REPLACEMENT Crystalloid and Cell Savers from th... | 38 Surgery |
SUBJECTIVE The patient is brought in by an assistant with some of his food diary sheets. They wonder if the patient needs to lose anymore weight. OBJECTIVE The patient s weight today is 186-1/2 pounds which is down 1-1/2 pounds in the past month. He has lost a total of 34-1/2 pounds. I praised this. I went o... | 35 SOAP / Chart / Progress Notes |
PREOPERATIVE DIAGNOSIS Persistent abnormal uterine bleeding after endometrial ablation. POSTOPERATIVE DIAGNOSIS Persistent abnormal uterine bleeding after endometrial ablation. PROCEDURE PERFORMED Total abdominal hysterectomy TAH with a right salpingo-oophorectomy. COMPLICATIONS None. ESTIMATED BLOOD LOSS... | 24 Obstetrics / Gynecology |
PREOPERATIVE DIAGNOSES Bilateral inguinal hernia bilateral hydroceles. POSTOPERATIVE DIAGNOSES Bilateral inguinal hernia bilateral hydroceles. PROCEDURES Bilateral inguinal hernia and bilateral hydrocele repair with an ilioinguinal nerve block bilaterally by surgeon 20 mL given. ANESTHESIA General inhalat... | 39 Urology |
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... | 22 Neurology |
PREOPERATIVE DIAGNOSIS Brain tumors multiple. POSTOPERATIVE DIAGNOSES Brain tumors multiple - adenocarcinoma and metastasis from breast. PROCEDURE Occipital craniotomy removal of large tumor using the inner hemispheric approach stealth system operating microscope and CUSA. PROCEDURE The patient was place... | 38 Surgery |
ABNORMAL CHOLESTEROL RESULT LETTER Recently you had a cholesterol test done. The cholesterol levels were abnormal. These are usually associated with increased risk for stroke and heart attack. I am writing this letter to you to let you know that your levels are high enough that I think intervention is the next best ... | 20 Letters |
NAME OF PROCEDURE 1. Selective coronary angiography. 2. Placement of overlapping 3.0 x 18 and 3.0 x 8 mm Xience stents in the proximal right coronary artery. 3. Abdominal aortography. INDICATIONS The patient is a 65-year-old gentleman with a history of exertional dyspnea and a cramping-like chest pain. Thallium ... | 3 Cardiovascular / Pulmonary |
ADMITTING DIAGNOSIS Right C5-C6 herniated nucleus pulposus. PRIMARY OPERATIVE PROCEDURE Anterior cervical discectomy at C5-6 and placement of artificial disk replacement. SUMMARY This is a pleasant 43-year-old woman who has been having neck pain and right arm pain for a period of time which has not responded... | 23 Neurosurgery |
CHIEF COMPLAINT Headache. HPI This is a 24-year-old man who was seen here originally on the 13th with a headache and found to have a mass on CT scan. He was discharged home with a follow up to neurosurgery on the 14th. Apparently an MRI the next day showed that the mass was an aneurysm and he is currently sche... | 12 Emergency Room Reports |
CHIEF COMPLAINT One-month followup. HISTORY OF PRESENT ILLNESS The patient is an 88-year-old Caucasian female. She comes here today with a friend. The patient has no complaints. She states she has been feeling well. Her knees are not hurting her at all anymore and she is not needing Bextra any longer. I thin... | 35 SOAP / Chart / Progress Notes |
PREOPERATIVE DIAGNOSES 1. Hypermenorrhea. 2. Pelvic pain. 3. Infertility. POSTOPERATIVE DIAGNOSES 1. Enlarged fibroid uterus. 2. Infertility. 3. Pelvic pain. 4. Probable bilateral tubal occlusion. PROCEDURE PERFORMED 1. Dilatation and curettage. 2. Laparoscopy. 3. Injection of indigo carmine dye. GROSS FIN... | 38 Surgery |
CHIEF COMPLAINT Right knee. HISTORY OF THE PRESENT ILLNESS The patient presents today for follow up of osteoarthritis Grade IV of the bilateral knees and flexion contracture doing great. Physical therapy is helping. The subjective pain is on the bilateral knees right worse than left. Pain Localized to the bi... | 27 Orthopedic |
PROBLEMS AND ISSUES 1. Headaches nausea and dizziness consistent with a diagnosis of vestibular migraine recommend amitriptyline for prophylactic treatment and Motrin for abortive treatment. 2. Some degree of peripheral neuropathy consistent with diabetic neuropathy encouraged her to watch her diet and exercis... | 5 Consult - History and Phy. |
PREOPERATIVE DIAGNOSIS Right breast mass with abnormal mammogram. POSTOPERATIVE DIAGNOSIS Right breast mass with abnormal mammogram. PROCEDURE PERFORMED Right breast excisional biopsy with needle-localization. ANESTHESIA Local with sedation. COMPLICATIONS None. SPECIMEN Right breast mass and confirmat... | 38 Surgery |
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... | 14 Gastroenterology |
CHILD PHYSICAL EXAMINATION VITAL SIGNS Birth weight is grams length occipitofrontal circumference . Character of cry was lusty. GENERAL APPEARANCE Well. BREATHING Unlabored. SKIN Clear. No cyanosis pallor or icterus. Subcutaneous tissue is ample. HEAD Normal. Fontanelles are soft and flat. Su... | 25 Office Notes |
PREOPERATIVE DIAGNOSIS Right upper eyelid squamous cell carcinoma. POSTOPERATIVE DIAGNOSIS Right upper eyelid squamous cell carcinoma. PROCEDURE PERFORMED Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid. COMPLICATIONS None.... | 38 Surgery |
CHIEF COMPLAINT 1. Infection. 2. Pelvic pain. 3. Mood swings. 4. Painful sex. HISTORY OF PRESENT ILLNESS The patient is a 29-year-old female who is here today with the above-noted complaints. She states that she has been having a lot of swelling and infection in her inner thigh area with the folliculitis she h... | 5 Consult - History and Phy. |
OPERATIVE NOTE The patient was taken to the operating room and placed in the supine position on the operating room table. The patient was prepped and draped in usual sterile fashion. An incision was made in the groin crease overlying the internal ring. This incision was about 1.5 cm in length. The incision was c... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Left adnexal mass. POSTOPERATIVE DIAGNOSIS Left ovarian lesion. PROCEDURE PERFORMED Laparoscopy with left salpingo-oophorectomy. ANESTHESIA General. ESTIMATED BLOOD LOSS Less than 50 cc. COMPLICATIONS None. FINDINGS The labia and perineum were within normal limits. The hymen... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Metopic synostosis with trigonocephaly. POSTOPERATIVE DIAGNOSIS Metopic synostosis with trigonocephaly. PROCEDURES PERFORMED 1. Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z-osteotomies. 2. Bone grafts. 3. Bilateral forehead reconstruction wit... | 6 Cosmetic / Plastic Surgery |
HISTORY OF PRESENT ILLNESS The patient is an 18-year-old girl brought in by her father today for evaluation of a right knee injury. She states that approximately 3 days ago while playing tennis she had a non-contact injury in which she injured the right knee. She had immediate pain and swelling. At this time she... | 27 Orthopedic |
IDENTIFYING DATA The patient is a 40-year-old white male. He is married on medical leave from his job as a tree cutter and lives with his wife and five children. CHIEF COMPLAINT AND REACTION TO HOSPITALIZATION The patient is admitted on a 72-hour involuntary treatment for dangerousness to others after repeated... | 32 Psychiatry / Psychology |
REASON FOR CONSULT I was asked to see this patient with metastatic non-small-cell lung cancer on hospice with inferior ST-elevation MI. HISTORY OF PRESENT ILLNESS The patient from prior strokes has expressive aphasia is not able to express herself in a clear meaningful fashion. Her daughter who accompanies her... | 17 Hospice - Palliative Care |
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