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CONCOMITANT CHEMORADIOTHERAPY FOR CURATIVE INTENT PATIENTS This patient is receiving combined radiotherapy and chemotherapy in an effort to maximize the chance of control of this cancer. The chemotherapy is given in addition to the radiotherapy not only to act as a cytotoxic agent on its own but also to potentiate a... | 16 Hematology - Oncology |
REASON FOR CONSULTATION Glioma. HISTORY OF PRESENT ILLNESS The patient is a 71-year-old woman who was initially diagnosed with a brain tumor in 1982. She underwent radiation therapy for this although craniotomy was not successful for a biopsy because of seizure activity during the surgery. She did well for the... | 5 Consult - History and Phy. |
PREOPERATIVE DIAGNOSES 1. Postoperative wound infection. 2. Left gluteal abscess. 3. Intraperitoneal pigtail catheter. POSTOPERATIVE DIAGNOSES 1. Postoperative wound infection. There was an intraperitoneal foreign body. 2. Left gluteal abscess. 3. Intraperitoneal pigtail catheter. PROCEDURES 1. Incision and dra... | 38 Surgery |
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... | 15 General Medicine |
REASON FOR VISIT Six-month follow-up visit for CAD. He is a 67-year-old man who suffers from chronic anxiety and coronary artery disease and DJD. He has been having a lot of pain in his back and pain in his left knee. He is also having trouble getting his nerves under control. He is having stomach pains and occasi... | 35 SOAP / Chart / Progress Notes |
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... | 10 Discharge Summary |
IMPRESSION Abnormal electroencephalogram revealing generalized poorly organized slowing with more prominent slowing noted at the right compared to the left hemisphere head regions and rare sharp wave activity noted bilaterally somewhat more prevalent on the right. Clinical correlation is suggested. | 22 Neurology |
REASON FOR VISIT Ms. ABC is a 67-year-old woman with adult hydrocephalus who returns to clinic for a routine evaluation. She comes to clinic by herself. HISTORY OF PRESENT ILLNESS She has been followed for her hydrocephalus since 2002. She also had an anterior cervical corpectomy and fusion from C3 though C5 in... | 22 Neurology |
HISTORY The patient is a 52-year-old right-handed female with longstanding bilateral arm pain which is predominantly in the medial aspect of her arms and hands as well as left hand numbness worse at night and after doing repetitive work with her left hand. She denies any weakness. No significant neck pain chang... | 33 Radiology |
PREOPERATIVE DIAGNOSES 1. Clinical stage T2 NX MX transitional cell carcinoma of the urinary bladder status post chemotherapy and radiation therapy. 2. New right hydronephrosis. POSTOPERATIVE DIAGNOSES 1. Clinical stage T4a N3 M1 transitional cell carcinoma of the urinary bladder status post chemotherapy and... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Bilateral undescended testes. POSTOPERATIVE DIAGNOSIS Bilateral undescended testes. OPERATION PERFORMED Bilateral orchiopexy. ANESTHESIA General. HISTORY This 8-year-old boy has been found to have a left inguinally situated undescended testes. Ultrasound showed metastasis to be hi... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Varicose veins. POSTOPERATIVE DIAGNOSIS Varicose veins. PROCEDURE PERFORMED 1. Ligation and stripping of left greater saphenous vein to the level of the knee. 2. Stripping of multiple left lower extremity varicose veins. ANESTHESIA General endotracheal. ESTIMATED BLOOD LOSS Approxi... | 38 Surgery |
PREOPERATIVE DIAGNOSES 1. Left spermatocele. 2. Family planning. POSTOPERATIVE DIAGNOSES 1. Left spermatocele. 2. Family planning. PROCEDURE PERFORMED 1. Left spermatocelectomy/epididymectomy. 2. Bilateral partial vasectomy. ANESTHESIA General. ESTIMATED BLOOD LOSS Minimal. SPECIMEN Left-sided spermat... | 39 Urology |
PROCEDURES Total knee replacement. PROCEDURE DESCRIPTION The patient was bought to the operating room and placed in the supine position. After induction of anesthesia a tourniquet was placed on the upper thigh. Sterile prepping and draping proceeded. The tourniquet was inflated to 300 mmHg. A midline incisio... | 27 Orthopedic |
HISTORY OF PRESENT ILLNESS In short the patient is a 55-year-old gentleman with long-standing morbid obesity resistant to nonsurgical methods of weight loss with BMI of 69.7 with comorbidities of hypertension atrial fibrillation hyperlipidemia possible sleep apnea and also osteoarthritis of the lower extremiti... | 2 Bariatrics |
INDICATION FOR STUDY Chest pains CAD and cardiomyopathy. MEDICATIONS Humulin lisinopril furosemide spironolactone omeprazole carvedilol pravastatin aspirin hydrocodone and diazepam. BASELINE EKG Sinus rhythm at 71 beats per minute left anterior fascicular block LVBB. PERSANTINE RESULTS Heart ra... | 33 Radiology |
SUBJECTIVE I am following the patient today for immune thrombocytopenia. Her platelets fell to 10 on 01/09/07 and shortly after learning of that result I increased her prednisone to 60 mg a day. Repeat on 01/16/07 revealed platelets up at 43. No bleeding problems have been noted. I have spoken with her hematolo... | 15 General Medicine |
PROCEDURES Cystourethroscopy and transurethral resection of prostate. COMPLICATIONS None. ADMITTING DIAGNOSIS Difficulty voiding. HISTORY This 67-year old Hispanic male patient was admitted because of enlarged prostate and symptoms of bladder neck obstruction. Physical examination revealed normal heart and lun... | 10 Discharge Summary |
PREOPERATIVE DIAGNOSES 1. Adrenal mass right sided. 2. Umbilical hernia. POSTOPERATIVE DIAGNOSES 1. Adrenal mass right sided. 2. Umbilical hernia. OPERATION PERFORMED Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair. ANESTHESIA General. CLINICAL NOTE This is a 52-year-old inmate ... | 38 Surgery |
SUBJECTIVE The patient complains of backache stomachache and dysuria for the last two days. Fever just started today and cough. She has history of kidney stones less than a year ago and had a urinary tract infection at that time. Her back started hurting last night. PAST MEDICAL HISTORY She denies sexual act... | 5 Consult - History and Phy. |
PREOPERATIVE DIAGNOSIS Left inguinal hernia. POSTOPERATIVE DIAGNOSIS Left direct and indirect inguinal hernia. PROCEDURE PERFORMED Repair of left inguinal hernia with Prolene mesh. ANESTHESIA IV sedation with local. COMPLICATIONS None. DISPOSITION The patient tolerated the procedure well and was transfe... | 38 Surgery |
HISTORY The patient is a 5-1/2-year-old with Down syndrome complex heart disease consisting of atrioventricular septal defect and tetralogy of Fallot with pulmonary atresia discontinuous pulmonary arteries and bilateral superior vena cava with a left cava draining to the coronary sinus and a right aortic arch. As... | 3 Cardiovascular / Pulmonary |
INDICATIONS The patient is a 22-year-old female with past medical history of syncope. The patient is also complaining of dizziness. She was referred here by Dr. X for tilt table. TECHNIQUE Risks and benefits explained to the patient. Consent obtained. She was lying down on her back for 20 minutes and her bloo... | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSIS Nuclear sclerotic cataract right eye. POSTOPERATIVE DIAGNOSIS Nuclear sclerotic cataract right eye. OPERATIVE PROCEDURES Kelman phacoemulsification with posterior chamber intraocular lens right eye. ANESTHESIA Topical. COMPLICATIONS None. INDICATION This is a 40-year-old male... | 26 Ophthalmology |
PREOPERATIVE DIAGNOSIS Coronary occlusive disease. POSTOPERATIVE DIAGNOSIS Coronary occlusive disease. OPERATION PROCEDURE Coronary bypass graft x2 utilizing left internal mammary artery the left anterior descending reverse autogenous reverse autogenous saphenous vein graft to the obtuse marginal. Total car... | 3 Cardiovascular / Pulmonary |
Chief Complaint Abdominal pain nausea vomiting fever altered mental status. History of Present Illness 55 yo WM with reactive airways disease allergic rhinitis who was in his usual state of health until he underwent a dental extraction with administration of cephalexin 1 week prior to admission. Approximately ... | 5 Consult - History and Phy. |
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... | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSIS Ageing face. POSTOPERATIVE DIAGNOSIS Ageing face. OPERATIVE PROCEDURE 1. Cervical facial rhytidectomy. 2. Quadrilateral blepharoplasty. 3. Autologous fat injection to the upper lip. OPERATIONS PERFORMED 1. Cervical facial rhytidectomy. 2. Quadrilateral blepharoplasty. 3. Autologous ... | 26 Ophthalmology |
PREOPERATIVE DIAGNOSIS Varicose veins. POSTOPERATIVE DIAGNOSIS Varicose veins. PROCEDURE PERFORMED 1. Ligation and stripping of left greater saphenous vein to the level of the knee. 2. Stripping of multiple left lower extremity varicose veins. ANESTHESIA General endotracheal. ESTIMATED BLOOD LOSS Approxi... | 3 Cardiovascular / Pulmonary |
ADMITTING DIAGNOSES 1. Fever. 2. Otitis media. 3. Possible sepsis. HISTORY OF PRESENT ILLNESS The patient is a 10-month-old male who was seen in the office 1 day prior to admission. He has had a 2-day history of fever that has gone up to as high as 103.6 degrees F. He has also had intermittent cough nasal cong... | 10 Discharge Summary |
IDENTIFYING DATA The patient is a 36-year-old Caucasian male. CHIEF COMPLAINT The patient relates that he originally came to this facility because of failure to accomplish task difficulty saying what he wanted to say and being easily distracted. HISTORY OF PRESENT ILLNESS The patient has been receiving servi... | 32 Psychiatry / Psychology |
ADMITTING DIAGNOSES 1. Fever. 2. Otitis media. 3. Possible sepsis. HISTORY OF PRESENT ILLNESS The patient is a 10-month-old male who was seen in the office 1 day prior to admission. He has had a 2-day history of fever that has gone up to as high as 103.6 degrees F. He has also had intermittent cough nasal cong... | 29 Pediatrics - Neonatal |
SUBJECTIVE This is a followup dietary consultation for hyperlipidemia hypertension and possible metabolic syndrome. The patient reports that she has worked hard for a number of weeks following the meal plan prescribed but felt like she was gaining weight and not losing weight on it. She is not sure that she was... | 9 Diets and Nutritions |
DISCHARGE SUMMARY SUMMARY OF TREATMENT PLANNING Two major problems were identified at the admission of this adolescent 1. | 32 Psychiatry / Psychology |
CHIEF COMPLAINT Increased work of breathing. HISTORY OF PRESENT ILLNESS The patient is a 2-month-old female with a 9-day history of illness. Per mom s report the illness started 9 days ago with a dry cough. The patient was eating normal up until approximately three days ago. Mom was using a vaporizer at night... | 12 Emergency Room Reports |
HISTORY OF PRESENT ILLNESS This is a 77-year-old male who presents with gross hematuria that started this morning. The patient is a difficult historian does have a speech impediment slow to answer questions but daughter was able to answer lot of questions too. He is complaining of no other pain. He denies any... | 39 Urology |
CHIEF COMPLAINT Not gaining weight. HISTORY OF PRESENT ILLNESS The patient is a 1-month-26-day-old African-American female in her normal state of health until today when she was taken to her primary care physician s office to establish care and to follow up on her feeds. The patient appeared to have failure-to-t... | 5 Consult - History and Phy. |
CHIEF COMPLAINT Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain. HISTORY OF PRESENT ILLNESS The patient is a 45-year-old white male who was admitted with acute back pain. The patient reports that he had chronic problem with back pain for approximately 20 years ... | 27 Orthopedic |
FINDINGS There is moderate to severe generalized neuronal loss of the cerebral hemispheres with moderate to severe ventricular enlargement and prominent CSF within the subarachnoid spaces. There is confluent white matter hyperintensity in a bi-hemispherical centrum semiovale distribution extending to the lateral ventr... | 22 Neurology |
PREOPERATIVE DIAGNOSES 1.Stage IV endometriosis with severe pelvic pain. 2.Status post prior left salpingoophorectomy. POSTOPERATIVE DIAGNOSES 1.Stage IV endometriosis with severe pelvic pain. 2.Status post prior left salpingoophorectomy. 3.Severe adhesions. TYPE OF ANESTHESIA General endotracheal tube. TECHNICAL ... | 38 Surgery |
PREOPERATIVE DIAGNOSES Increased intracranial pressure and cerebral edema due to severe brain injury. POSTOPERATIVE DIAGNOSES Increased intracranial pressure and cerebral edema due to severe brain injury. PROCEDURE Burr hole and insertion of external ventricular drain catheter. ANESTHESIA Just bedside sedat... | 38 Surgery |
SUBJECTIVE This is a 56-year-old female who comes in for a dietary consultation for hyperlipidemia hypertension gastroesophageal reflux disease and weight reduction. The patient states that her husband has been diagnosed with high blood cholesterol as well. She wants some support with some dietary recommendation... | 5 Consult - History and Phy. |
Chief Complaint Chronic abdominal pain. History of Present Illness 23-year-old Hispanic male who presented for evaluation of chronic abdominal pain. Patient described the pain as dull achy constant and located at the epigastric area with some radiation to the back. There are also occasional episodes of stabbing e... | 5 Consult - History and Phy. |
PROCEDURE Gastroscopy. PREOPERATIVE DIAGNOSES Dysphagia possible stricture. POSTOPERATIVE DIAGNOSIS Gastroparesis. MEDICATION MAC. DESCRIPTION OF PROCEDURE The Olympus gastroscope was introduced into the hypopharynx and passed carefully through the esophagus stomach and duodenum. The hypopharynx was ... | 38 Surgery |
HISTORY The patient is a 4-month-old who presented with respiratory distress and absent femoral pulses with subsequent evaluation including echocardiogram that demonstrated severe coarctation of the aorta with a peak gradient of 29 mmHg and associated dilated cardiomyopathy with fractional shortening of 16 . A bicu... | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSIS Subglottic stenosis. POSTOPERATIVE DIAGNOSIS Subglottic stenosis. OPERATIVE PROCEDURES Direct laryngoscopy and bronchoscopy. ANESTHESIA General inhalation. DESCRIPTION OF PROCEDURE The patient was taken to the operating room and placed supine on the operative table. General inhala... | 3 Cardiovascular / Pulmonary |
TECHNIQUE Sequential axial CT images were obtained from the base of the brain to the thoracic inlet following the uneventful administration of 100 CC Optiray 320 intravenous contrast. FINDINGS Scans through the base of the brain are unremarkable. The oropharynx and nasopharynx are within normal limits. The airw... | 11 ENT - Otolaryngology |
CHIEF COMPLAINT Increased work of breathing. HISTORY OF PRESENT ILLNESS The patient is a 2-month-old female with a 9-day history of illness. Per mom s report the illness started 9 days ago with a dry cough. The patient was eating normal up until approximately three days ago. Mom was using a vaporizer at night... | 3 Cardiovascular / Pulmonary |
REASON FOR CONSULTATION Mesothelioma. HISTORY OF PRESENT ILLNESS The patient is a 73-year-old pleasant Caucasian male who is known to me from his previous hospitalization. He has also been seen by me in the clinic in the last few weeks. He was admitted on January 18 2008 with recurrent malignant pleural effus... | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSIS Wrist ganglion. POSTOPERATIVE DIAGNOSIS Wrist ganglion. TITLE OF PROCEDURE Excision of dorsal wrist ganglion. PROCEDURE After administering appropriate antibiotics and general anesthesia the upper extremity was prepped and draped in the usual standard fashion. The arm was exsanguina... | 27 Orthopedic |
PREOPERATIVE DIAGNOSIS Right inguinal hernia. POSTOPERATIVE DIAGNOSIS Direct right inguinal hernia. TITLE OF PROCEDURE Marlex repair of right inguinal hernia. ANESTHESIA Spinal. PROCEDURE IN DETAIL The patient was taken to the operative suite placed on the table in the supine position and given a spina... | 38 Surgery |
PROCEDURE PERFORMED Extracapsular cataract extraction with posterior chamber intraocular lens placement by phacoemulsification. ANESTHESIA Peribulbar. COMPLICATIONS None. DESCRIPTION OF PROCEDURE The patient was brought to the operating room after the eye was dilated with topical Mydriacyl and Neo-Synephrin... | 26 Ophthalmology |
EXAM Carotid and cerebral arteriograms. INDICATION Abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery. IMPRESSION 1. Complete occlusion of the left common carotid artery approximately 3 cm distal to its origin. 2. Mild stenosis of the right internal carotid artery measu... | 33 Radiology |
REASON FOR CONSULTATION New-onset seizure. HISTORY OF PRESENT ILLNESS The patient is a 2-1/2-year-old female with a history of known febrile seizures who was placed on Keppra oral solution at 150 mg b.i.d. to help prevent febrile seizures. Although this has been a very successful treatment in terms of her febri... | 29 Pediatrics - Neonatal |
REASON FOR VISIT This is a routine return appointment for this 71-year-old woman with chronic atrial fibrillation. Her chief complaint today is shortness of breath. HISTORY OF PRESENT ILLNESS I last saw her in 09/2008. Since then she has been admitted to ABCD Hospital from 11/05/2008 through 11/08/2008 for a n... | 5 Consult - History and Phy. |
PREOPERATIVE DIAGNOSIS Carpal tunnel syndrome. POSTOPERATIVE DIAGNOSIS Carpal tunnel syndrome. PROCEDURE Endoscopic release of left transverse carpal ligament. ANESTHESIA Monitored anesthesia care with regional anesthesia provided by surgeon. TOURNIQUET TIME 12 minutes. OPERATIVE PROCEDURE IN DETAIL ... | 27 Orthopedic |
PREOPERATIVE DIAGNOSIS Right trigger thumb. POSTOPERATIVE DIAGNOSIS Right trigger thumb. SURGERY Release of A1 pulley CPT code 26055. ANESTHESIA General LMA. TOURNIQUET TIME 9 minutes at 200 torr. FINDINGS The patient was found to have limitations to extension at the IP joint to the right thumb. He ... | 38 Surgery |
GENERAL REVIEW OF SYSTEMS General No fevers chills or sweats. No weight loss or weight gain. Cardiovascular No exertional chest pain orthopnea PND or pedal edema. No palpitations. Neurologic No paresis paresthesias or syncope. Eyes No double vision or blurred vision. Ears No tinnitus or decreased aud... | 15 General Medicine |
NEUROLOGICAL EXAMINATION At present the patient is awake alert and fully oriented. There is no evidence of cognitive or language dysfunction. Cranial nerves Visual fields are full. Funduscopic examination is normal. Extraocular movements full. Pupils equal round react to light. There is no evidence of ny... | 5 Consult - History and Phy. |
SUBJECTIVE The patient returns to the Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema. She was last seen in the clinic in March 2004. Since that time she has been hospitalized for psychiatric problems and now is in a nursing facility. She is very frustrated with her living situation and w... | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSIS Inguinal hernia. POSTOPERATIVE DIAGNOSIS Direct inguinal hernia. PROCEDURE PERFORMED Rutkow direct inguinal herniorrhaphy. ANESTHESIA General endotracheal. DESCRIPTION OF PROCEDURE After informed consent was obtained the patient was brought to the operative suite and placed supine... | 38 Surgery |
CHIEF COMPLAINT AND IDENTIFICATION A is a 23-month-old girl who has a history of reactive airway disease who is being treated on an outpatient basis for pneumonia who presents with cough and fever. HISTORY OF PRESENT ILLNESS The patient is to known to have reactive airway disease and uses Pulmicort daily and alb... | 3 Cardiovascular / Pulmonary |
PROCEDURE Lumbar puncture with moderate sedation. INDICATION The patient is a 2-year 2-month-old little girl who presented to the hospital with severe anemia hemoglobin 5.8 elevated total bilirubin consistent with hemolysis and weak positive direct Coombs test. She was transfused with packed red blood cells. ... | 38 Surgery |
IDENTIFYING DATA Psychosis. HISTORY OF PRESENT ILLNESS The patient is a 28-year-old Samoan female who was her grandmother s caretaker. Her grandmother unfortunately had passed away recently and then the patient had developed erratic behavior. She had lived with her parents and son but parents removed son from ... | 32 Psychiatry / Psychology |
EXAM Screening full-field digital mammogram. HISTORY Screening examination of a 58-year-old female who currently denies complaints. Patient has had diagnosis of right breast cancer in 1984 with subsequent radiation therapy. The patient s sister was also diagnosed with breast cancer at the age of 59. TECHNIQUE ... | 24 Obstetrics / Gynecology |
REASON Right lower quadrant pain. HISTORY OF PRESENT ILLNESS The patient is a pleasant 48-year-old female with an approximately 24-hour history of right lower quadrant pain which she describes as being stabbed with a knife radiating around her side to her right flank. She states that is particularly bad when u... | 14 Gastroenterology |
XYZ D.C. Re ABC Dear Dr. XYZ I had the pleasure of seeing your patient ABC today MM/DD/YYYY in consultation. He is an unfortunate 19-year-old right-handed male who was injured in a motor vehicle accident on MM/DD/YYYY where he was the driver of an automobile which was struck on the front passenger s side. The... | 27 Orthopedic |
ADMITTING DIAGNOSIS Cerebrovascular accident CVA . HISTORY OF PRESENT ILLNESS The patient is a 56-year-old gentleman with a significant past medical history for nasopharyngeal cancer status post radiation therapy to his pharynx and neck in 1991 who presents to the emergency room after awakening at 2 30 a.m. this... | 22 Neurology |
PREOPERATIVE DIAGNOSES 1. Deformity right breast reconstruction. 2. Excess soft tissue anterior abdomen and flank. 3. Lipodystrophy of the abdomen. POSTOPERATIVE DIAGNOSES 1. Deformity right breast reconstruction. 2. Excess soft tissue anterior abdomen and flank. 3. Lipodystrophy of the abdomen. PROCEDURES ... | 2 Bariatrics |
CIRCUMCISION - OLDER PERSON OPERATIVE NOTE The patient was taken to the operating room and placed in the supine position on the operating table. General endotracheal anesthesia was administered. The patient was prepped and draped in the usual sterile fashion. A 4-0 silk suture is used as a stay-stitch of the glan... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Congenital myotonic muscular dystrophy with bilateral planovalgus feet. POSTOPERATIVE DIAGNOSIS Congenital myotonic muscular dystrophy with bilateral planovalgus feet. PROCEDURE Bilateral Crawford subtalar arthrodesis with open Achilles Z-lengthening and bilateral long-leg cast. ANESTHES... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Recurrent anterior dislocating left shoulder. POSTOPERATIVE DIAGNOSIS Recurrent anterior dislocating left shoulder. PROCEDURE PERFORMED Arthroscopic debridement of the left shoulder with attempted arthroscopic Bankart repair followed by open Bankart arthroplasty of the left shoulder. PRO... | 38 Surgery |
PROCEDURE Sleep study. CLINICAL INFORMATION This patient is a 56-year-old gentleman who had symptoms of obstructive sleep apnea with snoring hypertension. The test was done 01/24/06. The patient weighed 191 pounds five feet seven inches tall. SLEEP QUESTIONNAIRE According to the patient s own estimate the pat... | 36 Sleep Medicine |
ADMITTING DIAGNOSES 1. Fever. 2. Otitis media. 3. Possible sepsis. HISTORY OF PRESENT ILLNESS The patient is a 10-month-old male who was seen in the office 1 day prior to admission. He has had a 2-day history of fever that has gone up to as high as 103.6 degrees F. He has also had intermittent cough nasal cong... | 11 ENT - Otolaryngology |
DESCRIPTION OF PROCEDURE After appropriate operative consent was obtained the patient was brought supine to the operating room and placed on the operating room table. After intravenous sedation was administered a retrobulbar block consisting of 2 Xylocaine with 0.75 Marcaine and Wydase was administered to the rig... | 38 Surgery |
HISTORY The patient is a 4-month-old who presented today with supraventricular tachycardia and persistent cyanosis. The patient is a product of a term pregnancy that was uncomplicated and no perinatal issues are raised. Parents however did note the patient to be quite dusky since the time of her birth however ... | 29 Pediatrics - Neonatal |
CERVICAL SELECTIVE NERVE ROOT BLOCK PREPROCEDURE PREPARATION After being explained the risks and benefits of the procedure the patient signed the standard informed consent form. The patient was placed in the prone position and standard ASA monitors applied. Intravenous access was established and IV sedation was u... | 28 Pain Management |
EXAM MRI of the brain without contrast. HISTORY Daily headaches for 6 months in a 57-year-old. TECHNIQUE Noncontrast axial and sagittal images were acquired through the brain in varying degrees of fat and water weighting. FINDINGS The brain is normal in signal intensity and morphology for age. There are no... | 33 Radiology |
PREOPERATIVE DIAGNOSIS T11 compression fracture with intractable pain. POSTOPERATIVE DIAGNOSIS T11 compression fracture with intractable pain. OPERATION PERFORMED Unilateral transpedicular T11 vertebroplasty. ANESTHESIA Local with IV sedation. COMPLICATIONS None. SUMMARY The patient in the operating r... | 27 Orthopedic |
ADMITTING DIAGNOSIS Trauma/ATV accident resulting in left open humerus fracture. DISCHARGE DIAGNOSIS Trauma/ATV accident resulting in left open humerus fracture. SECONDARY DIAGNOSIS None. HISTORY OF PRESENT ILLNESS For complete details please see dictated history and physical by Dr. X dated July 23 2008. ... | 27 Orthopedic |
CHIEF COMPLAINT Questionable foreign body right nose. Belly and back pain. SUBJECTIVE Mr. ABC is a 2-year-old boy who is brought in by parents stating that the child keeps complaining of belly and back pain. This does not seem to be slowing him down. They have not noticed any change in his urine or bowels... | 15 General Medicine |
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... | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSIS Symptomatic disk herniation C7-T1. FINAL DIAGNOSIS Symptomatic disk herniation C7-T1. PROCEDURES PERFORMED 1. Anterior cervical discectomy with decompression of spinal cord C7-T1. 2. Anterior cervical fusion C7-T1. 3. Anterior cervical instrumentation anterior C7-T1. 4. Insertion of... | 23 Neurosurgery |
PREPROCEDURE DIAGNOSIS Abdominal pain diarrhea and fever. POSTPROCEDURE DIAGNOSIS Pending pathology. PROCEDURES PERFORMED Colonoscopy with multiple biopsies including terminal ileum cecum hepatic flexure and sigmoid colon. | 38 Surgery |
REASON FOR VISIT Overactive bladder with microscopic hematuria. HISTORY OF PRESENT ILLNESS The patient is a 56-year-old noted to have microscopic hematuria with overactive bladder. Her cystoscopy performed was unremarkable. She continues to have some episodes of frequency and urgency mostly with episodes during... | 39 Urology |
PREOPERATIVE DIAGNOSIS Right hip osteoarthritis. POSTOPERATIVE DIAGNOSIS Right hip osteoarthritis. PROCEDURES PERFORMED Total hip replacement on the right side using the following components 1. Zimmer trilogy acetabular system 10-degree elevated rim located at the 12 o clock position. 2. Trabecular metal mo... | 38 Surgery |
EARS NOSE MOUTH AND THROAT EARS/NOSE The auricles are normal to palpation and inspection without any surrounding lymphadenitis. There are no signs of acute trauma. The nose is normal to palpation and inspection externally without evidence of acute trauma. Otoscopic examination of the auditory canals and tympani... | 25 Office Notes |
EXAM Bilateral diagnostic mammogram and right breast ultrasound. History of palpable abnormality at 10 o clock in the right breast. Family history of a sister with breast cancer at age 43. TECHNIQUE CC and MLO views of both breasts were obtained. Spot compression views of the palpable area were also obtained. ... | 33 Radiology |
DATE OF ADMISSION MM/DD/YYYY. DATE OF DISCHARGE MM/DD/YYYY. ADMITTING DIAGNOSIS Peritoneal carcinomatosis from appendiceal primary. DISCHARGE DIAGNOSIS Peritoneal carcinomatosis from appendiceal primary. SECONDARY DIAGNOSIS Diarrhea. ATTENDING PHYSICIAN AB CD M.D. SERVICE General surgery C Surger... | 10 Discharge Summary |
PREOPERATIVE DIAGNOSIS Low back pain. POSTOPERATIVE DIAGNOSIS Low back pain. PROCEDURE PERFORMED 1. Lumbar discogram L2-3. 2. Lumbar discogram L3-4. 3. Lumbar discogram L4-5. 4. Lumbar discogram L5-S1. ANESTHESIA IV sedation. PROCEDURE IN DETAIL The patient was brought to the Radiology Suite and placed... | 22 Neurology |
PREOPERATIVE DIAGNOSIS Syncopal episodes with injury. See electrophysiology consultation. POSTOPERATIVE DIAGNOSES 1. Normal electrophysiologic studies. 2. No inducible arrhythmia. 3. Procainamide infusion negative for Brugada syndrome. PROCEDURES 1. Comprehensive electrophysiology studies with attempted arrhy... | 3 Cardiovascular / Pulmonary |
HISTORY OF PRESENT ILLNESS A 14-day-old was seen by private doctor because of blister. On Friday she was noted to have a small blister near her umbilicus. They went to their doctor on Saturday culture was drawn. It came back today growing MRSA. She has been doing well. They put her on bacitracin ointment nea... | 8 Dermatology |
PREOPERATIVE DIAGNOSES 1. Ta grade III TIS transitional cell carcinoma of the urinary bladder. 2. Lower tract outlet obstructive symptoms secondary to benign prostatic hypertrophy. 3. Inability to pass a Foley catheter x3. POSTOPERATIVE DIAGNOSES 1. Ta grade III TIS transitional cell carcinoma of the urinary blad... | 39 Urology |
PREOPERATIVE DIAGNOSIS Carcinoma of the left upper lobe. PROCEDURES PERFORMED 1. Bronchoscopy with aspiration. 2. Left upper lobectomy. PROCEDURE DETAILS With patient in supine position under general anesthesia with endotracheal tube in place the flexible bronchoscope was then placed down through the endotrac... | 3 Cardiovascular / Pulmonary |
DIAGNOSIS Multiparous female desires permanent sterilization. NAME OF OPERATION Laparoscopic bilateral tubal ligation with Falope rings. ANESTHESIA General ET tube. COMPLICATIONS None. FINDINGS Normal female anatomy except for mild clitoromegaly and a posterior uterine fibroid. PROCEDURE The patient... | 24 Obstetrics / Gynecology |
PREOPERATIVE DIAGNOSIS Neurologic devastation secondary to nonaccidental trauma. POSTOPERATIVE DIAGNOSES Neurologic devastation secondary to nonaccidental trauma. PROCEDURE Laparoscopic G-tube placement 14-French 1.2-cm MIC-Key . INDICATIONS FOR PROCEDURE This patient is a 5-month-old baby boy who presente... | 38 Surgery |
PREOPERATIVE DIAGNOSES Dysphagia and esophageal spasm. POSTOPERATIVE DIAGNOSES Esophagitis and esophageal stricture. PROCEDURE Gastroscopy. MEDICATIONS MAC. DESCRIPTION OF PROCEDURE The Olympus gastroscope was introduced into the oropharynx and passed carefully through the esophagus stomach and duodenu... | 14 Gastroenterology |
PREOPERATIVE DIAGNOSES Prior history of anemia abdominal bloating. POSTOPERATIVE DIAGNOSIS External hemorrhoids otherwise unremarkable colonoscopy. PREMEDICATIONS Versed 5 mg Demerol 50 mg IV. REPORT OF PROCEDURE Digital rectal exam revealed external hemorrhoids. The colonoscope was inserted into the re... | 38 Surgery |
HISTORY OF PRESENT ILLNESS This is a 12-year-old male who was admitted to the Emergency Department who fell off his bicycle not wearing a helmet a few hours ago. There was loss of consciousness. The patient complains of neck pain. CHRONIC/INACTIVE CONDITIONS None. PERSONAL/FAMILY/SOCIAL HISTORY/ILLNESSES ... | 12 Emergency Room Reports |
CHIEF REASON FOR CONSULTATION Evaluate exercise-induced chest pain palpitations dizzy spells shortness of breath and abnormal EKG. HISTORY OF PRESENT ILLNESS This 72-year-old female had a spell of palpitations that lasted for about five to ten minutes. During this time patient felt extremely short of breath... | 3 Cardiovascular / Pulmonary |
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