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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... | 38 Surgery |
CHIEF COMPLAINT Newly diagnosed T-cell lymphoma. HISTORY OF PRESENT ILLNESS The patient is a very pleasant 40-year-old gentleman who reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago. He was originally treated with antibiotics as a possible tooth abscess... | 16 Hematology - Oncology |
PROBLEMS LIST 1. Type 1 diabetes mellitus insulin pump requiring. 2. Chronic kidney disease stage III. 3. Sweet syndrome. 4. Hypertension. 5. Dyslipidemia. 6. Osteoporosis. 7. Anemia. 8. A 25-hydroxy-vitamin D deficiency. 9. Peripheral neuropathy manifested by insensate feet. 10. Hypothyroidism. 11. Diabe... | 35 SOAP / Chart / Progress Notes |
PROCEDURE IN DETAIL After written consent was obtained from the patient the patient was brought back into the operating room and identified. The patient was placed on the operating room table in supine position and given anesthetic. Once adequate anesthesia had been achieved a careful examination of the shoulder ... | 27 Orthopedic |
CLINICAL INDICATIONS MRSA bacteremia rule out endocarditis. The patient has aortic stenosis. DESCRIPTION OF PROCEDURE The transesophageal echocardiogram was performed after getting verbal and a written consent signed. Then a multiplane TEE probe was introduced into the upper esophagus mid esophagus lower eso... | 33 Radiology |
PREOPERATIVE DIAGNOSES 1. Bilateral bronchopneumonia. 2. Empyema of the chest left. POSTOPERATIVE DIAGNOSES 1. Bilateral bronchopneumonia. 2. Empyema of the chest left. PROCEDURES 1. Diagnostic bronchoscopy. 2. Limited left thoracotomy with partial pulmonary decortication and insertion of chest tubes x2. DESCRI... | 38 Surgery |
HISTORY OF PRESENT ILLNESS A 67-year-old male with COPD and history of bronchospasm who presents with a 3-day history of increased cough respiratory secretions wheezings and shortness of breath. He was seen by me in the office on the day of admission and noted to be dyspneic with audible wheezing and he was adm... | 3 Cardiovascular / Pulmonary |
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... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis. POSTOPERATIVE DIAGNOSIS Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis. SURGICAL PROCEDURE PERFORMED Tonsillectomy and adenoidectomy. ANESTHESIA General endotracheal technique. SURGIC... | 11 ENT - Otolaryngology |
CHIEF COMPLAINT Left breast cancer. HISTORY The patient is a 57-year-old female who I initially saw in the office on 12/27/07 as a referral from the Tomball Breast Center. On 12/21/07 the patient underwent image-guided needle core biopsy of a 1.5 cm lesion at the 7 o clock position of the left breast inferom... | 16 Hematology - Oncology |
PREOPERATIVE DIAGNOSIS Right buccal space infection and abscess tooth #T. POSTOPERATIVE DIAGNOSIS Right buccal space infection and abscess tooth #T. PROCEDURE Extraction of tooth #T and incision and drainage I D of right buccal space infection. ANESTHESIA General oral endotracheal tube. COMPLICATIONS ... | 7 Dentistry |
HISTORY OF PRESENT ILLNESS The patient is a 55-year-old Hispanic male who was seen initially in the office February 15 2006 with epigastric and right upper quadrant abdominal pain nausea dizziness and bloating. The patient at that time stated that he had established diagnosis of liver cirrhosis. Since the las... | 14 Gastroenterology |
HISTORY OF PRESENT ILLNESS The patient is a 50-year-old African American female with past medical history significant for hypertension and endstage renal disease on hemodialysis secondary to endstage renal disease last hemodialysis was on June 22 2007. The patient presents with no complaints for cadaveric renal ... | 21 Nephrology |
HISTORY The patient is a 19-year-old male who was involved in a fight approximately an hour prior to his ED presentation. He punched a guy few times on the face might be the mouth and then punched a drinking glass breaking it and lacerating his right hand. He has three lacerations on his right hand. His wound w... | 15 General Medicine |
ADMISSION DIAGNOSIS Symptomatic thyroid goiter. DISCHARGE DIAGNOSIS Symptomatic thyroid goiter. PROCEDURE PERFORMED DURING THIS HOSPITALIZATION Total thyroidectomy. INDICATIONS FOR THE SURGERY Briefly the patient is a 71-year-old female referred with increasingly symptomatic large nodular thyroid goiter. ... | 15 General Medicine |
HISTORY OF PRESENT ILLNESS The patient is a 45-year-old male complaining of abdominal pain. The patient also has a long-standing history of diabetes which is treated with Micronase daily. PAST MEDICAL HISTORY There is no significant past medical history noted today. PHYSICAL EXAMINATION HEENT Patient denies e... | 5 Consult - History and Phy. |
PROCEDURES Esophagogastroduodenoscopy and colonoscopy with biopsy and polypectomy. REASON FOR PROCEDURE Child with abdominal pain and rectal bleeding. Rule out inflammatory bowel disease allergic enterocolitis rectal polyps and rectal vascular malformations. CONSENT History and physical examination was per... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Cervical carcinoma in situ. POSTOPERATIVE DIAGNOSIS Cervical carcinoma in situ. OPERATION PERFORMED Cervical cone biopsy dilatation curettage. SPECIMENS Cone biopsy endocervical curettings endometrial curettings. INDICATIONS FOR PROCEDURE The patient recently presented with a ... | 38 Surgery |
HISTORY OF PRESENT ILLNESS Mr. ABC is a 60-year-old gentleman who had a markedly abnormal stress test earlier today in my office with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only. He required 3 sublingual nitro... | 25 Office Notes |
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... | 27 Orthopedic |
PREOPERATIVE DIAGNOSES 1. Squamous cell carcinoma of the head and neck. 2. Ethanol and alcohol abuse. POSTOPERATIVE DIAGNOSES 1. Squamous cell carcinoma of the head and neck. 2. Ethanol and alcohol abuse. PROCEDURE 1. Failed percutaneous endoscopic gastrostomy tube placement. 2. Open Stamm gastrotomy tube. 3. Lysis ... | 14 Gastroenterology |
HISTORY OF PRESENT ILLNESS This is a 70-year-old female with a past medical history of chronic kidney disease stage 4 history of diabetes mellitus diabetic nephropathy peripheral vascular disease status post recent PTA of right leg admitted to the hospital because of swelling of the right hand and left foot. ... | 15 General Medicine |
PREOPERATIVE DIAGNOSIS Tailor s bunion right foot. POSTOPERATIVE DIAGNOSIS Tailor s bunion right foot. PROCEDURE Closing wedge osteotomy fifth metatarsal with internal screw fixation right foot. ANESTHESIA Local infiltrate with IV sedation. INDICATIONS FOR SURGERY The patient has had a longstanding h... | 27 Orthopedic |
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... | 38 Surgery |
SUBJECTIVE The patient is a 60-year-old female who complained of coughing during meals. Her outpatient evaluation revealed a mild-to-moderate cognitive linguistic deficit which was completed approximately 2 months ago. The patient had a history of hypertension and TIA/stroke. The patient denied history of heart... | 5 Consult - History and Phy. |
CC Orthostatic lightheadedness. HX This 76 y/o male complained of several months of generalized weakness and malaise and a two week history of progressively worsening orthostatic dizziness. The dizziness worsened when moving into upright positions. In addition he complained of intermittent throbbing holocranial h... | 22 Neurology |
PREOPERATIVE DIAGNOSIS Morton s neuroma third interspace left foot. POSTOPERATIVE DIAGNOSIS Morton s neuroma third interspace left foot. OPERATION PERFORMED Excision of neuroma third interspace left foot. ANESTHESIA General local was confirmed by surgeon . HEMOSTASIS Ankle pneumatic tourniquet 225... | 38 Surgery |
PHYSICAL EXAMINATION This 71-year-old man went to his primary care physician for a routine physical. His only complaints were nocturia times two and a gradual slowing down feeling. The physical examination on 1/29 was within normal limits except for the digital rectal exam which revealed an asymmetric prostate g... | 35 SOAP / Chart / Progress Notes |
CHIEF COMPLAINT Falls at home. HISTORY OF PRESENT ILLNESS The patient is an 82-year-old female who fell at home and presented to the emergency room with increased anxiety. Family members who are present state that the patient had been increasingly anxious and freely admitted that she was depressed at home. They... | 22 Neurology |
PREOPERATIVE DIAGNOSES 1. Right pelvic pain. 2. Right ovarian mass. POSTOPERATIVE DIAGNOSES 1. Right pelvic pain. 2. Right ovarian mass. 3. 8 cm x 10 cm right ovarian cyst with ovarian torsion. PROCEDURE PERFORMED Laparoscopic right salpingooophorectomy. ANESTHESIA General with endotracheal tube. COMPLICAT... | 24 Obstetrics / Gynecology |
PREOPERATIVE DIAGNOSIS Invasive carcinoma of left breast. POSTOPERATIVE DIAGNOSIS Invasive carcinoma of left breast. OPERATION PERFORMED Left modified radical mastectomy. ANESTHESIA General endotracheal. INDICATION FOR THE PROCEDURE The patient is a 52-year-old female who recently underwent a left breast... | 24 Obstetrics / Gynecology |
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... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Chronic hypertrophic adenotonsillitis. POSTOPERATIVE DIAGNOSIS Chronic hypertrophic adenotonsillitis. OPERATIVE PROCEDURE Adenotonsillectomy primary patient under age 12. ANESTHESIA General endotracheal anesthesia. PROCEDURE IN DETAIL This patient was brought from the holding are... | 11 ENT - Otolaryngology |
PREOPERATIVE DIAGNOSIS Left testicular torsion possibly detorsion. POSTOPERATIVE DIAGNOSIS Left testicular torsion possibly detorsion. PROCEDURE Left scrotal exploration with detorsion. Already de-torsed bilateral testes fixation and bilateral appendix testes cautery. ANESTHETIC A 0.25 Marcaine local w... | 38 Surgery |
PREOPERATIVE DIAGNOSES Malnutrition and dysphagia. POSTOPERATIVE DIAGNOSES Malnutrition and dysphagia with two antral polyps and large hiatal hernia. PROCEDURES Esophagogastroduodenoscopy with biopsy of one of the polyps and percutaneous endoscopic gastrostomy tube placement. ANESTHESIA IV sedation 1 Xylo... | 14 Gastroenterology |
PREOPERATIVE DIAGNOSES 1. Congenital chylous ascites and chylothorax. 2. Rule out infradiaphragmatic lymphatic leak. POSTOPERATIVE DIAGNOSES Diffuse intestinal and mesenteric lymphangiectasia. ANESTHESIA General. INDICATION The patient is an unfortunate 6-month-old baby boy who has been hospitalized most... | 14 Gastroenterology |
PRELIMINARY DIAGNOSES 1. Contusion of the frontal lobe of the brain. 2. Closed head injury and history of fall. 3. Headache probably secondary to contusion. FINAL DIAGNOSES 1. Contusion of the orbital surface of the frontal lobes bilaterally. 2. Closed head injury. 3. History of fall. COURSE IN THE HOSPITAL ... | 22 Neurology |
PRESENT ILLNESS The patient is a very pleasant 69-year-old Caucasian male whom we are asked to see primarily because of a family history of colon cancer but the patient also has rectal bleeding on a weekly basis and also heartburn once every 1 or 2 weeks. The patient states that he had his first colonoscopy 6 year... | 5 Consult - History and Phy. |
PROCEDURE PERFORMED 1. Placement of a subclavian single-lumen tunneled Hickman central venous catheter. 2. Surgeon-interpreted fluoroscopy. OPERATION IN DETAIL After obtaining informed consent from the patient including a thorough explanation of the risks and benefits of the aforementioned procedure the patient ... | 38 Surgery |
CHIEF COMPLAINT Non-healing surgical wound to the left posterior thigh. HISTORY OF PRESENT ILLNESS This is a 49-year-old white male who sustained a traumatic injury to his left posterior thighthis past year while in ABCD. He sustained an injury from the patellar from a boat while in the water. He was air lifted... | 5 Consult - History and Phy. |
PREOPERATIVE DIAGNOSIS Visually significant posterior capsule opacity right eye. POSTOPERATIVE DIAGNOSIS Visually significant posterior capsule opacity right eye. OPERATIVE PROCEDURES YAG laser posterior capsulotomy right eye. ANESTHESIA Topical anesthesia using tetracaine ophthalmic drops. INDICATIONS F... | 26 Ophthalmology |
PREOPERATIVE DIAGNOSIS Subcapital left hip fracture. POSTOPERATIVE DIAGNOSIS Subcapital left hip fracture. PROCEDURE PERFORMED Austin-Moore bipolar hemiarthroplasty left hip. ANESTHESIA Spinal. COMPLICATIONS None. ESTIMATED BLOOD LOSS Less than 100 cc. HISTORY The patient is an 86-year-old female ... | 38 Surgery |
HISTORY OF PRESENT ILLNESS The patient is a 57-year-old female being seen today for evaluation of pain and symptoms related to a recurrent bunion deformity in bilateral feet right greater than left. The patient states she is having increasing symptoms of pain and discomfort associated with recurrence of bunion def... | 27 Orthopedic |
SINGLE CHAMBER PACEMAKER IMPLANTATION PREOPERATIVE DIAGNOSIS Mobitz type II block with AV dissociation and syncope. POSTOPERATIVE DIAGNOSIS Mobitz type II block status post single chamber pacemaker implantation Boston Scientific Altrua 60 serial number 123456. PROCEDURES 1. Left subclavian access under fluor... | 3 Cardiovascular / Pulmonary |
PROCEDURE Caudal epidural steroid injection without fluoroscopy. ANESTHESIA Local sedation. VITAL SIGNS See nurse s records. PROCEDURE DETAILS INT was placed. The patient was in the prone position. The back was prepped with Betadine. Lidocaine 1.5 was used to make a skin wheal over the sacral hiatus. A... | 28 Pain Management |
PREOPERATIVE DIAGNOSIS Hemangioma nasal tip. POSTOPERATIVE DIAGNOSIS Hemangioma nasal tip. PROCEDURE PERFORMED 1. Debulking of hemangioma of the nasal tip through an open rhinoplasty approach. 2. Rhinoplasty. ESTIMATED BLOOD LOSS Minimal. FINDINGS Large hemangioma involving the midline of the columel... | 38 Surgery |
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 ... | 27 Orthopedic |
PREOPERATIVE DIAGNOSES 1. Fullness in right base of the tongue. 2. Chronic right ear otalgia. POSTOPERATIVE DIAGNOSIS Pending pathology. PROCEDURE PERFORMED Microsuspension direct laryngoscopy with biopsy. ANESTHESIA General. INDICATION This is a 50-year-old female who presents to the office with a chief... | 38 Surgery |
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