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COMPARISON STUDIES None. MEDICATION Lopressor 5 mg IV. HEART RATE AFTER MEDICATION 64bpm EXAM TECHNIQUE Tomographic images were obtained of the heart and chest with a 64 detector row scanner using slice thicknesses of less than 1 mm. 80cc’s of Isovue 370 was injected in the right arm. TECHNICAL QUALITY Exami... | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSES 1. Hallux rigidus left foot. 2. Elevated first metatarsal left foot. POSTOPERATIVE DIAGNOSES 1. Hallux rigidus left foot. 2. Elevated first metatarsal left foot. PROCEDURE PERFORMED 1. Austin/Youngswick bunionectomy with Biopro implant. 2. Screw fixation left foot. HISTORY This 5... | 38 Surgery |
CHIEF COMPLAINT Cough and abdominal pain for two days. HISTORY OF PRESENT ILLNESS This is a 76-year-old female who has a history of previous pneumonia also hypertension and macular degeneration who presents with generalized body aches cough nausea and right-sided abdominal pain for two days. The patient sta... | 15 General Medicine |
ADMITTING DIAGNOSIS Aftercare of multiple trauma from an motor vehicle accident. DISCHARGE DIAGNOSES 1. Aftercare following surgery for injury and trauma. 2. Decubitus ulcer lower back. 3. Alcohol induced persisting dementia. 4. Anemia. 5. Hypokalemia. 6. Aftercare healing traumatic fracture of the lower arm... | 15 General Medicine |
PROCEDURES 1. Right frontal craniotomy with resection of right medial frontal brain tumor. 2. Stereotactic image-guided neuronavigation for resection of tumor. 3. Microdissection and micro-magnification for resection of brain tumor. ANESTHESIA General via endotracheal tube. INDICATIONS FOR THE PROCEDURE The p... | 23 Neurosurgery |
HISTORY The patient is a 51-year-old female that was seen in consultation at the request of Dr. X on 06/04/2008 regarding chronic nasal congestion difficulty with swallowing and hearing loss. The patient reports that she has been having history of recurrent sinus infection averages about three times per year. D... | 11 ENT - Otolaryngology |
PREOPERATIVE DIAGNOSIS Iron deficiency anemia. POSTOPERATIVE DIAGNOSIS Diverticulosis. PROCEDURE Colonoscopy. MEDICATIONS MAC. PROCEDURE The Olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve and th... | 38 Surgery |
REASON FOR ADMISSION Rectal bleeding. HISTORY OF PRESENT ILLNESS The patient is a very pleasant 68-year-old male with history of bilateral hernia repair who presents with 3 weeks of diarrhea and 1 week of rectal bleeding. He states that he had some stomach discomfort in the last 4 weeks. He has had some physic... | 14 Gastroenterology |
S - An 83-year-old diabetic female presents today stating that she would like diabetic foot care. O - On examination the lateral aspect of her left great toenail is deeply ingrown. Her toenails are thick and opaque. Vibratory sensation appears to be intact. Dorsal pedal pulses are 1/4. There is no hair growth se... | 31 Podiatry |
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... | 5 Consult - History and Phy. |
OPERATIVE PROCEDURE 1. Thromboendarterectomy of right common external and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure. 2. Coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending and reverse autogenous saphenous vein graft to th... | 38 Surgery |
PREOPERATIVE DIAGNOSES 1. Recurrent spinal stenosis at L3-L4 L4-L5 and L5-S1. 2. Spondylolisthesis which is unstable at L4-L5. 3. Recurrent herniated nucleus pulposus at L4-L5 bilaterally. POSTOPERATIVE DIAGNOSES 1. Recurrent spinal stenosis at L3-L4 L4-L5 and L5-S1. 2. Spondylolisthesis which is unstable ... | 27 Orthopedic |
Please accept this letter of follow up on patient xxx xxx. He is now three months out from a left carotid angioplasty and stent placement. He was a part of a CapSure trial. He has done quite well with no neurologic or cardiac event in the three months of follow up. He had a follow-up ultrasound performed today that sh... | 20 Letters |
PREOPERATIVE DIAGNOSES Multiparity requested sterilization and upper abdominal wall skin mass. POSTOPERATIVE DIAGNOSES Multiparity requested sterilization and upper abdominal wall skin mass. OPERATION PERFORMED Postpartum tubal ligation and removal of upper abdominal skin wall mass. ESTIMATED BLOOD LOSS L... | 24 Obstetrics / Gynecology |
REASON FOR CONSULTATION New murmur with bacteremia. HISTORY OF PRESENT ILLNESS The patient is an 84-year-old female admitted with jaundice and a pancreatic mass who was noted to have a new murmur bacteremia and fever. The patient states that apart from the fever she was having no other symptoms and denies any... | 3 Cardiovascular / Pulmonary |
FLEXIBLE BRONCHOSCOPY The flexible bronchoscopy is performed under conscious sedation in the Pediatric Intensive Care Unit. I explained to the parents that the possible risks include irritation of the nasal mucosa which can be associated with some bleeding risk of contamination of the lower airways by passage of t... | 29 Pediatrics - Neonatal |
SUBJECTIVE This is a 6-year-old male who comes in rechecking his ADHD medicines. We placed him on Adderall first time he has been on a stimulant medication last month. Mother said the next day he had a wonderful improvement and he has been doing very well with the medicine. She has two concerns. It seems like... | 35 SOAP / Chart / Progress Notes |
CHIEF COMPLAINT Sinus problems. SINUSITIS HISTORY The problem began 2 weeks ago and is constant. Symptoms include postnasal drainage sore throat facial pain coughing headaches and congestion. Additional symptoms include snoring nasal burning and teeth pain. The symptoms are characterized as moderate to severe.... | 11 ENT - Otolaryngology |
REASON FOR CONSULTATION Post-surgical medical management. PROCEDURE DONE Right total knee replacement. MEDICAL HISTORY 1. Arthritis of the right knee. 2. Hypertension. PAST SURGICAL HISTORY Hysterectomy Cesarean section left hip arthroplasty and breast biopsy. MEDICATIONS Hyzaar 12.5 mg p.o. daily Fe... | 5 Consult - History and Phy. |
HISTORY OF PRESENT ILLNESS The patient is a 22-year-old male who sustained a mandible fracture and was seen in the emergency department at Hospital. He was seen in my office today and scheduled for surgery today for closed reduction of the mandible fractures. PREOPERATIVE DIAGNOSES Left angle and right body mand... | 38 Surgery |
CC Confusion. HX A 71 y/o RHM with a history of two strokes one in 11/90 and one in 11/91 had been in a stable state of health until 12/31/92 when he became confused and displayed left-sided weakness and difficulty speaking. The symptoms resolved within hours and recurred the following day. He was then evalu... | 33 Radiology |
CHIEF COMPLAINT Decreased ability to perform daily living activities secondary to right knee surgery. HISTORY OF PRESENT ILLNESS The patient is a 61-year-old white female status post right total knee replacement secondary to degenerative joint disease performed by Dr. A at ABCD Hospital on 08/21/2007. The patien... | 10 Discharge Summary |
HISTORY A is a young lady who came here with a diagnosis of seizure disorder and history of Henoch-Schonlein purpura with persistent proteinuria. A was worked up for collagen vascular diseases and is here to find out the results. Also was recommended to take 7.5 mg of Mobic every day for her joint pains. She sta... | 34 Rheumatology |
PREOPERATIVE DIAGNOSES 1. Prostatism. 2. Bladder calculus. OPERATION Holmium laser cystolithalopaxy. POSTOPERATIVE DIAGNOSES 1. Prostatism. 2. Bladder calculus. ANESTHESIA General. INDICATIONS This is a 62-year-old male diabetic and urinary retention with apparent neurogenic bladder and intermittent self... | 39 Urology |
REPORT The electroencephalogram shows background activity at about 9-10 cycle/second bilaterally. Little activity in the beta range is noted. Waves of 4-7 cycle/second of low amplitude were occasionally noted. Abundant movements and technical artifacts are noted throughout this tracing. Hyperventilation was not ... | 22 Neurology |
PREOPERATIVE DIAGNOSES 1. Herniated nucleus pulposus C5-C6. 2. Herniated nucleus pulposus C6-C7. POSTOPERATIVE DIAGNOSES 1. Herniated nucleus pulposus C5-C6. 2. Herniated nucleus pulposus C6-C7. PROCEDURE PERFORMED 1. Anterior cervical decompression C5-C6. 2. Anterior cervical decompression C6-C7. 3. Anter... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Voluntary sterility. POSTOPERATIVE DIAGNOSIS Voluntary sterility. OPERATIVE PROCEDURE Bilateral vasectomy. ANESTHESIA Local. INDICATIONS FOR PROCEDURE A gentleman who is here today requesting voluntary sterility. Options were discussed for voluntary sterility and he has elected to... | 38 Surgery |
REVIEW OF SYSTEMS CONSTITUTIONAL Patient denies fevers chills sweats and weight changes. EYES Patient denies any visual symptoms. EARS NOSE AND THROAT No difficulties with hearing. No symptoms of rhinitis or sore throat. CARDIOVASCULAR Patient denies chest pains palpitations orthopnea and paroxysmal noc... | 25 Office Notes |
PREOPERATIVE DIAGNOSES Bilateral inguinal hernias with bilateral hydroceles after right inguinal hernia repair cerebral palsy asthma seizure disorder developmental delay and gastroesophageal reflux disease. POSTOPERATIVE DIAGNOSES Left inguinal hernia bilateral hydroceles and right torsed appendix testis. ... | 39 Urology |
PROCEDURES 1. Release of ventral chordee. 2. Circumcision. 3. Repair of partial duplication of urethral meatus. INDICATIONS The patient is an 11-month-old baby boy who presented for evaluation of a duplicated urethral meatus as well as ventral chordee and dorsal prepuce hooding. He is here electively for surgic... | 38 Surgery |
TESTICULAR ULTRASOUND REASON FOR EXAM Left testicular swelling for one day. FINDINGS The left testicle is normal in size and attenuation it measures 3.2 x 1.7 x 2.3 cm. The right epididymis measures up to 9 mm. There is a hydrocele on the right side. Normal flow is seen within the testicle and epididymis on t... | 33 Radiology |
PREOPERATIVE DIAGNOSIS Empyema. POSTOPERATIVE DIAGNOSIS Empyema. PROCEDURE PERFORMED 1. Right thoracotomy total decortication. 2. Intraoperative bronchoscopy. ANESTHESIA General. COMPLICATIONS None. ESTIMATED BLOOD LOSS 300 cc. FLUIDS 2600 cc IV crystalloid. URINE 300 cc intraoperatively. INDIC... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Herniated lumbar disk with intractable back pain. POSTOPERATIVE DIAGNOSIS Herniated lumbar disk with intractable back pain. OPERATION PERFORMED L3-L5 epidural steroid injection with epidural catheter under fluoroscopy. ANESTHESIA Local/IV sedation. COMPLICATIONS None. SUMMARY Th... | 28 Pain Management |
REASON FOR VISIT I have been asked to see this 63-year-old man with a dilated cardiomyopathy by Dr. X at ABCD Hospital. He presents with a chief complaint of heart failure. HISTORY OF PRESENT ILLNESS In retrospect he has had symptoms for the past year of heart failure. He feels in general OK but is stressed... | 3 Cardiovascular / Pulmonary |
ADMISSION DIAGNOSIS Microinvasive carcinoma of the cervix. DISCHARGE DIAGNOSIS Microinvasive carcinoma of the cervix. PROCEDURE PERFORMED Total vaginal hysterectomy. HISTORY OF PRESENT ILLNESS The patient is a 36-year-old white female gravida 7 para 5 last period mid March status post tubal ligation. ... | 24 Obstetrics / Gynecology |
DISCHARGE DIAGNOSES 1. Multiple extensive subcutaneous abscesses right thigh. 2. Massive open wound right thigh status post right excision of multiple subcutaneous abscesses right thigh. PROCEDURES PERFORMED 1. On 03/05/08 by Dr. X was massive debridement of soft tissue right lateral thigh and hip. 2. Soft t... | 15 General Medicine |
REASON FOR VISIT Followup evaluation and management of chronic medical conditions. HISTORY OF PRESENT ILLNESS The patient has been doing quite well since he was last seen. He comes in today with his daughter. He has had no symptoms of CAD or CHF. He had followup with Dr. X and she thought he was doing quite we... | 35 SOAP / Chart / Progress Notes |
PRINCIPAL DIAGNOSIS Mullerian adenosarcoma. HISTORY OF PRESENT ILLNESS The patient is a 56-year-old presenting with a large mass aborted through the cervix. PHYSICAL EXAM CHEST Clear. There is no heart murmur. ABDOMEN Nontender. PELVIC There is a large mass in the vagina. HOSPITAL COURSE The patien... | 10 Discharge Summary |
SUBJECTIVE Mr. Sample Patient returns to the Sample Clinic with the chief complaint of painful right heel. The patient states that the heel has been painful for approximately two weeks it is starts with the first step in the morning and gets worse with activity during the day. The patient states that he is curren... | 31 Podiatry |
CC Weakness. HX This 30 y/o RHM was in good health until 7/93 when he began experiencing RUE weakness and neck pain. He was initially treated by a chiropractor and after an unspecified length of time developed atrophy and contractures of his right hand. He then went to a local neurosurgeon and a cervical spine C... | 22 Neurology |
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... | 38 Surgery |
REASON FOR HOSPITALIZATION Suspicious calcifications upper outer quadrant left breast. HISTORY OF PRESENT ILLNESS The patient is a 78-year-old woman who had undergone routine screening mammography on 06/04/08. That study disclosed the presence of punctate calcifications that were felt to be in a cluster distrib... | 15 General Medicine |
SUBJECTIVE This 32-year-old female comes in again still having not got a primary care physician. She said she was at Dr. XYZ office today for her appointment and they cancelled her appointment because she has not gotten her Project Access insurance into affect. She says that Project Access is trying to find her a... | 35 SOAP / Chart / Progress Notes |
INDICATIONS Ischemic cardiomyopathy status post inferior wall myocardial infarction status post left anterior descending PTCA and stenting. PROCEDURE DONE Adenosine Myoview stress test. STRESS ECG RESULTS The patient was stressed by intravenous adenosine 140 mcg/kg/minute infused over four minutes. The bas... | 33 Radiology |
PREOPERATIVE DIAGNOSES 1. Chronic adenotonsillitis. 2. Ankyloglossia POSTOPERATIVE DIAGNOSES 1. Chronic adenotonsillitis. 2. Ankyloglossia PROCEDURE PERFORMED 1. Adenoidectomy and tonsillectomy. 2. Lingual frenulectomy. ANESTHESIA General endotracheal. FINDINGS/SPECIMEN Tonsil and adenoid tissue. COMPLIC... | 11 ENT - Otolaryngology |
EXAM Cardiac catheterization and coronary intervention report. PROCEDURES 1. Left heart catheterization coronary angiography left ventriculography. 2. PTCA/Endeavor stent proximal LAD. INDICATIONS Acute anterior ST-elevation MI. ACCESS Right femoral artery 6-French. MEDICATIONS 1. IV Valium. 2. IV Ben... | 3 Cardiovascular / Pulmonary |
SUBJECTIVE This 68-year-old man presents to the emergency department for three days of cough claims that he has brought up some green and grayish sputum. He says he does not feel short of breath. He denies any fever or chills. REVIEW OF SYSTEMS HEENT Denies any severe headache or sore throat. CHEST No true p... | 12 Emergency Room Reports |
CHIEF COMPLAINT Abdominal pain. HISTORY OF PRESENT ILLNESS The patient is a 71-year-old female patient of Dr. X. The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent. She was seen 3 to 4 days ago at ABC ER and underwent evalua... | 15 General Medicine |
CC Found unresponsive. HX 39 y/o RHF complained of a severe HA at 2AM 11/4/92. It was unclear whether she had been having HA prior to this. She took an unknown analgesic then vomited then lay down in bed with her husband. When her husband awoke at 8AM he found her unresponsive with stiff straight arms and a ... | 33 Radiology |
HISTORY OF PRESENT ILLNESS The patient is a 41-year-old man with the AIDS complicated with recent cryptococcal infection disseminated MAC and Kaposi s sarcoma. His viral load in July of 2007 was 254 000 and CD4 count was 7. He was recently admitted for debility and possible pneumonia. He was started on antiretro... | 17 Hospice - Palliative Care |
CHIEF COMPLAINT 1/1 This 59 year old female presents today complaining that her toenails are discolored thickened and painful. Duration Condition has existed for 6 months. Severity Severity of condition is worsening. ALLERGIES Patient admits allergies to dairy products penicillin. MEDICATION HISTORY None. ... | 31 Podiatry |
EXAM CT of abdomen with and without contrast. CT-guided needle placement biopsy. HISTORY Left renal mass. TECHNIQUE Pre and postcontrast enhanced images were acquired through the kidneys. FINDINGS Comparison made to the prior MRI. There is re-demonstration of multiple bilateral cystic renal lesions. Seve... | 33 Radiology |
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 ... | 3 Cardiovascular / Pulmonary |
EXAM CT head without contrast. INDICATIONS Assaulted positive loss of consciousness rule out bleed. TECHNIQUE CT examination of the head was performed without intravenous contrast administration. There are no comparison studies. FINDINGS There are no abnormal extraaxial fluid collections. There is no mi... | 22 Neurology |
CHIEF COMPLAINT Right hydronephrosis. HISTORY OF PRESENT ILLNESS The patient is a 56-year-old female who has a history of uterine cancer breast cancer mesothelioma. She is scheduled to undergo mastectomy in two weeks. In September 1999 she was diagnosed with right breast cancer and underwent lumpectomy and a... | 21 Nephrology |
OPERATION Left lower lobectomy. OPERATIVE PROCEDURE IN DETAIL The patient was brought to the operating room and placed in the supine position. After general endotracheal anesthesia was induced the appropriate monitoring devices were placed. The patient was placed in the right lateral decubitus position. The l... | 38 Surgery |
HISTORY OF PRESENT ILLNESS The patient is a charming and delightful 46-year-old woman admitted with palpitations and presyncope. The patient is active and a previously healthy young woman who has had nine years of occasional palpitations. Symptoms occur three to four times per year and follow no identifiable patte... | 3 Cardiovascular / Pulmonary |
Doctor s Address Dear Doctor This letter serves as a reintroduction of my patient A who will be seeing you on Thursday 06/12/2008. As you know he is an unfortunate gentleman who has reflex sympathetic dystrophy of both lower extremities. His current symptoms are more severe on the right and he has had a persisti... | 20 Letters |
PREOPERATIVE DIAGNOSES 1. Chronic pelvic pain. 2. Dysmenorrhea. 3. Dyspareunia. 4. Endometriosis. 5. Enlarged uterus. 6. Menorrhagia. POSTOPERATIVE DIAGNOSES 1. Chronic pelvic pain. 2. Dysmenorrhea. 3. Dyspareunia. 4. Endometriosis. 5. Enlarged uterus. 6. Menorrhagia. PROCEDURE Total abdominal hysterec... | 24 Obstetrics / Gynecology |
PREOPERATIVE DIAGNOSES 1. End-stage renal disease hypertension diabetes need for chronic arteriovenous access. 2. Ischemic cardiomyopathy ejection fraction 20 . POSTOPERATIVE DIAGNOSES 1. End-stage renal disease hypertension diabetes need for chronic arteriovenous access. 2. Ischemic cardiomyopathy ejection... | 38 Surgery |
CHIEF COMPLAINT Testicular pain. HISTORY OF PRESENT ILLNESS The patient is a 4-year-old boy with a history of abrupt onset of left testicular pain at 11 30 this morning. He was unable to walk and would not stand upright and had fairly significant discomfort so the parents checked his panel because of it. Beca... | 12 Emergency Room Reports |
ADMISSION DIAGNOSIS Adenocarcinoma of the prostate. HISTORY The patient is a 71-year-old male whose personal physician Dr. X identified a change in the patient s PSA from 7/2008 4.2 to 4/2009 10.5 . The patient underwent a transrectal ultrasound and biopsy and was found to have a Gleason 3+4 for a score of 7... | 39 Urology |
ADMISSION DIAGNOSIS Morbid obesity. BMI is 51. DISCHARGE DIAGNOSIS Morbid obesity. BMI is 51. PROCEDURE Laparoscopic gastric bypass. SERVICE Surgery. CONSULT Anesthesia and pain. HISTORY OF PRESENT ILLNESS Ms. A is a 27-year-old woman who suffered from morbid obesity for many years. She has made m... | 2 Bariatrics |
PREOPERATIVE DIAGNOSES 1. Dyspnea on exertion with abnormal stress echocardiography. 2. Frequent PVCs. 3. Metabolic syndrome. POSTOPERATIVE DIAGNOSES 1. A 50 distal left main and two-vessel coronary artery disease with normal left ventricular systolic function. 2. Frequent PVCs. 3. Metabolic syndrome. PROCEDURES... | 3 Cardiovascular / Pulmonary |
ADMITTING DIAGNOSIS Kawasaki disease. DISCHARGE DIAGNOSIS Kawasaki disease resolving. HOSPITAL COURSE This is a 14-month-old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis mild arthritis with edema rash resolving and with elevated ne... | 0 Allergy / Immunology |
SUBJECTIVE This 3-year-old male is brought by his mother with concerns about his eating. He has become a very particular eater and not eating very much in general. However her primary concern was he was vomiting sometimes after particular foods. They had noted that when he would eat raw carrots within 5 to 10 ... | 35 SOAP / Chart / Progress Notes |
The patient states that she has been doing fairly well at home. She balances her own checkbook. She does not do her own taxes but she has never done so in the past. She states that she has no problems with cooking meals getting her own meals and she is still currently driving. She denies burning any dishes becau... | 22 Neurology |
The patient presented in the early morning hours of February 12 2007 with contractions. The patient was found to be in false versus early labor and managed as an outpatient. The patient returned to labor and delivery approximately 12 hours later with regular painful contractions. There was minimal cervical dilatio... | 38 Surgery |
CT HEAD WITHOUT CONTRAST CT FACIAL BONES WITHOUT CONTRAST AND CT CERVICAL SPINE WITHOUT CONTRAST REASON FOR EXAM Motor vehicle collision. CT HEAD TECHNIQUE Noncontrast axial CT images of the head were obtained without contrast. FINDINGS There is no acute intracranial hemorrhage mass effect midline shift o... | 27 Orthopedic |
PROCEDURE Punch biopsy of right upper chest skin lesion. ESTIMATED BLOOD LOSS Minimal. FLUIDS Minimal. COMPLICATIONS None. PROCEDURE The area around the lesion was anesthetized after she gave consent for her procedure. Punch biopsy including some portion of lesion and normal tissue was performed. Hemos... | 38 Surgery |
FINDINGS By dates the patient is 8 weeks 2 days. There is a gestational sac within the endometrial cavity measuring 2.1cm consistent with 6 weeks 4 days. There is a fetal pole measuring 7mm consistent with 6 weeks 4 days. There was no fetal heart motion on Doppler or on color Doppler. There is no fluid within the end... | 24 Obstetrics / Gynecology |
REFERRING DIAGNOSIS Motor neuron disease. PERTINENT HISTORY AND EXAMINATION Briefly the patient is an 83-year-old woman with a history of progression of dysphagia for the past year dysarthria weakness of her right arm cramps in her legs and now with progressive weakness in her upper extremities. SUMMARY T... | 33 Radiology |
DIAGNOSIS Left sciatica. ANESTHESIA Intravenous sedation NAME OF OPERATION 1. Left L5-S1 transforaminal epidural steroid block with fluoroscopy. 2. Left L4-5 transforaminal epidural steroid block with fluoroscopy. 3. Monitored intravenous Versed sedation. PROCEDURE The patient was taken to the block room. ... | 28 Pain Management |
PREOPERATIVE DIAGNOSES 1. Request for cosmetic surgery. 2. Facial asymmetry following motor vehicle accident. POSTOPERATIVE DIAGNOSES 1. Request for cosmetic surgery. 2. Facial asymmetry following motor vehicle accident. PROCEDURES 1. Endoscopic subperiosteal midface lift using the endotine midface suspension d... | 38 Surgery |
CHIEF COMPLAINT Right ankle sprain. HISTORY OF PRESENT ILLNESS This is a 56-year-old female who fell on November 26 2007 at 11 30 a.m. while at work. She did not recall the specifics of her injury but she thinks that her right foot inverted and subsequently noticed pain in the right ankle. She describes no oth... | 5 Consult - History and Phy. |
PAST MEDICAL HISTORY He has difficulty climbing stairs difficulty with airline seats tying shoes used to public seating and lifting objects off the floor. He exercises three times a week at home and does cardio. He has difficulty walking two blocks or five flights of stairs. Difficulty with snoring. He has mu... | 2 Bariatrics |
EXAM Barium enema. CLINICAL HISTORY A 4-year-old male with a history of encopresis and constipation. TECHNIQUE A single frontal scout radiograph of the abdomen was performed. A rectal tube was inserted in usual sterile fashion and retrograde instillation of barium contrast was followed via spot fluoroscopic ... | 33 Radiology |
PROCEDURE Circumcision. ANESTHESIA EMLA. FINDINGS Normal penis. The foreskin was normal in appearance and measured 1.6 cm. There was no bleeding at the circumcision site. PROCEDURE Patient was placed on the circumcision restraint board. EMLA had been applied approximately 90 minutes before. A time-out w... | 39 Urology |
EXAM Thoracic Spine. REASON FOR EXAM Injury. INTERPRETATION The thoracic spine was examined in the AP lateral and swimmer s projections. There is mild chronic-appearing anterior wedging of what is believed to represent T11 and 12 vertebral bodies. A mild amount of anterior osteophytic lipping is seen involv... | 27 Orthopedic |
ADMISSION DIAGNOSES Hyperglycemia cholelithiasis obstructive sleep apnea diabetes mellitus and hypertension. DISCHARGE DIAGNOSES Hyperglycemia cholelithiasis obstructive sleep apnea diabetes mellitus hypertension and cholecystitis. PROCEDURE Laparoscopic cholecystectomy. SERVICE Surgery. HISTORY OF... | 15 General Medicine |
DIAGNOSES 1. Term pregnancy. 2. Possible rupture of membranes prolonged. PROCEDURE Induction of vaginal delivery of viable male Apgars 8 and 9. HOSPITAL COURSE The patient is a 20-year-old female gravida 4 para 0 who presented to the office. She had small amount of leaking since last night. On exam she ... | 25 Office Notes |
CHIEF COMPLAINT Altered mental status. HISTORY OF PRESENT ILLNESS The patient is a 69-year-old male transferred from an outlying facility with diagnosis of a stroke. History is taken mostly from the emergency room record. The patient is unable to give any history and no family member is present for questioning. Whe... | 5 Consult - History and Phy. |
CHIEF COMPLAINT Blood in toilet. HISTORY Ms. ABC is a 77-year-old female who is brought down by way of ambulance from XYZ Nursing Home after nursing staff had noted there to be blood in the toilet after she had been sitting on the toilet. They did not note any urine or stool in the toilet and the patient had no ... | 12 Emergency Room Reports |
PROBLEMS LIST 1. Nonischemic cardiomyopathy. 2. Branch vessel coronary artery disease. 3. Congestive heart failure NYHA Class III. 4. History of nonsustained ventricular tachycardia. 5. Hypertension. 6. Hepatitis C. INTERVAL HISTORY The patient was recently hospitalized for CHF exacerbation and was discharge... | 5 Consult - History and Phy. |
OPERATION Left lower lobectomy. OPERATIVE PROCEDURE IN DETAIL The patient was brought to the operating room and placed in the supine position. After general endotracheal anesthesia was induced the appropriate monitoring devices were placed. The patient was placed in the right lateral decubitus position. The l... | 3 Cardiovascular / Pulmonary |
REASON FOR EXAM Lower quadrant pain with nausea vomiting and diarrhea. TECHNIQUE Noncontrast axial CT images of the abdomen and pelvis are obtained. FINDINGS Please note evaluation of the abdominal organs is secondary to the lack of intravenous contrast material. Gallstones are seen within the gallbladder lu... | 14 Gastroenterology |
CHIEF COMPLAINT Left foot pain. HISTORY XYZ is a basketball player for University of Houston who sustained an injury the day prior. They were traveling. He came down on another player s foot sustaining what he describes as an inversion injury. Swelling and pain onset immediately. He was taped but was able to contin... | 4 Chiropractic |
PREOPERATIVE DIAGNOSIS Femoroacetabular impingement. POSTOPERATIVE DIAGNOSIS Femoroacetabular impingement. OPERATIONS PERFORMED 1. Left hip arthroscopic debridement. 2. Left hip arthroscopic femoral neck osteoplasty. 3. Left hip arthroscopic labral repair. ANESTHESIA General. OPERATION IN DETAIL The pati... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Persistent pneumonia right upper lobe of the lung possible mass. POSTOPERATIVE DIAGNOSIS Persistent pneumonia right upper lobe of the lung possible mass. PROCEDURE Bronchoscopy with brush biopsies. DESCRIPTION OF PROCEDURE After obtaining an informed consent the patient was taken... | 38 Surgery |
PAST MEDICAL HISTORY The patient denies any significant past medical history. PAST SURGICAL HISTORY The patient denies any significant surgical history. MEDICATIONS The patient takes no medications. ALLERGIES No known drug allergies. SOCIAL HISTORY She denies use of cigarettes alcohol or drugs. FAMILY H... | 33 Radiology |
CHIEF COMPLAINT Jaw pain. HISTORY OF PRESENT ILLNESS This is a 58-year-old male who started out having toothache in the left lower side of the mouth that is now radiating into his jaw and towards his left ear. Triage nurse reported that he does not believe it is his tooth because he has regular dental appointmen... | 12 Emergency Room Reports |
REASON FOR CONSULT Anxiety. CHIEF COMPLAINT I felt anxious yesterday. HPI A 69-year-old white female with a history of metastatic breast cancer depression anxiety recent UTI and obstructive uropathy admitted to the ABCD Hospital on February 6 2007 for lightheadedness weakness and shortness of breath.... | 32 Psychiatry / Psychology |
NUCLEAR MEDICINE HEPATOBILIARY SCAN REASON FOR EXAM Right upper quadrant pain. COMPARISONS CT of the abdomen dated 02/13/09 and ultrasound of the abdomen dated 02/13/09. Radiopharmaceutical 6.9 mCi of Technetium-99m Choletec. FINDINGS Imaging obtained up to 30 minutes after the injection of radiopharmaceutical... | 33 Radiology |
CHIEF COMPLAINT Mental status changes after a fall. HISTORY Ms. ABC is a 76-year-old female with Alzheimer s apparently is normally very talkative active independent but with advanced Alzheimer s. Apparently she tripped backwards hitting her head on a wheelchair and had although no loss consciousness had ... | 5 Consult - History and Phy. |
GROSS DESCRIPTION A. Received fresh labeled with patient s name designated right upper lobe wedge is an 8.0 x 3.5 x 3.0 cm wedge of lung which has an 11.5 cm staple line. There is a 0.8 x 0.7 x 0.5 cm sessile tumor with surrounding pleural puckering. B. Received fresh labeled with patient s name designated l... | 19 Lab Medicine - Pathology |
EXAM CT Abdomen Pelvis W WO Contrast REASON FOR EXAM Status post aortobiiliac graft repair. TECHNIQUE 5 mm spiral thick spiral CT scanning was performed through the entire abdomen and pelvis utilizing intravenous dynamic bolus contrast enhancement. No oral or rectal contrast was utilized. Comparison i... | 14 Gastroenterology |
REASON FOR CONSULTATION Management of blood pressure. HISTORY OF PRESENT ILLNESS The patient is a 38-year-old female admitted following a delivery. The patient had a cesarean section. Following this the patient was treated for her blood pressure. She was sent home and she came back again apparently with uncon... | 24 Obstetrics / Gynecology |
CC Progressive unsteadiness following head trauma. HX A7 7 y/o male fell as he was getting out of bed and struck his head 4 weeks prior to admission. He then began to experience progressive unsteadiness and gait instability for several days after the fall. He was then evaluated at a local ER and prescribed mecl... | 33 Radiology |
PREOPERATIVE DIAGNOSIS Acute appendicitis. POSTOPERATIVE DIAGNOSIS Acute appendicitis gangrenous. PROCEDURE Appendectomy. DESCRIPTION OF PROCEDURE The patient was taken to the operating room under urgent conditions. After having obtained an informed consent he was placed in the operating room and under a... | 14 Gastroenterology |
She has a past ocular history including cataract extraction with lens implants in both eyes in 2001 and 2003. She also has a history of glaucoma diagnosed in 1990 and macular degeneration. She has been followed in her home country and is here visiting family. She had the above-mentioned observation and was brought i... | 5 Consult - History and Phy. |
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