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PREOPERATIVE DIAGNOSES 1. Post anterior cervical discectomy and fusion at C4-C5 and C5-C6 with possible pseudoarthrosis at C4-C5. 2. Cervical radiculopathy involving the left arm. 3. Disc degeneration at C3-C4 and C6-C7. POSTOPERATIVE DIAGNOSES 1. Post anterior cervical discectomy and fusion at C4-C5 and C5-C6 with... | 38 Surgery |
SUBJECTIVE The patient is a 78-year-old female with the problem of essential hypertension. She has symptoms that suggested intracranial pathology but so far work-up has been negative. She is taking hydrochlorothiazide 25-mg once a day and K-Dur 10-mEq once a day with adequate control of her blood pressure. She de... | 35 SOAP / Chart / Progress Notes |
TITLE OF OPERATION Youngswick osteotomy with internal screw fixation of the first right metatarsophalangeal joint of the right foot. PREOPERATIVE DIAGNOSIS Hallux limitus deformity of the right foot. POSTOPERATIVE DIAGNOSIS Hallux limitus deformity of the right foot. ANESTHESIA Monitored anesthesia care wit... | 27 Orthopedic |
PREOPERATIVE DIAGNOSES 1. Nasopharyngeal mass. 2. Right upper lid skin lesion. POSTOPERATIVE DIAGNOSES 1. Nasopharyngeal tube mass. 2. Right upper lid skin lesion. PROCEDURES PERFORMED 1. Functional endoscopic sinus surgery. 2. Excision of nasopharyngeal mass via endoscopic technique. 3. Excision of right upp... | 11 ENT - Otolaryngology |
ADMISSION DIAGNOSES 1. Pneumonia failed outpatient treatment. 2. Hypoxia. 3. Rheumatoid arthritis. DISCHARGE DIAGNOSES 1. Atypical pneumonia suspected viral. 2. Hypoxia. 3. Rheumatoid arthritis. 4. Suspected mild stress-induced adrenal insufficiency. HOSPITAL COURSE This very independent 79-year old had s... | 10 Discharge Summary |
CC Memory loss. HX This 77 y/o RHF presented with a one year history of progressive memory loss. Two weeks prior to her evaluation at UIHC she agreed to have her sister pick her up for church at 8 15AM Sunday morning. That Sunday she went to pick up her sister at her sister s home and when her sister was not there... | 33 Radiology |
NAME OF PROCEDURE Left heart catheterization with ventriculography selective coronary angiography. INDICATIONS Acute coronary syndrome. TECHNIQUE OF PROCEDURE Standard Judkins right groin. Catheters used were a 6 French pigtail 6 French JL4 6 French JR4. ANTICOAGULATION The patient was on heparin at ... | 38 Surgery |
REASON FOR EXAMINATION Face asleep. COMPARISON EXAMINATION None. TECHNIQUE Multiple axial images were obtained of the brain. 5 mm sections were acquired. 2.5-mm sections were acquired without injection of intravenous contrast. Reformatted sagittal and coronal images were obtained. DISCUSSION No acute intracr... | 33 Radiology |
PREOPERATIVE DIAGNOSES 1. Carotid artery occlusive disease. 2. Peripheral vascular disease. POSTOPERATIVE DIAGNOSES 1. Carotid artery occlusive disease. 2. Peripheral vascular disease. OPERATIONS PERFORMED 1. Bilateral carotid cerebral angiogram. 2. Right femoral-popliteal angiogram. FINDINGS The right caro... | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSES 1. Torn lateral meniscus right knee. 2. Chondromalacia of the patella right knee. POSTOPERATIVE DIAGNOSES 1. Torn lateral meniscus right knee. 2. Chondromalacia of the patella right knee. PROCEDURE PERFORMED 1. Arthroscopic lateral meniscoplasty. 2. Patellar shaving of the right knee... | 38 Surgery |
CHIEF COMPLAINT Vomiting and nausea. HPI The patient is a 52-year-old female who said she has had 1 week of nausea and vomiting which is moderate-to-severe. She states she has it at least once a day. It can be any time but can also be postprandial. She states she will vomit up some dark brown-to-green fluid.... | 15 General Medicine |
DIAGNOSIS Cognitive linguistic impairment secondary to stroke. NUMBER OF SESSIONS COMPLETED 5 HOSPITAL COURSE The patient is a 73-year-old female who was referred to Medical Center s Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits. Based on the initia... | 37 Speech - Language |
HISTORY OF PRESENT ILLNESS This is a 48-year-old black male with stage IV chronic kidney disease likely secondary to HIV nephropathy who presents to clinic for followup having missed prior clinic appointments. He was last seen in this clinic on 05/29/2007 by Dr. X. This is the first time that I have met the patie... | 5 Consult - History and Phy. |
REASON FOR EXAM Left arm and hand numbness. TECHNIQUE Noncontrast axial CT images of the head were obtained with 5 mm slice thickness. FINDINGS There is an approximately 5-mm shift of the midline towards the right side. Significant low attenuation is seen throughout the white matter of the right frontal pari... | 33 Radiology |
PREOPERATIVE DIAGNOSIS Vitreous hemorrhage right eye. POSTOPERATIVE DIAGNOSIS Vitreous hemorrhage right eye. PROCEDURE Vitrectomy right eye. PROCEDURE IN DETAIL The patient was prepared and draped in the usual manner for a vitrectomy procedure under local anesthesia. Initially a 5 cc retrobulbar inject... | 26 Ophthalmology |
REASON FOR CONSULTATION Thyroid mass diagnosed as papillary carcinoma. HISTORY OF PRESENT ILLNESS The patient is a 16-year-old young lady who was referred from the Pediatric Endocrinology Department by Dr. X for evaluation and surgical recommendations regarding treatment of a mass in her thyroid which has now b... | 16 Hematology - Oncology |
SUBJECTIVE He is a 29-year-old white male who is a patient of Dr. XYZ and he comes in today complaining that he was stung by a Yellow Jacket Wasp yesterday and now has a lot of swelling in his right hand and right arm. He says that he has been stung by wasps before and had similar reactions. He just said that he w... | 8 Dermatology |
HISTORY OF PRESENT ILLNESS The patient is a 26-year-old female referred to Physical Therapy for low back pain. The patient has a history of traumatic injury to low back. The patient stated initial injury occurred eight years ago when she fell at a ABC Store. The patient stated she received physical therapy one... | 27 Orthopedic |
PREOPERATIVE DIAGNOSES Carious teeth #2 and #19 and left mandibular dental abscess. POSTOPERATIVE DIAGNOSES Carious teeth #2 and #19 and left mandibular dental abscess. PROCEDURES Extraction of teeth #2 and #19 and incision and drainage of intraoral and extraoral of left mandibular dental abscess. ANESTHESIA ... | 38 Surgery |
ADMITTING DIAGNOSIS Intractable migraine with aura. DISCHARGE DIAGNOSIS Migraine with aura. SECONDARY DIAGNOSES 1. Bipolar disorder. 2. Iron deficiency anemia. 3. Anxiety disorder. 4. History of tubal ligation. PROCEDURES DURING THIS HOSPITALIZATION 1. CT of the head with and without contrast which was ne... | 10 Discharge Summary |
CC Headache. HX This 51 y/o RHM was moving furniture several days prior to presentation when he struck his head vertex against a door panel. He then stepped back and struck his back on a trailer hitch. There was no associated LOC but he felt dazed. He complained a HA since the accident. The following day he beg... | 33 Radiology |
EXAM Chest PA Lateral. REASON FOR EXAM Shortness of breath evaluate for pneumothorax versus left-sided effusion. INTERPRETATION There has been interval development of a moderate left-sided pneumothorax with near complete collapse of the left upper lobe. The lower lobe appears aerated. There is stable dif... | 3 Cardiovascular / Pulmonary |
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... | 24 Obstetrics / Gynecology |
TECHNIQUE Sequential axial CT images were obtained from the base of the brain to the upper abdomen following the uneventful administration of 100cc Optiray 350 intravenous contrast. FINDINGS The heart size is normal and there is no pericardial effusion. The aorta and great vessels are normal in caliber. The cen... | 33 Radiology |
PREOPERATIVE DIAGNOSIS Chronic otitis media. POSTOPERATIVE DIAGNOSIS Chronic otitis media. PROCEDURE PERFORMED Bilateral myringotomy tubes and adenoidectomy. INDICATIONS FOR PROCEDURE The patient is an 8-year-old child with history of recurrent otitis media. The patient has had previous tube placement. Tu... | 11 ENT - Otolaryngology |
PREOPERATIVE DIAGNOSIS Symptomatic pericardial effusion. POSTOPERATIVE DIAGNOSIS Symptomatic pericardial effusion. PROCEDURE PERFORMED Subxiphoid pericardiotomy. ANESTHESIA General via ET tube. ESTIMATED BLOOD LOSS 50 cc. FINDINGS This is a 70-year-old black female who underwent a transhiatal esophage... | 38 Surgery |
MYOVIEW NUCLEAR STRESS STUDY REASON FOR THE TEST Angina coronary artery disease. FINDINGS The patient exercised according to the Lexiscan nuclear stress study received a total of 0.4 mg of Lexiscan. At peak hyperemic effect 25.8 mCi of Myoview injected for the stress imaging and earlier 8.1 mCi of Myoview inj... | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSES Term pregnancy nonreassuring fetal heart tracing. POSTOPERATIVE DIAGNOSES Term pregnancy nonreassuring fetal heart tracing. OPERATION Primary cesarean section by low-transverse incision. ANESTHESIA Epidural. ESTIMATED BLOOD LOSS 450 mL. COMPLICATIONS None. CONDITION Stable.... | 24 Obstetrics / Gynecology |
PREOPERATIVE DIAGNOSES Left obstructed renal ureteropelvic junction obstruction status post pyeloplasty percutaneous procedure and pyeloureteroscopy x2 and status post Pseudomonas pyelonephritis x6 renal insufficiency and solitary kidney. POSTOPERATIVE DIAGNOSES Left obstructed renal ureteropelvic junction o... | 39 Urology |
CC Right shoulder pain. HX This 46 y/o RHF presented with a 4 month history of right neck and shoulder stiffness and pain. The symptoms progressively worsened over the 4 month course. 2 weeks prior to presentation she began to develop numbness in the first and second fingers of her right hand and RUE pain. The late... | 33 Radiology |
PREOPERATIVE DIAGNOSIS Left distal radius fracture metaphyseal extraarticular. POSTOPERATIVE DIAGNOSIS Left distal radius fracture metaphyseal extraarticular. PROCEDURE Open reduction and internal fixation of left distal radius. IMPLANTS Wright Medical Micronail size 2. ANESTHESIA LMA. TOURNIQUET TIME ... | 38 Surgery |
HISTORY OF PRESENT ILLNESS She is a 28-year-old G1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood-tinged vomit starting approximately worse over the past couple of days. This is patient s fourth trip to the emergency room and second trip for admission. PAST MEDICAL HISTORY ... | 15 General Medicine |
PREOPERATIVE DIAGNOSIS Bunion left foot. POSTOPERATIVE DIAGNOSIS Bunion left foot. PROCEDURE PERFORMED 1. Bunionectomy with first metatarsal osteotomy base wedge type with internal screw fixation. 2. Akin osteotomy with internal wire fixation of left foot. HISTORY This 19-year-old Caucasian female presents... | 27 Orthopedic |
PREOPERATIVE DIAGNOSES 1. End-stage renal disease. 2. Left subclavian vein occlusion. 3. Status post chronic tracheostomy. 4. Status post coronary artery bypass grafting. 5. Right subclavian vein stenosis. POSTOPERATIVE DIAGNOSES 1. End-stage renal disease. 2. Left subclavian vein occlusion. 3. Status post chro... | 21 Nephrology |
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... | 38 Surgery |
EXAM CT abdomen without contrast and pelvis without contrast reconstruction. REASON FOR EXAM Right lower quadrant pain rule out appendicitis. TECHNIQUE Noncontrast CT abdomen and pelvis. An intravenous line could not be obtained for the use of intravenous contrast material. FINDINGS The appendix is norma... | 33 Radiology |
CHIEF COMPLAINT Penile discharge infected-looking glans. HISTORY OF PRESENT ILLNESS The patient is a 67-year-old African-American male who was recently discharged from the hospital on July 21 2008 after being admitted for altered mental status and before that after undergoing right above knee amputation for we... | 39 Urology |
PREOPERATIVE DIAGNOSES 1. Blepharochalasia. 2. Lower lid large primary and secondary bagging. POSTOPERATIVE DIAGNOSES 1. Blepharochalasia. 2. Lower lid large primary and secondary bagging. PROCEDURE Quad blepharoplasty. ANESTHESIA General. ESTIMATED BLOOD LOSS Minimal. CONDITION The patient did well. ... | 6 Cosmetic / Plastic Surgery |
PREOPERATIVE DIAGNOSIS Pelvic pain. POSTOPERATIVE DIAGNOSES 1. Pelvic pain. 2. Pelvic endometriosis. 3. Pelvic adhesions. PROCEDURE PERFORMED 1. Laparoscopy. 2. Harmonic scalpel ablation of endometriosis. 3. Lysis of adhesions. 4. Cervical dilation. ANESTHESIA General. SPECIMEN Peritoneal biopsy. ESTI... | 38 Surgery |
HISTORY Patient is a 54-year-old male admitted with diagnosis of CVA with right hemiparesis. Patient is currently living in ABC with his son as this was closer his to his job. At discharge he will live with his spouse in a new job. The home is single level with no steps. Prior to admission his wife reports that ... | 5 Consult - History and Phy. |
CHIEF COMPLAINT Nausea and feeling faint. HPI The patient is a 74-year-old white female brought in by husband. The patient is a vague historian at times. She reports her appetite has been fair over the last several days. Today she complains of some nausea. She feels weak. No other specific complaints. REVIE... | 15 General Medicine |
EXAM Modified barium swallow. SYMPTOM Dysphagia with possible aspiration. FINDINGS A cookie deglutition study was performed. The patient was examined in the direct lateral position. Patient was challenged with thin liquids thick liquid semisolids and solids. Persistently demonstrable is the presence of pene... | 33 Radiology |
CC Found down. HX 54y/o RHF went to bed at 10 PM at her boyfriend s home on 1/16/96. She was found lethargic by her son the next morning. Three other individuals in the house were lethargic and complained of HA that same morning. Her last memory was talking to her granddaughter at 5 00PM on 1/16/96. She next rememb... | 15 General Medicine |
PREOPERATIVE DIAGNOSIS Visually significant nuclear sclerotic cataract right eye. POSTOPERATIVE DIAGNOSIS Visually significant nuclear sclerotic cataract right eye. OPERATIVE PROCEDURES Phacoemulsification with posterior chamber intraocular lens implantation right eye. ANESTHESIA Monitored anesthesia car... | 26 Ophthalmology |
HISTORY OF PRESENT ILLNESS This is a week gestational age delivered by at on . Gestational age was determined by last menstrual period and consistent with trimester ultrasound. rupture of membranes occurred prior to delivery and amniotic fluid was clear. The baby was vertex presentation. T... | 15 General Medicine |
SUBJECTIVE This 46-year-old white male with Down’s syndrome presents with his mother for followup of hypothyroidism as well as onychomycosis. He has finished six weeks of Lamisil without any problems. He is due to have an ALT check today. At his appointment in April I also found that he was hypothyroid with ele... | 35 SOAP / Chart / Progress Notes |
PROCEDURE Informed consent was obtained from the patient. Special mention was made of the possibility of infection and necrosis of the heel pad. The patient was placed in the supine position. The tender area in the medial aspect of the heel was identified by palpation. After proper preparation with antiseptic s... | 28 Pain Management |
INDICATIONS FOR PROCEDURE The patient has presented with atypical type right arm discomfort and neck discomfort. She had noninvasive vascular imaging demonstrating suspected right subclavian stenosis. Of note there was bidirectional flow in the right vertebral artery as well as 250 cm per second velocities in the r... | 3 Cardiovascular / Pulmonary |
PAST MEDICAL HX Significant for asthma pneumonia and depression. PAST SURGICAL HX None. MEDICATIONS Prozac 20 mg q.d. She desires to be on the NuvaRing. ALLERGIES Lactose intolerance. SOCIAL HX She denies smoking or alcohol or drug use. PE VITALS Stable. Weight 114 lb. Height 5 feet 2 inches. ... | 5 Consult - History and Phy. |
CURRENT MEDICATIONS Lortab. PREVIOUS MEDICAL HISTORY Cardiac stent in 2000. PATIENT S GOAL To eat again by mouth. STUDY A trial of Passy-Muir valve was completed to allow the patient to achieve hands-free voicing and also to improve his secretion management. A clinical swallow evaluation was not completed ... | 5 Consult - History and Phy. |
PROCEDURES PERFORMED C5-C6 anterior cervical discectomy allograft fusion and anterior plating. ESTIMATED BLOOD LOSS 10 mL. CLINICAL NOTE This is a 57-year-old gentleman with refractory neck pain with single-level degeneration of the cervical spine and there was also some arm pain. We decided go ahead with a... | 27 Orthopedic |
PREOPERATIVE DIAGNOSIS Colovesical fistula. POSTOPERATIVE DIAGNOSES 1. Colovesical fistula. 2. Intraperitoneal abscess. PROCEDURE PERFORMED 1. Exploratory laparotomy. 2. Low anterior colon resection. 3. Flexible colonoscopy. 4. Transverse loop colostomy and JP placement. ANESTHESIA General. HISTORY Thi... | 14 Gastroenterology |
PREOPERATIVE DIAGNOSIS Antibiotic-associated diarrhea. POSTOPERATIVE DIAGNOSIS Antibiotic-associated diarrhea. OPERATION PERFORMED Colonoscopy with random biopsies and culture. INDICATIONS The patient is a 50-year-old woman who underwent hemorrhoidectomy approximately one year ago. She has been having ... | 14 Gastroenterology |
PROCEDURE Upper endoscopy. PREOPERATIVE DIAGNOSIS Dysphagia. POSTOPERATIVE DIAGNOSIS 1. GERD biopsied. 2. Distal esophageal reflux-induced stricture dilated to 18 mm. 3. Otherwise normal upper endoscopy. MEDICATIONS Fentanyl 125 mcg and Versed 7 mg slow IV push. INDICATIONS This is a 50-year-old white... | 14 Gastroenterology |
REASON FOR REFERRAL Facial twitching. HISTORY OF PRESENT ILLNESS The patient had several episodes where she felt like her face was going to twitch which she could suppress it with grimacing movements of her mouth and face. She reports she is still having right posterior head pressure like sensations approximate... | 5 Consult - History and Phy. |
REASON FOR REFERRAL The patient is a 76-year-old Caucasian gentleman who works full-time as a tax attorney. He was referred for a neuropsychological evaluation by Dr. X after a recent hospitalization for possible transient ischemic aphasia. Two years ago a similar prolonged confusional spell was reported as well.... | 5 Consult - History and Phy. |
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... | 21 Nephrology |
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 ... | 38 Surgery |
VITAL SIGNS Reveal a blood pressure of temperature of respirations and pulse of . CONSTITUTIONAL Normal appearance for chronological age does not appear chronically ill. HEENT The pupils are equal and reactive. Funduscopic examination is normal. Posterior pharynx is normal. Tympanic membranes are... | 5 Consult - History and Phy. |
PREOPERATIVE DIAGNOSIS Gross hematuria. POSTOPERATIVE DIAGNOSIS Gross hematuria. OPERATIONS Cystopyelogram clot evacuation transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder. ANESTHESIA Spinal. FINDINGS Significant amount of bladder clots measuring about 150... | 38 Surgery |
SUBJECTIVE The patient is a 7-year-old male who comes in today with a three-day history of emesis and a four-day history of diarrhea. Apparently his brother had similar symptoms. They had eaten some chicken and then ate some more of it the next day and I could not quite understand what the problem was because th... | 35 SOAP / Chart / Progress Notes |
REASON FOR CONSULTATION Hemoptysis. HISTORY OF PRESENT ILLNESS The patient is an 80-year-old African-American male very well known to my service with a past medical history significant for asbestos exposure. The patient also has a very extensive cardiac history that would be outlined below. He is being admitt... | 5 Consult - History and Phy. |
CHIEF COMPLAINT 1/1 This 62 year old female presents today for evaluation of angina. Associated signs and symptoms Associated signs and symptoms include chest pain nausea pain radiating to the arm and pain radiating to the jaw. Context The patient has had no previous treatments for this condition. Duration Con... | 5 Consult - History and Phy. |
1. Pelvic tumor. 2. Cystocele. 3. Rectocele. POSTOPERATIVE DIAGNOSES 1. Degenerated joint. 2. Uterine fibroid. 3. Cystocele. 4. Rectocele. PROCEDURE PERFORMED 1. Total abdominal hysterectomy. 2. Bilateral salpingooophorectomy. 3. Repair of bladder laceration. 4. Appendectomy. 5. Marshall-Marchetti-Krant... | 38 Surgery |
INDICATIONS FOR PROCEDURE A 51-year-old obese white female with positive family history of coronary disease and history of chest radiation for Hodgkin disease 20 years ago with no other identifiable risk factors who presents with an acute myocardial infarction with elevated enzymes. The chest pain occurred early Tu... | 3 Cardiovascular / Pulmonary |
2-D ECHOCARDIOGRAM Multiple views of the heart and great vessels reveal normal intracardiac and great vessel relationships. Cardiac function is normal. There is no significant chamber enlargement or hypertrophy. There is no pericardial effusion or vegetations seen. Doppler interrogation including color flow imagin... | 3 Cardiovascular / Pulmonary |
COMPARISON None. MEDICATIONS Lopressor 5mg IV at 0920 hours. HEART RATE Recorded heart rate 55 to 57bpm. EXAM Initial unenhanced axial CT imaging of the heart was obtained with ECG gating for the purpose of coronary artery calcium scoring Agatston Method and calcium volume determination. 18 gauge IV Intracath ... | 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... | 3 Cardiovascular / Pulmonary |
DELIVERY NOTE This G1 P0 with EDC 12/23/08 presented with SROM about 7.30 this morning. Her prenatal care complicated by GBS screen positive and a transfer of care at 34 weeks from Idaho. Exam upon arrival 2 to 3 cm 100 effaced -1 station and by report pool of fluid was positive for Nitrazine and positive fern... | 38 Surgery |
FINDINGS There is a large intrasellar mass lesion producing diffuse expansion of the sella turcica. This mass lesions measures approximately 16 x 18 x 18mm craniocaudal x AP x mediolateral in size. | 33 Radiology |
CHIEF COMPLAINT Severe tonsillitis palatal cellulitis and inability to swallow. HISTORY OF PRESENT ILLNESS This patient started having sore throat approximately one week ago however yesterday it became much worse. He was unable to swallow. He complained to his parent. He was taken to Med Care and did not g... | 11 ENT - Otolaryngology |
PREOPERATIVE DIAGNOSIS Sterilization candidate. POSTOPERATIVE DIAGNOSIS Sterilization candidate. PROCEDURE PERFORMED 1. Cervical dilatation. 2. Laparoscopic bilateral partial salpingectomy. ANESTHESIA General endotracheal. COMPLICATIONS None. ESTIMATED BLOOD LOSS Less than 50 cc. SPECIMEN Portions ... | 24 Obstetrics / Gynecology |
PROCEDURE Circumcision. PRE-PROCEDURE DIAGNOSIS Normal male phallus. POST-PROCEDURE DIAGNOSIS Normal male phallus. ANESTHESIA 1 lidocaine without epinephrine. INDICATIONS The risks and benefits of the procedure were discussed with the parents. The risks are infection hemorrhage and meatal stenosis. ... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Adenoid hypertrophy. POSTOPERATIVE DIAGNOSIS Adenoid hypertrophy. PROCEDURE PERFORMED Adenoidectomy. ANESTHESIA General endotracheal. DESCRIPTION OF PROCEDURE The patient was taken to the operating room and prepped and draped in the usual fashion after induction of general endotrac... | 11 ENT - Otolaryngology |
PREOPERATIVE DIAGNOSIS Prostate cancer Gleason score 4+3 with 85 burden and 8/12 cores positive. POSTOPERATIVE DIAGNOSIS Prostate cancer Gleason score 4+3 with 85 burden and 8/12 cores positive. PROCEDURE DONE Open radical retropubic prostatectomy with bilateral lymph node dissection. INDICATIONS This i... | 38 Surgery |
CHIEF COMPLAINT Burn right arm. HISTORY OF PRESENT ILLNESS This is a Workers Compensation injury. This patient a 41 year-old male was at a coffee shop where he works as a cook and hot oil splashed onto his arm burning from the elbow to the wrist on the medial aspect. He has had it cooled and presents wi... | 5 Consult - History and Phy. |
REASON FOR CONSULTATION Pneumatosis coli in the cecum. HISTORY OF PRESENT ILLNESS The patient is an 87-year-old gentleman who was admitted on 10/27/07 with weakness and tiredness with aspiration pneumonia. The patient is very difficult to obtain information from however he appears to be having frequent nausea ... | 5 Consult - History and Phy. |
CC Progressive lower extremity weakness. HX This 54 y/o RHF presented on 7/3/93 with a 2 month history of lower extremity weakness. She was admitted to a local hospital on 5/3/93 for a 3 day h/o of progressive BLE weakness associated with incontinence and BLE numbness. There was little symptom of upper extremity we... | 27 Orthopedic |
PREOPERATIVE DIAGNOSES 1. Basal cell carcinoma right cheek. 2. Basal cell carcinoma left cheek. 3. Bilateral ruptured silicone gel implants. 4. Bilateral Baker grade IV capsular contracture. 5. Breast ptosis. POSTOPERATIVE DIAGNOSES 1. Basal cell carcinoma right cheek. 2. Basal cell carcinoma left cheek. 3. ... | 16 Hematology - Oncology |
S - A 44-year-old 250-pound male presents with extreme pain in his left heel. This is his chief complaint. He says that he has had this pain for about two weeks. He works on concrete floors. He says that in the mornings when he gets up or after sitting he has extreme pain and great difficulty in walking. He als... | 31 Podiatry |
PREOPERATIVE DIAGNOSIS Extensive perianal and intra-anal condyloma. POSTOPERATIVE DIAGNOSIS Extensive perianal and intra-anal condyloma. PROCEDURE PERFORMED Cauterization of peri and intra-anal condylomas. ANESTHESIA IV sedation and local. SPECIMEN Multiple condylomas were sent to pathology. ESTIMATED BL... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Right lateral base of tongue lesion probable cancer. POSTOPERATIVE DIAGNOSIS Right lateral base of tongue lesion probable cancer. PROCEDURE PERFORMED Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion. ANESTHESIA General. FINDINGS An ulceration i... | 38 Surgery |
PREOP DIAGNOSIS Basal Cell CA. POSTOP DIAGNOSIS Basal Cell CA. LOCATION Mid parietal scalp. PREOP SIZE 1.5 x 2.9 cm POSTOP SIZE 2.7 x 2.9 cm INDICATION Poorly defined borders. COMPLICATIONS None. HEMOSTASIS Electrodessication. PLANNED RECONSTRUCTION Simple Linear Closure. DESCRIPTION OF PROCED... | 38 Surgery |
HISTORY OF PRESENT ILLNESS The patient is a 55-year-old gentleman who presents for further evaluation of right leg weakness. He has difficulty recollecting the exact details and chronology of his problem. To the best of his recollection he thinks that about six months ago he developed weakness of his right leg. ... | 5 Consult - History and Phy. |
CHIEF COMPLAINT Nausea vomiting diarrhea and fever. HISTORY OF PRESENT ILLNESS This patient is a 76-year-old woman who was treated with intravenous ceftriaxone and intravenous clindamycin at a care facility for pneumonia. She has developed worsening confusion fever and intractable diarrhea. She was brought... | 15 General Medicine |
PROCEDURE Endotracheal intubation. INDICATION Respiratory failure. BRIEF HISTORY The patient is a 52-year-old male with metastatic osteogenic sarcoma. He was admitted two days ago with small bowel obstruction. He has been on Coumadin for previous PE and currently on heparin drip. He became altered and subse... | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSIS Thyroid goiter. POSTOPERATIVE DIAGNOSIS Thyroid goiter. PROCEDURE PERFORMED Total thyroidectomy. ANESTHESIA 1. General endotracheal anesthesia. 2. 9 cc of 1 lidocaine with 1 100 000 epinephrine. COMPLICATIONS None. PATHOLOGY Thyroid. INDICATIONS The patient is a female with ... | 38 Surgery |
REASON FOR CONSULTATION Atrial fibrillation. HISTORY OF PRESENT ILLNESS The patient is a 78-year-old Hispanic woman with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia. Apparently the patient is a resi... | 5 Consult - History and Phy. |
PREOPERATIVE DIAGNOSIS Right profound mixed sensorineural conductive hearing loss. POSTOPERATIVE DIAGNOSIS Right profound mixed sensorineural conductive hearing loss. PROCEDURE PERFORMED Right middle ear exploration with a Goldenberg TORP reconstruction. ANESTHESIA General ESTIMATED BLOOD LOSS Less than... | 38 Surgery |
CC Rapidly progressive amnesia. HX This 63 y/o RHM presented with a 1 year history of progressive anterograde amnesia. On presentation he could not remember anything from one minute to the next. He also had some retrograde memory loss in that he could not remember the names of his grandchildren but had generally ... | 22 Neurology |
HISTORY AND CLINICAL DATA The patient is an 88-year-old gentleman followed by Dr. X his primary care physician Dr. Y for the indication of CLL and Dr. Z for his cardiovascular issues. He presents to the Care Center earlier today with approximately a one-week history of increased progressive shortness of breath o... | 5 Consult - History and Phy. |
CHIEF COMPLAINT Congestion tactile temperature. HISTORY OF PRESENT ILLNESS The patient is a 21-day-old Caucasian male here for 2 days of congestion - mom has been suctioning yellow discharge from the patient s nares plus she has noticed some mild problems with his breathing while feeding but negative for any p... | 5 Consult - History and Phy. |
PROCEDURE Esophagogastroduodenoscopy with biopsy. REASON FOR PROCEDURE The child with history of irritability and diarrhea with gastroesophageal reflux. Rule out reflux esophagitis allergic enteritis and ulcer disease as well as celiac disease. He has been on Prevacid 7.5 mg p.o. b.i.d. with suboptimal contr... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Screening. POSTOPERATIVE DIAGNOSIS Tiny Polyps. PROCEDURE PERFORMED Colonoscopy. PROCEDURE The procedure indications and risks were explained to the patient who understood and agreed. He was sedated with Versed 3 mg Demerol 25 mg during the examination. A digital rectal exam... | 38 Surgery |
PREOPERATIVE DIAGNOSES 1. Maxillary atrophy. 2. Severe mandibular atrophy. 3. Acquired facial deformity. 4. Masticatory dysfunction. POSTOPERATIVE DIAGNOSES 1. Maxillary atrophy. 2. Severe mandibular atrophy. 3. Acquired facial deformity. 4. Masticatory dysfunction. PROCEDURE PERFORMED Autologous iliac cre... | 7 Dentistry |
PREOPERATIVE DIAGNOSIS Acute appendicitis. POSTOPERATIVE DIAGNOSIS Acute appendicitis. PROCEDURE Laparoscopic appendectomy. ANESTHESIA General endotracheal. INDICATIONS Patient is a pleasant 31-year-old gentleman who presented to the hospital with acute onset of right lower quadrant pain. History as wel... | 14 Gastroenterology |
EXAM MRI of lumbar spine without contrast. HISTORY A 24-year-old female with chronic back pain. TECHNIQUE Noncontrast axial and sagittal images were acquired through the lumbar spine in varying degrees of fat and water weighting. FINDINGS The visualized cord is normal in signal intensity and morphology with... | 33 Radiology |
HISTORY OF PRESENT ILLNESS This is a follow-up visit on this 16-year-old male who is currently receiving doxycycline 150 mg by mouth twice daily as well as hydroxychloroquine 200 mg by mouth three times a day for Q-fever endocarditis. He is also taking digoxin aspirin warfarin and furosemide. Mother reports tha... | 3 Cardiovascular / Pulmonary |
DIAGNOSIS Possible cerebrovascular accident. DESCRIPTION The EEG was obtained using 21 electrodes placed in scalp-to-scalp and scalp-to-vertex montages. The background activity appears to consist of fairly organized somewhat pleomorphic low to occasional medium amplitude of 7-8 cycle per second activity and was ... | 22 Neurology |
HISTORY OF PRESENT ILLNESS This is a 41-year-old registered nurse R.N. . She was admitted following an overdose of citalopram and warfarin. The patient has had increasing depression and has been under stress as a result of dissolution of her second marriage. She notes starting in January her husband of five yea... | 5 Consult - History and Phy. |
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