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TITLE OF OPERATION Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nod... | 13 Endocrinology |
REFERRAL INDICATION AND PREPROCEDURE DIAGNOSES 1. Dilated cardiomyopathy. 2. Ejection fraction less than 10 . 3. Ventricular tachycardia. 4. Bradycardia with likely high degree of pacing. PROCEDURES PLANNED AND PERFORMED 1. Implantation of biventricular automatic implantable cardioverter defibrillator. 2. Fluoros... | 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 ... | 6 Cosmetic / Plastic Surgery |
PROCEDURE PERFORMED 1. Right femoral artery access. 2. Selective right and left coronary angiogram. 3. Left heart catheterization. 4. Left ventriculogram. INDICATIONS FOR PROCEDURE A 50-year-old lady with known history of coronary artery disease with previous stenting to the left anterior descending artery pres... | 3 Cardiovascular / Pulmonary |
DESCRIPTION OF OPERATION The patient was brought to the operating room and appropriately identified. Local anesthesia was obtained with a 50/50 mixture of 2 lidocaine and 0.75 bupivacaine given as a peribulbar block. The patient was prepped and draped in the usual sterile fashion. A lid speculum was used to pro... | 38 Surgery |
TITLE OF OPERATION Left-sided large hemicraniectomy for traumatic brain injury and increased intracranial pressure. INDICATION FOR SURGERY The patient is a patient well known to my service. She came in with severe traumatic brain injury and severe multiple fractures of the right side of the skull. I took her t... | 23 Neurosurgery |
PREOP DIAGNOSES 1. Left pilon fracture. 2. Left great toe proximal phalanx fracture. POSTOP DIAGNOSES 1. Left pilon fracture. 2. Left great toe proximal phalanx fracture. OPERATION PERFORMED 1. External fixation of left pilon fracture. 2. Closed reduction of left great toe T1 fracture. ANESTHESIA General. ... | 27 Orthopedic |
PREOPERATIVE DIAGNOSIS Bunion right foot. POSTOPERATIVE DIAGNOSIS Bunion right foot. PROCEDURE PERFORMED Austin/akin bunionectomy right foot. HISTORY This 77-year-old African-American female presents to ABCD General Hospital with the above chief complaint. The patient states she has had a bunion deformi... | 38 Surgery |
PREOPERATIVE DIAGNOSES 1. Nasolabial mesiolabial fold. 2. Mid glabellar fold. POSTOPERATIVE DIAGNOSES 1. Nasolabial mesiolabial fold. 2. Mid glabellar fold. TITLE OF PROCEDURES 1. Perlane injection for the nasolabial fold. 2. Restylane injection for the glabellar fold. ANESTHESIA Topical with Lasercai... | 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 ... | 23 Neurosurgery |
PROCEDURES 1. Right and left heart catheterization. 2. Coronary angiography. 3. Left ventriculography. PROCEDURE IN DETAIL After informed consent was obtained the patient was taken to the cardiac catheterization laboratory. Patient was prepped and draped in sterile fashion. Via modified Seldinger technique t... | 38 Surgery |
EXAM CT chest with contrast. HISTORY Abnormal chest x-ray which demonstrated a region of consolidation versus mass in the right upper lobe. TECHNIQUE Post contrast-enhanced spiral images were obtained through the chest. FINDINGS There are several discrete patchy air-space opacities in the right upper lob... | 33 Radiology |
EXTERNAL EXAMINATION The autopsy is begun at 8 30 A.M. on May 24 2004. The body is presented in a black body bag. The victim is wearing a white sleeveless turtleneck shirt and navy blue sweatpants. Jewelry included two smooth-textured silver hoop pierced earrings 1-inch diameter one in each ear and one 1-inch wi... | 1 Autopsy |
PROCEDURE Carpal tunnel release with transverse carpal ligament reconstruction. PROCEDURE IN DETAIL After administering appropriate antibiotics and MAC anesthesia the upper extremity was prepped and draped in the usual standard fashion. The arm was exsanguinated with Esmarch and the tourniquet inflated to 250 ... | 27 Orthopedic |
PREOPERATIVE DIAGNOSES 1. Nasal septal deviation. 2. Bilateral internal nasal valve collapse. 3. Bilateral external nasal valve collapse. POSTOPERATIVE DIAGNOSES 1. Nasal septal deviation. 2. Bilateral internal nasal valve collapse. 3. Bilateral external nasal valve collapse. PROCEDURES 1. Revision septoplast... | 11 ENT - Otolaryngology |
Her axial back pain is greatly improved but not completely eradicated. There is absolutely no surgery at this point in time that would be beneficial for her axial back pain due to her lumbar internal disc disruption. PAST MEDICAL HISTORY Significant for anxiety disorder. PAST SURGICAL HISTORY Foot surgery abdo... | 5 Consult - History and Phy. |
SUBJECTIVE This patient presents to the office today because he has not been feeling well. He was in for a complete physical on 05/02/2008. According to the chart the patient gives a history of feeling bad for about two weeks. At first he thought it was stress and anxiety and then he became worried it was someth... | 35 SOAP / Chart / Progress Notes |
ADMISSION DIAGNOSIS Symptomatic cholelithiasis. DISCHARGE DIAGNOSIS Symptomatic cholelithiasis. SERVICE Surgery. CONSULTS None. HISTORY OF PRESENT ILLNESS Ms. ABC is a 27-year-old woman who apparently presented with complaint of symptomatic cholelithiasis. She was afebrile. She was taken by Dr. X to th... | 10 Discharge Summary |
PREOPERATIVE DIAGNOSES 1. Left carpal tunnel syndrome. 2. Stenosing tenosynovitis of right middle finger trigger finger . POSTOPERATIVE DIAGNOSES 1. Left carpal tunnel syndrome. 2. Stenosing tenosynovitis of right middle finger trigger finger . PROCEDURES 1. Endoscopic release of left transverse carpal ligame... | 38 Surgery |
CC Difficulty with word finding. HX This 27y/o RHF experienced sudden onset word finding difficulty and slurred speech on the evening of 2/19/96. She denied any associated dysphagia diplopia numbness or weakness of her extremities. She went to sleep with her symptoms on 2/19/96 and awoke with them on 2/20/96. Sh... | 22 Neurology |
SUBJECTIVE This 1+ year black female new patient in dermatology sent in for consult from ABC Practice for initial evaluation of a lifelong history of atopic eczema. The patient’s mom is from Tanzania. The patient has been treated with Elidel cream b.i.d. for six months but apparently this has stopped working no... | 8 Dermatology |
CC Low Back Pain LBP with associated BLE weakness. HX This 75y/o RHM presented with a 10 day h/o progressively worsening LBP. The LBP started on 12/3/95 began radiating down the RLE on 12/6/95 then down the LLE on 12/9/95. By 12/10/95 he found it difficult to walk. On 12/11/95 he drove himself to his local ... | 27 Orthopedic |
SUBJECTIVE The patient is admitted for shortness of breath continues to do fairly well. The patient has chronic atrial fibrillation on anticoagulation INR of 1.72. The patient did undergo echocardiogram which shows aortic stenosis severe. The patient does have an outside cardiologist. I understand she was s... | 3 Cardiovascular / Pulmonary |
CHIEF COMPLAINT A 2-month-old female with 1-week history of congestion and fever x2 days. HISTORY OF PRESENT ILLNESS The patient is a previously healthy 2-month-old female who has had a cough and congestion for the past week. The mother has also reported irregular breathing which she describes as being rapid b... | 5 Consult - History and Phy. |
PREOPERATIVE DIAGNOSES 1. Neuromuscular dysphagia. 2. Protein-calorie malnutrition. POSTOPERATIVE DIAGNOSES 1. Neuromuscular dysphagia. 2. Protein-calorie malnutrition. PROCEDURES PERFORMED 1. Esophagogastroduodenoscopy with photo. 2. Insertion of a percutaneous endoscopic gastrostomy tube. ANESTHESIA IV se... | 38 Surgery |
PREOPERATIVE DIAGNOSES 1. Postdates pregnancy. 2. Failure to progress. 3. Meconium stained amniotic fluid. POSTOPERATIVE DIAGNOSES 1. Postdates pregnancy. 2. Failure to progress. 3. Meconium stained amniotic fluid. OPERATION Primary low-transverse C-section. ANESTHESIA Epidural. DESCRIPTION OF OPERATION ... | 24 Obstetrics / Gynecology |
REASON FOR VISIT This is an 83-year-old woman referred for diagnostic lumbar puncture for possible malignancy by Dr. X. She is accompanied by her daughter. HISTORY OF PRESENT ILLNESS The patient daughter tells me that over the last month the patient has gradually stopped walking even with her walker and her left... | 22 Neurology |
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... | 22 Neurology |
CHIEF COMPLAINT Blood in urine. HISTORY OF PRESENT ILLNESS This is a 78-year-old male who has prostate cancer with metastatic disease to his bladder and in several locations throughout the skeletal system including the spine and shoulder. The patient has had problems with hematuria in the past but the patient n... | 15 General Medicine |
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... | 5 Consult - History and Phy. |
PROCEDURE NOTE Pacemaker ICD interrogation. HISTORY OF PRESENT ILLNESS The patient is a 67-year-old gentleman who was admitted to the hospital. He has had ICD pacemaker implantation. This is a St. Jude Medical model current DRRS 12345 pacemaker. DIAGNOSIS Severe nonischemic cardiomyopathy with prior ventric... | 38 Surgery |
PREOPERATIVE DIAGNOSES 1. Intrauterine pregnancy at 39 plus weeks gestation. 2. Gestational hypertension. 3. Thick meconium. 4. Failed vacuum attempted delivery. POSTOPERATIVE DIAGNOSES 1. Intrauterine pregnancy at 39 plus weeks gestation. 2. Gestational hypertension. 3. Thick meconium. 4. Failed vacuum attempt... | 38 Surgery |
EXAM MRI SPINAL CORD CERVICAL WITHOUT CONTRAST CLINICAL Right arm pain numbness and tingling. FINDINGS Vertebral alignment and bone marrow signal characteristics are unremarkable. The C2-3 and C3-4 disk levels appear unremarkable. At C4-5 broad based disk/osteophyte contacts the ventral surface of the spinal cord ... | 33 Radiology |
PRESENTATION A 16-year-old male presents to the emergency department ED with rectal bleeding and pain on defecation. HISTORY A 16-year-old African American male presents to the ED with a chief complaint of rectal bleeding and pain on defecation. The patient states that he was well until about three days prior ... | 12 Emergency Room Reports |
HISTORY This 15-day-old female presents to Children s Hospital and transferred from Hospital Emergency Department for further evaluation. Information is obtained in discussion with the mother and the grandmother in review of previous medical records. This patient had the onset on the day of presentation of a jelly... | 29 Pediatrics - Neonatal |
OPERATIVE PROCEDURE Bronchoscopy brushings washings and biopsies. HISTORY This is a 41-year-old woman admitted to Medical Center with a bilateral pulmonary infiltrate immunocompromise. INDICATIONS FOR THE PROCEDURE Bilateral infiltrates immunocompromised host and pneumonia. Prior to procedure the patient ... | 38 Surgery |
XYZ Street City State Dear Dr. CD Thank you for seeing Mr. XYZ a pleasant 19-year-old male who has seen you in 2005 for suspected seizure activity. He comes to my office today continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years. He is requesting to come off the Dilantin a... | 22 Neurology |
PREPROCEDURE DIAGNOSIS End-stage renal disease. POSTPROCEDURE DIAGNOSIS End-stage renal disease. PROCEDURES PERFORMED 1. Left arm fistulogram. 2. Percutaneous transluminal angioplasty of the proximal and distal cephalic vein. 3. Ultrasound-guided access of left upper arm brachiocephalic fistula. ANESTHESIA ... | 38 Surgery |
PREOPERATIVE DIAGNOSIS C4-C5 C5-C6 stenosis. PREOPERATIVE DIAGNOSIS C4-C5 C5-C6 stenosis. PROCEDURE C4-C5 C5-C6 anterior cervical discectomy and fusion. COMPLICATIONS None. ANESTHESIA General. INDICATIONS OF PROCEDURE The patient is a 62-year-old female who presents with neck pain as well as upper ... | 38 Surgery |
CHIEF COMPLAINT This 32 year-old female presents today for an initial obstetrical examination. Home pregnancy test was positive. The patient indicates fetal activity is not yet detected due to early stage of pregnancy . LMP 02/13/2002 EDD 11/20/2002 GW 8.0 weeks. Patient has been trying to conceive for 6 m... | 24 Obstetrics / Gynecology |
CHIEF COMPLAINT Mental changes today. HISTORY OF PRESENT ILLNESS This patient is a resident from Mazatlan Mexico visiting her son here in Utah with a history of diabetes. She usually does not take her meal on time and also not having her regular meals lately. The patient usually still takes her diabetic med... | 5 Consult - History and Phy. |
HISTORY OF PRESENT ILLNESS The patient is a 17-year-old female who presents to the emergency room with foreign body and airway compromise and was taken to the operating room. She was intubated and fishbone. PAST MEDICAL HISTORY Significant for diabetes hypertension asthma cholecystectomy and total hysterect... | 12 Emergency Room Reports |
PREOPERATIVE DIAGNOSIS Cervical myelopathy C3-4 secondary to stenosis from herniated nucleus pulposus C3-4. POSTOPERATIVE DIAGNOSES Cervical myelopathy C3-4 secondary to stenosis from herniated nucleus pulposus C3-4. OPERATIVE PROCEDURES 1. Anterior cervical discectomy with decompression C3-4. 2. Arthrod... | 38 Surgery |
SUBJECTIVE This is a 54-year-old female who comes for dietary consultation for weight reduction secondary to diabetes. She did attend diabetes education classes at Abc Clinic. She comes however wanting to really work at weight reduction. She indicates that she has been on the Atkins diet for about two years and... | 5 Consult - History and Phy. |
REASON FOR VISIT The patient presents for a followup for history of erythema nodosum. HISTORY OF PRESENT ILLNESS This is a 25-year-old woman who is attending psychology classes. She was diagnosed with presumptive erythema nodosum in 2004 based on a biopsy consistent with erythema nodosum but not entirely specif... | 5 Consult - History and Phy. |
HISTORY Patient is a 21-year-old white woman who presented with a chief complaint of chest pain. She had been previously diagnosed with hyperthyroidism. Upon admission she had complaints of constant left sided chest pain that radiated to her left arm. She had been experiencing palpitations and tachycardia. She ... | 15 General Medicine |
GENERAL EVALUATION Fetal Cardiac Activity Normal at 150BPM. Fetal Lie Longitudinal. Fetal Presentation Cephalic. Placenta Anterior Grade I. Uterus Normal. Cervix Closed. Adnexa Not seen. Amniotic Fluid Normal. BIOMETRY BPD 8.4 cm consistent with 33 weeks 6 days gestation HC 29.8 cm consistent with 3... | 33 Radiology |
REASON FOR EXAM 1. Angina. 2. Coronary artery disease. INTERPRETATION This is a technically acceptable study. DIMENSIONS Anterior septal wall 1.2 posterior wall 1.2 left ventricular end diastolic 6.0 end systolic 4.7. The left atrium is 3.9. FINDINGS Left atrium was mildly to moderately dilated. No m... | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSIS End-stage renal disease with failing AV dialysis fistula. POSTOPERATIVE DIAGNOSIS End-stage renal disease with failing AV dialysis fistula. PROCEDURE Construction of right upper arm hemodialysis fistula with transposition of deep brachial vein. ANESTHESIA Endotracheal. DESCRIPTION OF ... | 38 Surgery |
DIAGNOSIS Ankle sprain left ankle. HISTORY The patient is a 31-year-old female who was referred to Physical Therapy secondary to a fall on 10/03/08. The patient states that she tripped over her dog toy and fell with her left foot inverted. The patient states that she received a series of x-rays and MRIs that w... | 27 Orthopedic |
CHIEF COMPLAINT A lot has been thrown at me. The patient is interviewed with husband in room. HISTORY OF PRESENT ILLNESS This is a 69-year-old Caucasian woman with a history of Huntington disease who presented to Hospital four days ago after an overdose of about 30 Haldol tablets 5 mg each and Tylenol tablet 3... | 5 Consult - History and Phy. |
She started her periods at age 13. She is complaining of a three-month history of lower abdominal pain for which she has been to the emergency room twice. She describes the pain as bilateral intermittent and non-radiating. It decreases slightly when she eats and increases with activity. She states the pain when i... | 24 Obstetrics / Gynecology |
SUBJECTIVE This is a 2-year-old female who comes in for just rechecking her weight her breathing status and her diet. The patient is in foster care has a long history of the prematurity born at 22 weeks. She has chronic lung disease is on ventilator but doing sprints has been doing very well is up to 4-1/2... | 5 Consult - History and Phy. |
EXAM MRI CERVICAL SPINE CLINICAL A57-year-old male. Received for outside consultation is an MRI examination performed on 11/28/2005. FINDINGS Normal brainstem-cervical cord junction. Normal cisterna magna with no tonsillar ectopia. Normal clivus with a normal craniovertebral junction. Normal anterior atlantoaxial a... | 33 Radiology |
DIAGNOSIS AT ADMISSION Hypothermia. DIAGNOSES ON DISCHARGE 1. Hypothermia. 2. Rule out sepsis was negative as blood cultures sputum cultures and urine cultures were negative. 3. Organic brain syndrome. 4. Seizure disorder. 5. Adrenal insufficiency. 6. Hypothyroidism. 7. Anemia of chronic disease. HOSPITAL COURSE ... | 10 Discharge Summary |
SUBJECTIVE The patient is keeping a food journal that she brought in. She is counting calorie points which ranged 26 to 30 per day. She is exercising pretty regularly. She attends Overeaters Anonymous and her sponsor is helping her and told her to get some ideas on how to plan snacks to prevent hypoglycemia. Th... | 35 SOAP / Chart / Progress Notes |
PREPROCEDURE DIAGNOSIS Chest pain secondary to fractured ribs unmanageable with narcotics. POSTPROCEDURE DIAGNOSIS Chest pain secondary to fractured ribs unmanageable with narcotics. PROCEDURE Intercostal block from fourth to tenth intercostal spaces left. INDICATIONS I was requested by Dr. X to do an in... | 28 Pain Management |
PREOPERATIVE DIAGNOSES 1. Pelvic pain. 2. Ectopic pregnancy. POSTOPERATIVE DIAGNOSES 1. Pelvic pain. 2. Ectopic pregnancy. 3. Hemoperitoneum. PROCEDURES PERFORMED 1. Dilation and curettage D C . 2. Laparoscopy. 3. Right salpingectomy. 4. Lysis of adhesions. 5. Evacuation of hemoperitoneum. ANESTHESIA G... | 24 Obstetrics / Gynecology |
PREOPERATIVE DIAGNOSES 1. Left breast mass. 2. Hypertrophic scar of the left breast. POSTOPERATIVE DIAGNOSES 1. Left breast mass. 2. Hypertrophic scar of the left breast. PROCEDURE PERFORMED Excision of left breast mass and revision of scar. ANESTHESIA Local with sedation. SPECIMEN Scar with left breast ... | 16 Hematology - Oncology |
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... | 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... | 21 Nephrology |
DISCHARGE DIAGNOSIS 1. Respiratory failure improved. 2. Hypotension resolved. 3. Anemia of chronic disease stable. 4. Anasarca improving. 5. Protein malnourishment improving. 6. End-stage liver disease. HISTORY AND HOSPITAL COURSE The patient was admitted after undergoing a drawn out process with a small bowe... | 10 Discharge Summary |
As you know the patient is a 50-year-old right-handed Caucasian female who works as an independent contractor and as a human resources consultant. Her neurological history first begins in December of 1987 when she had a rather sudden onset of slurred speech and the hesitancy when she started to walk. She had HMO in... | 22 Neurology |
REASON FOR EXAM CVA. INDICATIONS CVA. This is technically acceptable. There is some limitation related to body habitus. DIMENSIONS The interventricular septum 1.2 posterior wall 10.9 left ventricular end-diastolic 5.5 and end-systolic 4.5 the left atrium 3.9. FINDINGS The left atrium was mildly dilated... | 33 Radiology |
EXAM Bilateral renal ultrasound. CLINICAL INDICATION UTI. TECHNIQUE Transverse and longitudinal sonograms of the kidneys were obtained. FINDINGS The right kidney is of normal size and echotexture and measures 5.7 x 2.2 x 3.8 cm. The left kidney is of normal size and echotexture and measures 6.2 x 2.8 x 3.0... | 33 Radiology |
CHIEF COMPLAINT - REASON FOR VISIT Pelvic Pain and vaginal discharge. ABNORMAL PAP HISTORY Date of abnormal pap 1998. Findings High grade squamous intraepithelial lesions. Previous colposcopic exam and biopsies showed mild dysplasia or CIN 1. Patient is sexually active and has had 1 partner. There is no history ... | 24 Obstetrics / Gynecology |
NERVE CONDUCTION STUDIES Bilateral ulnar sensory responses are absent. Bilateral median sensory distal latencies are prolonged with a severely attenuated evoked response amplitude. The left radial sensory response is normal and robust. Left sural response is absent. Left median motor distal latency is prolonged ... | 30 Physical Medicine - Rehab |
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 ... | 24 Obstetrics / Gynecology |
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... | 38 Surgery |
HEENT No history of headaches migraines vertigo syncope visual loss tinnitus sinusitis sore in the mouth hoarseness swelling or goiter. RESPIRATORY No shortness of breath wheezing dyspnea pulmonary disease tuberculosis or past pneumonias. CARDIOVASCULAR No history of palpitations irregular rhythm... | 15 General Medicine |
REASON FOR CONSULTATION Syncope. HISTORY OF PRESENT ILLNESS The patient is a 78-year-old lady followed by Dr. X in our practice with history of coronary artery disease status post coronary artery bypass grafting in 2005 presented to the emergency room following a syncopal episode. According to the patient and t... | 5 Consult - History and Phy. |
BILATERAL SCROTAL ORCHECTOMY PROCEDURE The patient is placed in the supine position prepped and draped in the usual manner. Under satisfactory general anesthesia the scrotum was approached and through a transverse mid scrotal incision the right testicle was delivered through the incision. Hemostasis was obtain... | 39 Urology |
TITLE OF OPERATION Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nod... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Herniated nucleus pulposus C5-C6 with spinal stenosis. POSTOPERATIVE DIAGNOSIS Herniated nucleus pulposus C5-C6 with spinal stenosis. PROCEDURE Anterior cervical discectomy with fusion C5-C6. PROCEDURE IN DETAIL The patient was placed in supine position. The neck was prepped and ... | 27 Orthopedic |
PREOPERATIVE DIAGNOSIS Rule out temporal arteritis. POSTOPERATIVE DIAGNOSIS Rule out temporal arteritis. PROCEDURE Bilateral temporal artery biopsy. ANESTHESIA Local anesthesia 1 Xylocaine with epinephrine. INDICATIONS I was consulted by Dr. X for this patient with bilateral temporal headaches to rule o... | 23 Neurosurgery |
PREOPERATIVE DIAGNOSES 1. Gastroesophageal reflux disease. 2. Hiatal hernia. POSTOPERATIVE DIAGNOSES 1. Gastroesophageal reflux disease. 2. Hiatal hernia. 3. Enterogastritis. PROCEDURE PERFORMED Esophagogastroduodenoscopy photography and biopsy. GROSS FINDINGS The patient has a history of epigastric abdo... | 38 Surgery |
PREOPERATIVE DIAGNOSES Vault prolapse and rectocele. POSTOPERATIVE DIAGNOSES Vault prolapse and rectocele. OPERATION Colpocleisis and rectocele repair. ANESTHESIA Spinal. ESTIMATED BLOOD LOSS Minimal. FLUIDS Crystalloid. BRIEF HISTORY OF THE PATIENT This is an 85-year-old female who presented to us... | 24 Obstetrics / Gynecology |
SUMMARY This patient is one-day postop open parathyroid exploration with subtotal parathyroidectomy and intraoperative PTH monitoring for parathyroid hyperplasia. She has had an uneventful postoperative night. She put out 1175 mL of urine since surgery. Her incision looks good. IV site and extremities are unrema... | 35 SOAP / Chart / Progress Notes |
FINDINGS There are posttraumatic cysts along the volar midline and volar lateral aspects of the lunate which are likely posttraumatic. There is no acute marrow edema series #12 images #5-7 . Marrow signal is otherwise normal in the distal radius and ulna throughout the carpals and throughout the proximal metacarpals... | 33 Radiology |
PREOPERATIVE DIAGNOSIS Closed displaced angulated fracture of the right distal radius. POSTOPERATIVE DIAGNOSIS Closed displaced angulated fracture of the right distal radius. PROCEDURE Open reduction and internal fixation ORIF of the right wrist using an Acumed locking plate. ANESTHESIA General laryngeal ... | 27 Orthopedic |
CLINICAL HISTORY Patient is a 37-year-old female with a history of colectomy for adenoma. During her preop evaluation it was noted that she had a lesion on her chest x-ray. CT scan of the chest confirmed a left lower mass. SPECIMEN Lung left lower lobe resection. IMMUNOHISTOCHEMICAL STUDIES Tumor cells show... | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSES 1. Left facial cellulitis. 2. Possible odontogenic abscess of the #18 #19 and #20. POSTOPERATIVE DIAGNOSES 1. Left facial cellulitis. 2. Possible odontogenic abscess of the #18 #19 and #20. PROCEDURE PERFORMED Attempted incision and drainage I D of odontogenic abscess. ANESTHESIA ... | 7 Dentistry |
REASON FOR NEUROLOGICAL CONSULTATION Muscle twitching clumsiness progressive pain syndrome and gait disturbance. HISTORY OF PRESENT ILLNESS The patient is a 62-year-old African-American male with a significant past medical history of diabetes hypertension previous stroke in 2002 with minimal residual right-s... | 5 Consult - History and Phy. |
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... | 33 Radiology |
REASON FOR CONSULTATION I was asked by Dr. X to see the patient in regard to his likely recurrent brain tumor. HISTORY OF PRESENT ILLNESS The patient was admitted for symptoms that sounded like postictal state. He was initially taken to Hospital. CT showed edema and slight midline shift and therefore he was tr... | 16 Hematology - Oncology |
PREOPERATIVE DIAGNOSES 1. Senile nuclear cataract left eye. 2. Senile cortical cataract left eye. POSTOPERATIVE DIAGNOSES 1. Senile nuclear cataract left eye. 2. Senile cortical cataract left eye. PROCEDURES Phacoemulsification of cataract extraocular lens implant in left eye. LENS IMPLANT USED A... | 26 Ophthalmology |
REASON FOR CONSULTATION Atrial fibrillation management. HISTORY OF PRESENT ILLNESS The patient is a very pleasant 62-year-old African American female with a history of hypertension hypercholesterolemia and CVA referred by Dr. X for evaluation and management of atrial fibrillation. The patient states that on Mo... | 5 Consult - History and Phy. |
FAMILY HISTORY Her father died from leukemia. Her mother died from kidney and heart failure. She has two brothers five sisters one with breast cancer two sons and a daughter. She describes cancer hypertension nervous condition kidney disease high cholesterol and depression in her family. SOCIAL HISTORY ... | 27 Orthopedic |
PREOPERATIVE DIAGNOSIS Squamous cell carcinoma left nasal cavity. POSTOPERATIVE DIAGNOSIS Squamous cell carcinoma left nasal cavity. OPERATIONS PERFORMED 1. Nasal endoscopy. 2. Partial rhinectomy. ANESTHESIA General endotracheal. INDICATIONS This is an 81-year-old gentleman who underwent septorhinoplas... | 38 Surgery |
PREOPERATIVE DIAGNOSES 1. Left facial cellulitis. 2. Possible odontogenic abscess of the #18 #19 and #20. POSTOPERATIVE DIAGNOSES 1. Left facial cellulitis. 2. Possible odontogenic abscess of the #18 #19 and #20. PROCEDURE PERFORMED Attempted incision and drainage I D of odontogenic abscess. ANESTHESIA ... | 38 Surgery |
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... | 8 Dermatology |
PREOPERATIVE DIAGNOSES 1. Ventilator-dependent respiratory failure. 2. Multiple strokes. POSTOPERATIVE DIAGNOSES 1. Ventilator-dependent respiratory failure. 2. Multiple strokes. PROCEDURES PERFORMED 1. Tracheostomy. 2. Thyroid isthmusectomy. ANESTHESIA General endotracheal tube. BLOOD LOSS Minimal less... | 38 Surgery |
CC Gait difficulty. HX This 59 y/o RHF was admitted with complaint of gait difficulty. The evening prior to admission she noted sudden onset of LUE and LLE weakness. She felt she favored her right leg but did not fall when walking. She denied any associated dysarthria facial weakness chest pain SOB visual chan... | 22 Neurology |
PREOPERATIVE DIAGNOSES 1. Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy. 2. Epidural fibrosis with nerve root entrapment. POSTOPERATIVE DIAGNOSES 1. Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy. 2. Epidural fibr... | 38 Surgery |
PREOPERATIVE DIAGNOSES 1. Hyperpyrexia/leukocytosis. 2. Ventilator-dependent respiratory failure. 3. Acute pancreatitis. POSTOPERATIVE DIAGNOSES 1. Hyperpyrexia/leukocytosis. 2. Ventilator-dependent respiratory failure. 3. Acute pancreatitis. PROCEDURE PERFORMED 1. Insertion of a right brachial artery arteria... | 3 Cardiovascular / Pulmonary |
ENDOVASCULAR BRACHYTHERAPY EBT The patient is to undergo a course of angioplasty for in-stent restenosis. The radiotherapy will be planned using simulation films when the Novoste system catheter markers are placed on either side of the coronary artery injury site. After this a calculation will take place to determ... | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSIS Volar laceration to right ring finger with possible digital nerve injury with possible flexor tendon injury. POSTOPERATIVE DIAGNOSES 1. Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis. 2. 25 laceration to the ... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Nasal deformity status post rhinoplasty. POSTOPERATIVE DIAGNOSIS Same. PROCEDURE Revision rhinoplasty CPT 30450 . Left conchal cartilage harvest CPT 21235 . ANESTHESIA General. INDICATIONS FOR THE PROCEDURE This patient is an otherwise healthy male who had a previous nasal frac... | 38 Surgery |
PREOPERATIVE DIAGNOSIS History of bladder tumor with abnormal cytology and areas of erythema. POSTOPERATIVE DIAGNOSIS History of bladder tumor with abnormal cytology and areas of erythema. PROCEDURE PERFORMED 1. Cystoscopy. 2. Bladder biopsy with fulguration. ANESTHESIA IV sedation with local. SPECIMEN U... | 38 Surgery |
CC Headache and diplopia. HX This 39 y/o African American female began experiencing severe constant pressure pain type headaches beginning the last week of 8/95. The pain localized to bifronto-temporal regions of the head and did not radiate. There was no associated nausea vomiting photophobia or phonophobia. The... | 5 Consult - History and Phy. |
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