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CHIEF COMPLAINT I need refills. HISTORY OF PRESENT ILLNESS The patient presents today stating that she needs refills on her Xanax and she would also like to get something to help her quit smoking. She is a new patient today. She states that she has mesothelioma in the lining of her stomach and that it does cau... | 25 Office Notes |
PREOPERATIVE DIAGNOSES 1. Hematochezia. 2. Refractory dyspepsia. POSTOPERATIVE DIAGNOSES 1. Colonic polyps at 35 cm and 15 cm. 2. Diverticulosis coli. 2. Acute and chronic gastritis. PROCEDURE PERFORMED 1. Colonoscopy to cecum with snare polypectomy. 2. Esophagogastroduodenoscopy with biopsies. INDICATIONS FO... | 38 Surgery |
PREOPERATIVE DIAGNOSES Open displaced infected left atrophic mandibular fracture failed dental implant. POSTOPERATIVE DIAGNOSES Open displaced infected left atrophic mandibular fracture failed dental implant. PROCEDURE PERFORMED Open reduction and internal fixation ORIF of left atrophic mandibular frac... | 27 Orthopedic |
PREOPERATIVE DIAGNOSES 1. Hallux abductovalgus right foot. 2. Hammer toe right foot second third fourth and fifth toes. 3. Tailor s bunionette right foot. 4. Degenerative joint disease right first metatarsophalangeal joint. 5. Rheumatoid arthritis. 6. Contracted fourth right metatarsophalangeal joint. POS... | 27 Orthopedic |
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... | 7 Dentistry |
PREOPERATIVE DIAGNOSIS Symptomatic disk herniation C7-T1. FINAL DIAGNOSIS Symptomatic disk herniation C7-T1. PROCEDURES PERFORMED 1. Anterior cervical discectomy with decompression of spinal cord C7-T1. 2. Anterior cervical fusion C7-T1. 3. Anterior cervical instrumentation anterior C7-T1. 4. Insertion of... | 27 Orthopedic |
PREOPERATIVE DIAGNOSIS Lateral epicondylitis. | 27 Orthopedic |
ACNE VULGARIS commonly referred to as just acne is a chronic inflammation of the skin that occurs most often during adolescence but can occur off and on throughout life. The skin eruptions most often appear on the face chest back and upper arms and are more common in males than females. SIGNS AND SYMPTOMS Bla... | 8 Dermatology |
ADMITTING DIAGNOSES 1. Vomiting probably secondary to gastroenteritis. 2. Goldenhar syndrome. 3. Severe gastroesophageal reflux. 4. Past history of aspiration and aspiration pneumonia. DISCHARGE DIAGNOSES 1. Gastroenteritis versus bowel obstruction. 2. Gastroesophageal reflux. 3. Goldenhar syndrome. 4. Anemia ... | 10 Discharge Summary |
HISTORY OF PRESENT ILLNESS Mr. A is a 50-year-old gentleman with a history of atrial fibrillation in the past more recently who has had atrial flutter who estimates he has had six cardioversions since 10/09 and estimates that he has had 12 to 24 in his life beginning in 2006 when the atrial fibrillation first eme... | 3 Cardiovascular / Pulmonary |
CHIEF COMPLAINT Toothache. HISTORY OF PRESENT ILLNESS This is a 29-year-old male who has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled. Complains of new tooth pain. The patient states his current toothache is to both upper and lower teeth on the left s... | 5 Consult - History and Phy. |
PREOPERATIVE DIAGNOSIS Malignant pleural effusion left with dyspnea. POSTOPERATIVE DIAGNOSIS Malignant pleural effusion left with dyspnea. PROCEDURE Thoracentesis left. DESCRIPTION OF PROCEDURE The patient was brought to the recovery area of the operating room. After obtaining the informed consent th... | 38 Surgery |
XYZ S. RE ABC Dear Dr. XYZ On your kind referral I had the pleasure of meeting and consulting with ABC on MM/DD/YYYY for evaluation regarding extraction of his mandibular left second molar tooth #18. This previously root-canaled tooth now failed is scheduled for removal. As per your request I agree that placem... | 20 Letters |
PREOPERATIVE DIAGNOSIS Headaches question of temporal arteritis. POSTOPERATIVE DIAGNOSIS Headaches question of temporal arteritis. PROCEDURE Bilateral temporal artery biopsies. DESCRIPTION OF PROCEDURE After obtaining an informed consent the patient was brought to the operating room where her right tempo... | 38 Surgery |
DELIVERY NOTE On 12/23/08 at 0235 hours a 23-year-old G1 P0 white female GBS negative under epidural anesthesia delivered a viable female infant with Apgar scores of 7 and 9. Points taken of for muscle tone and skin color. Weight and length are unknown at this time. Delivery was via spontaneous vaginal deli... | 24 Obstetrics / Gynecology |
PREOPERATIVE DX Dermatochalasis mechanical ptosis brow ptosis. POSTOPERATIVE DX Same PROCEDURE Upper lid blepharoplasty and direct brow lift ANESTHESIA Local with sedation INDICATIONS FOR SURGERY In the preoperative evaluation the patient was found to have visually significant and symptomatic dermatochala... | 26 Ophthalmology |
PREOPERATIVE DIAGNOSIS Cranial defect greater than 10 cm in diameter in the frontal region. POSTOPERATIVE DIAGNOSIS Cranial defect greater than 10 cm in diameter in the frontal region. PROCEDURE Bifrontal cranioplasty. ANESTHESIA General endotracheal anesthesia. ESTIMATED BLOOD LOSS Nil. INDICATIONS FOR ... | 23 Neurosurgery |
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 ... | 27 Orthopedic |
PREOPERATIVE DIAGNOSIS 1. Left chronic anterior and posterior ethmoiditis. 2. Left chronic maxillary sinusitis with polyps. 3. Left inferior turbinate hypertrophy. 4. Right anterior and posterior chronic ethmoiditis. 5. Right chronic maxillary sinusitis with polyps. 6. Right chronic inferior turbinate hypertroph... | 11 ENT - Otolaryngology |
HISTORY OF PRESENT ILLNESS The patient is a 68-year-old woman whom I have been following who has had angina. In any case today she called me because she had a recurrent left arm pain after her stent three days ago and this persisted after two sublingual nitroglycerin when I spoke to her. I advised her to call ... | 12 Emergency Room Reports |
CHIEF COMPLAINT This 5-year-old male presents to Children s Hospital Emergency Department by the mother with have asthma. Mother states he has been wheezing and coughing. They saw their primary medical doctor. He was evaluated at the clinic given the breathing treatment and discharged home was not having asth... | 12 Emergency Room Reports |
PAST MEDICAL HISTORY Significant for arthritis in her knee anxiety depression high insulin levels gallstone attacks and PCOS. PAST SURGICAL HISTORY None. SOCIAL HISTORY Currently employed. She is married. She is in sales. She does not smoke. She drinks wine a few drinks a month. CURRENT MEDICATIONS ... | 5 Consult - History and Phy. |
REASON FOR CONSULTATION Management of end-stage renal disease ESRD the patient on chronic hemodialysis being admitted for chest pain. HISTORY OF PRESENT ILLNESS This is a 66-year-old Native American gentleman a patient of Dr. X my associate who has a past medical history of coronary artery disease status ... | 21 Nephrology |
CHIEF COMPLAINT Stomach pain for 2 weeks. HISTORY OF PRESENT ILLNESS The patient is a 45yo Mexican man without significant past medical history who presents to the emergency room with complaints of mid-epigastric and right upper quadrant abdominal pain for the last 14 days. The pain was initially crampy and burning... | 14 Gastroenterology |
PROCEDURES Left heart catheterization left ventriculography and left and right coronary arteriography. INDICATIONS Chest pain and non-Q-wave MI with elevation of troponin I only. TECHNIQUE The patient was brought to the procedure room in satisfactory condition. The right groin was prepped and draped in rout... | 38 Surgery |
PROCEDURE PERFORMED Laparoscopic cholecystectomy with attempted intraoperative cholangiogram. PROCEDURE After informed consent was obtained the patient was brought to the operating room and placed supine on the operating room table. General endotracheal anesthesia was induced without incident. The patient was ... | 38 Surgery |
EXAM CT maxillofacial for trauma. FINDINGS CT examination of the maxillofacial bones was performed without contrast. Coronal reconstructions were obtained for better anatomical localization. There is normal appearance to the orbital rims. The ethmoid sphenoid and frontal sinuses are clear. There is polypoid ... | 11 ENT - Otolaryngology |
REASON FOR EVALUATION The patient is a 37-year-old white single male admitted to the hospital through the emergency room. I had seen him the day before in my office and recommended him to go into the hospital. He had just come from a trip to Taho in Nevada and he became homicidal while there. He started having th... | 5 Consult - History and Phy. |
EXAM CT scan of the abdomen and pelvis with contrast. REASON FOR EXAM Abdominal pain. COMPARISON EXAM None. TECHNIQUE Multiple axial images of the abdomen and pelvis were obtained. 5-mm slices were acquired after injection of 125 cc of Omnipaque IV. In addition oral ReadiCAT was given. Reformatted sagit... | 33 Radiology |
CHIEF COMPLAINT Right distal ureteral calculus. HISTORY OF PRESENT ILLNESS The patient had hematuria and a CT urogram at ABC Radiology on 01/04/07 showing a 1 cm non-obstructing calcification in the right distal ureter. He had a KUB also showing a teardrop shaped calcification apparently in the right lower urete... | 5 Consult - History and Phy. |
The patient was placed in the left lateral decubitus position medicated with the above medications to achieve and maintain a conscious sedation. Vital signs were monitored throughout the procedure without evidence of hemodynamic compromise or desaturation. The Olympus single-channel endoscope was passed under direct ... | 14 Gastroenterology |
EXAM Renal ultrasound. HISTORY Renal failure neurogenic bladder status-post cystectomy. TECHNIQUE Multiple ultrasonographic images of the kidneys were obtained in the transverse and longitudinal planes. COMPARISON Most recently obtained mm/dd/yy. FINDINGS The right kidney measures 12 x 5.2 x 4.6 cm and... | 21 Nephrology |
HISTORY This patient with prenatal care in my office who did have some preterm labor and was treated with nifedipine and was stable on nifedipine and bed rest unfortunately felt decreased fetal movement yesterday 12/29/08 presented to the hospital for evaluation on the evening of 12/29/08. At approximately 2030... | 24 Obstetrics / Gynecology |
HISTORY OF PRESENT ILLNESS Goes back to yesterday the patient went out for dinner with her boyfriend. The patient after coming home all the family members had some episodes of diarrhea it is unclear how many times the patient had diarrhea last night. She was found down on the floor this morning soiled her bowel... | 15 General Medicine |
PREOPERATIVE DIAGNOSIS Bilateral open mandible fracture open left angle and open symphysis fracture. POSTOPERATIVE DIAGNOSIS Bilateral open mandible fracture open left angle and open symphysis fracture. PROCEDURE Closed reduction of mandible fracture with MMF. ANESTHESIA General anesthesia via nasal endot... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Large left adnexal mass 8 cm in diameter. POSTOPERATIVE DIAGNOSIS Pelvic adhesions 6 cm ovarian cyst. PROCEDURES PERFORMED 1. Pelvic laparotomy. 2. Lysis of pelvic adhesions. 3. Left salpingooophorectomy with insertion of Pain-Buster Pain Management System by Dr. X. GROSS FINDINGS ... | 24 Obstetrics / Gynecology |
PREOPERATIVE DIAGNOSES 1. Hammertoe deformity left fifth digit. 2. Ulceration of the left fifth digit plantolaterally. POSTOPERATIVE DIAGNOSIS 1. Hammertoe deformity left fifth toe. 2. Ulceration of the left fifth digit plantolaterally. PROCEDURE PERFORMED 1. Arthroplasty of the left fifth digit proximal inte... | 27 Orthopedic |
SUBJECTIVE The patient is a 49-year-old white female established patient to Dermatology last seen in the office on 08/10/2004. She comes in today for reevaluation of her acne plus she has had what she calls a rash for the past two months now on her chest stomach neck and back. On examination this is a flarin... | 8 Dermatology |
PREOPERATIVE DIAGNOSIS ES L4-L5 and L5-S1 degenerative disk disease/disk protrusions/spondylosis with radiculopathy. POSTOPERATIVE DIAGNOSIS ES L4-L5 and L5-S1 degenerative disk disease/disk protrusions/spondylosis with radiculopathy. PROCEDURE 1. Left L4-L5 and L5-S1 Transforaminal Lumbar Interbody Fusion TL... | 38 Surgery |
OPERATION PERFORMED Dental prophylaxis under general anesthesia. PREOPERATIVE DIAGNOSES 1. Impacted wisdom teeth. 2. Moderate gingivitis. POSTOPERATIVE DIAGNOSES 1. Impacted wisdom teeth. 2. Moderate gingivitis. COMPLICATIONS None. ESTIMATED BLOOD LOSS Minimal. DURATION OF SURGERY One hour 17 minutes.... | 7 Dentistry |
TECHNIQUE Sequential axial CT images were obtained from the vertex to the skull base without contrast. FINDINGS There is mild generalized atrophy. Scattered patchy foci of decreased attenuation are seen within the sub cortical and periventricular white matter compatible with chronic small vessel ischemic changes... | 33 Radiology |
PREOPERATIVE DIAGNOSIS Right lateral epicondylitis. POSTOPERATIVE DIAGNOSIS Right lateral epicondylitis. OPERATION PERFORMED OssaTron extracorporeal shockwave therapy to right lateral epicondyle. ANESTHESIA Bier block. DESCRIPTION OF PROCEDURE With the patient under adequate Bier block anesthesia the pa... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Right occipital arteriovenous malformation. POSTOPERATIVE DIAGNOSIS Right occipital arteriovenous malformation. PROCEDURE PERFORMED CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking. Please note no qualified resident w... | 23 Neurosurgery |
MULTISYSTEM EXAM CONSTITUTIONAL The vital signs showed that the patient was afebrile blood pressure and heart rate were within normal limits. The patient appeared alert. EYES The conjunctiva was clear. The pupil was equal and reactive. There was no ptosis. The irides appeared normal. EARS NOSE AND THROAT ... | 15 General Medicine |
HISTORY OF PRESENT ILLNESS This is a 3-year-old female patient who was admitted today with a history of gagging. She was doing well until about 2 days ago when she developed gagging. No vomiting. No fever. She has history of constipation. She normally passes stool every two days after giving an enema. No rec... | 29 Pediatrics - Neonatal |
IDENTIFYING DATA The patient is a 30-year-old white male with a history of schizophrenia chronic paranoid was admitted for increasing mood lability paranoia and agitation. CHIEF COMPLAINT I am not sure. The patient has poor insight into hospitalization and need for treatment. HISTORY OF PRESENT ILLNESS T... | 32 Psychiatry / Psychology |
EXAM CT of the abdomen and pelvis without contrast. HISTORY Lower abdominal pain. FINDINGS Limited views of the lung bases demonstrate linear density most likely representing dependent atelectasis. There is a 1.6 cm nodular density at the left posterior sulcus. Noncontrast technique limits evaluation of the s... | 21 Nephrology |
PRINCIPAL DIAGNOSIS Mesothelioma. SECONDARY DIAGNOSES Pleural effusion atrial fibrillation anemia ascites esophageal reflux and history of deep venous thrombosis. PROCEDURES 1. On August 24 2007 decortication of the lung with pleural biopsy and transpleural fluoroscopy. 2. On August 20 2007 thoracentes... | 10 Discharge Summary |
INTERPRETATION 1. Predominant rhythm is normal sinus rhythm. 2. No supraventricular arrhythmia. 3. Frequent premature ventricular contractions. 4. Trigemini and couplets. 5. No high-grade atrial ventricular block was noted. 6. Diary was not kept. IMPRESSION Frequent premature atrial contractions couplets an... | 3 Cardiovascular / Pulmonary |
EXAM Cervical lumbosacral thoracic spine flexion and extension. HISTORY Back and neck pain. CERVICAL SPINE FINDINGS AP lateral with flexion and extension and both oblique projections of the cervical spine demonstrate alignment and soft tissue structures to be unremarkable. | 33 Radiology |
PREOPERATIVE DIAGNOSES 1. Status post multiple trauma/motor vehicle accident. 2. Acute respiratory failure. 3. Acute respiratory distress/ventilator asynchrony. 4. Hypoxemia. 5. Complete atelectasis of left lung. POSTOPERATIVE DIAGNOSES 1. Status post multiple trauma/motor vehicle accident. 2. Acute respirator... | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSIS Lumbar stenosis. POSTOPERATIVE DIAGNOSES Lumbar stenosis and cerebrospinal fluid fistula. TITLE OF THE OPERATION 1. Lumbar laminectomy for decompression with foraminotomies L3-L4 L4-L5 L5-S1 microtechniques. 2. Repair of CSF fistula microtechniques L5-S1 application of DuraSeal. INDIC... | 23 Neurosurgery |
CT ABDOMEN WITH AND WITHOUT CONTRAST AND CT PELVIS WITH CONTRAST REASON FOR EXAM Generalized abdominal pain nausea diarrhea and recent colonic resection in 11/08. TECHNIQUE Axial CT images of the abdomen were obtained without contrast. Axial CT images of the abdomen and pelvis were then obtained utilizing 100... | 14 Gastroenterology |
DIAGNOSES 1. Juvenile myoclonic epilepsy. 2. Recent generalized tonic-clonic seizure. MEDICATIONS 1. Lamictal 250 mg b.i.d. 2. Depo-Provera. INTERIM HISTORY The patient returns for followup. Since last consultation she has tolerated Lamictal well but she has had a recurrence of her myoclonic jerking. She ha... | 22 Neurology |
PREOPERATIVE DIAGNOSIS Left breast mass with abnormal mammogram. POSTOPERATIVE DIAGNOSIS Left breast mass with abnormal mammogram. PROCEDURE PERFORMED Needle-localized excisional biopsy of the left breast. ANESTHESIA Local with sedation. COMPLICATIONS None. SPECIMEN Breast mass. DISPOSITION The pati... | 38 Surgery |
PRE-ECLAMPSIA is a very serious condition unique to pregnancy in which blood pressure the kidneys and the central nervous system are compromised. It usually occurs from the 20th week of pregnancy to 7 days postpartum. The cause is unknown. It is also known as pregnancy-induced hypertension or toxemia of pregnancy.... | 24 Obstetrics / Gynecology |
PHYSICAL EXAMINATION GENERAL The patient is awake and alert in no apparent distress appropriate pleasant and cooperative. No dysarthria is noted. No discomfort on presentation is noted. HEAD Atraumatic normocephalic. Pupils are equal round and reactive to light. Extraocular muscles are intact. Sclerae ... | 15 General Medicine |
PREOPERATIVE DIAGNOSES 1. Eyebrow ptosis. 2. Dermatochalasia of upper and lower eyelids with tear trough deformity of the lower eyelid. 3. Cervical facial aging with submental lipodystrophy. OPERATION 1. Hairline biplanar temporal browlift. 2. Quadrilateral blepharoplasty with lateral canthopexy with arcus margi... | 6 Cosmetic / Plastic Surgery |
REASON FOR THE CONSULT Nonhealing right ankle stasis ulcer. HISTORY OF PRESENT ILLNESS This is a 52-year-old native American-Indian man with hypertension chronic intermittent bipedal edema and recurrent leg venous ulcers who was admitted on 01/27/09 for scheduled vascular surgery per Dr. X. I was consulted for... | 5 Consult - History and Phy. |
PREOPERATIVE DIAGNOSIS Bilateral hydroceles. POSTOPERATIVE DIAGNOSIS Bilateral hydroceles. PROCEDURE Bilateral scrotal hydrocelectomies large for both and 0.5 Marcaine wound instillation 30 mL given. ESTIMATED BLOOD LOSS Less than 10 mL. FLUIDS RECEIVED 800 mL. TUBES AND DRAINS A 0.25-inch Penrose... | 39 Urology |
PREOPERATIVE DIAGNOSIS Prostate cancer. POSTOPERATIVE DIAGNOSIS Prostate cancer. OPERATIVE PROCEDURE Radical retropubic prostatectomy with pelvic lymph node dissection. ANESTHESIA General epidural ESTIMATED BLOOD LOSS 800 cc. COMPLICATIONS None. INDICATIONS FOR SURGERY This is a 64-year-old man wit... | 39 Urology |
PREOPERATIVE DIAGNOSIS Symptomatic cholelithiasis. POSTOPERATIVE DIAGNOSIS Symptomatic cholelithiasis. PROCEDURE Laparoscopic cholecystectomy and appendectomy CPT 47563 44970 . ANESTHESIA General endotracheal. INDICATIONS This is an 18-year-old girl with sickle cell anemia who has had symptomatic chole... | 38 Surgery |
PROCEDURES PERFORMED Colonoscopy. INDICATIONS Renewed symptoms likely consistent with active flare of Inflammatory Bowel Disease not responsive to conventional therapy including sulfasalazine cortisone local therapy. PROCEDURE Informed consent was obtained prior to the procedure with special attention to be... | 14 Gastroenterology |
PREOPERATIVE DIAGNOSES 1. Acquired absence of bilateral breast status post previous bilateral DIEP flap reconstruction. 2. Bilateral breast asymmetry. 3. Right breast macromastia. 4. Right abdominal scar deformity. 5. Left abdominal scar deformity. 6. A 1.3 cm lesion right inferior breast. 7. Lesion measuring 0.... | 6 Cosmetic / Plastic Surgery |
HISTORY OF PRESENT ILLNESS Mr. A is a 50-year-old gentleman with a history of atrial fibrillation in the past more recently who has had atrial flutter who estimates he has had six cardioversions since 10/09 and estimates that he has had 12 to 24 in his life beginning in 2006 when the atrial fibrillation first eme... | 5 Consult - History and Phy. |
PREOPERATIVE DIAGNOSIS Open calcaneus fracture on the right. POSTOPERATIVE DIAGNOSIS Open calcaneus fracture on the right. PROCEDURES 1. Irrigation and debridement of skin subcutaneous tissue fascia and bone associated with an open fracture. 2. Placement of antibiotic-impregnated beads. ANESTHESIA Gene... | 27 Orthopedic |
PROCEDURE NOTE The patient was placed in a prone position. The neck was sterilely prepped using a cervical prep set. A lidocaine skin wheal was raised over the C5-6 interspace. A 20-gauge Tuohy needle was used. Loss of resistance was obtained using hanging drop technique. This was followed by 2 mL of radiograph... | 28 Pain Management |
The patient was told that the injection may cause more pain for two to three days afterwards and if this occurred they would best be served by icing the area 15-20 minutes every 6 hours. The patient was advised to protect the knee by limiting repetitive bending squatting kneeling and excessive heavy use for a week.... | 28 Pain Management |
She also had EMG/nerve conduction studies since she was last seen in our office that showed severe left ulnar neuropathy moderate right ulnar neuropathy bilateral mild-to-moderate carpal tunnel and diabetic neuropathy. She was referred to Dr. XYZ and will be seeing him on August 8 2006. She was also never referred ... | 22 Neurology |
PREOPERATIVE DIAGNOSES OM chronic serous simple or unspecified. Adenoid hyperplasia. Hypertrophy of tonsils. POSTOPERATIVE DIAGNOSIS Same as preoperative diagnosis. OPERATION Bilateral myringotomies with Armstrong grommet tubes Adenoidectomy and Tonsillectomy. ANESTHESIA General. COMPLICATIONS Non... | 38 Surgery |
EXAM CT stone protocol. REASON FOR EXAM History of stones rule out stones. TECHNIQUE Noncontrast CT abdomen and pelvis per renal stone protocol. FINDINGS Correlation is made with a prior examination dated 01/20/09. Again identified are small intrarenal stones bilaterally. These are unchanged. There is no... | 21 Nephrology |
PREOPERATIVE DIAGNOSIS Cholecystitis and cholelithiasis. POSTOPERATIVE DIAGNOSIS Cholecystitis and cholelithiasis. TITLE OF PROCEDURE 1. Laparoscopic cholecystectomy. 2. Intraoperative cholangiogram. ANESTHESIA General. PROCEDURE IN DETAIL The patient was taken to the operative suite and placed in the sup... | 14 Gastroenterology |
OPERATIONS 1. Mitral valve repair using a quadrangular resection of the P2 segment of the posterior leaflet. 2. Mitral valve posterior annuloplasty using a Cosgrove Galloway Medtronic fuser band. 3. Posterior leaflet abscess resection. ANESTHESIA General endotracheal anesthesia TIMES Aortic cross-clamp time wa... | 3 Cardiovascular / Pulmonary |
FINAL DIAGNOSIS/REASON FOR ADMISSION 1. Acute right lobar pneumonia. 2. Hypoxemia and hypotension secondary to acute right lobar pneumonia. 3. Electrolyte abnormality with hyponatremia and hypokalemia - corrected. 4. Elevated liver function tests etiology undetermined. 5. The patient has a history of moderate-to... | 10 Discharge Summary |
PREOPERATIVE DIAGNOSIS T12 compression fracture with cauda equina syndrome and spinal cord compression. POSTOPERATIVE DIAGNOSIS T12 compression fracture with cauda equina syndrome and spinal cord compression. OPERATION PERFORMED Decompressive laminectomy at T12 with bilateral facetectomies decompression of T1... | 27 Orthopedic |
TITLE OF OPERATION 1. Diagnostic arthroscopy exam under anesthesia left shoulder. 2. Debridement of chondral injury left shoulder. 3. Debridement superior glenoid left shoulder. 4. Arthrotomy. 5. Bankart lesion repair. 6. Capsular shift left shoulder Mitek suture anchors absorbable anchors with nonabsorba... | 27 Orthopedic |
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... | 5 Consult - History and Phy. |
PREOPERATIVE DIAGNOSES 1. Neck pain with bilateral upper extremity radiculopathy. 2. Residual stenosis C3-C4 C4-C5 C5-C6 and C6-C7 with probable instability. POSTOPERATIVE DIAGNOSES 1. Neck pain with bilateral upper extremity radiculopathy. 2. Residual stenosis C3-C4 C4-C5 C5-C6 and C6-C7 secondary to facet... | 27 Orthopedic |
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... | 3 Cardiovascular / Pulmonary |
CHIEF COMPLAINT Blood-borne pathogen exposure. HISTORY OF PRESENT ILLNESS The patient is a 54-year-old right-handed male who works as a phlebotomist and respiratory therapist at Hospital. The patient states that he was attempting to do a blood gas. He had his finger of the left hand over the pulse and was inserti... | 15 General Medicine |
HISTORY The patient is a 15-year-old female who was seen in consultation at the request of Dr. X on 05/15/2008 regarding enlarged tonsils. The patient has been having difficult time with having two to three bouts of tonsillitis this year. She does average about four bouts of tonsillitis per year for the past sever... | 11 ENT - Otolaryngology |
PREOPERATIVE DIAGNOSIS Herniated nucleus pulposus C5-C6. POSTOPERATIVE DIAGNOSIS Herniated nucleus pulposus C5-C6. PROCEDURE Anterior cervical discectomy fusion C5-C6 followed by instrumentation C5-C6 with titanium dynamic plating system Aesculap. Operating microscope was used for both illumination and magni... | 38 Surgery |
HISTORY We had the pleasure of seeing the patient today in our Pediatric Rheumatology Clinic. He was sent here with a chief complaint of joint pain in several joints for few months. This is a 7-year-old white male who has no history of systemic disease who until 2 months ago was doing well and 2 months ago he s... | 27 Orthopedic |
REASON FOR VISIT Mr. ABC is a 30-year-old man who returns in followup of his still moderate-to-severe sleep apnea. He returns today to review his response to CPAP. HISTORY OF PRESENT ILLNESS The patient initially presented with loud obnoxious snoring that disrupted the sleep of his bed partner. He was found to ... | 15 General Medicine |
CIRCUMCISION - OLDER PERSON OPERATIVE NOTE The patient was taken to the operating room and placed in the supine position on the operating table. General endotracheal anesthesia was administered. The patient was prepped and draped in the usual sterile fashion. A 4-0 silk suture is used as a stay-stitch of the glan... | 39 Urology |
Chief Complaint Confusion and hallucinations. History of Present Illness The patient was a 27-year-old Hispanic man who presented to St. Luke s Episcopal Hospital with a five day history of confusion and hallucinations. The patient was doing well until three months prior to admission when he developed wheezing and ... | 5 Consult - History and Phy. |
DOBUTAMINE STRESS ECHOCARDIOGRAM REASON FOR EXAM Chest discomfort evaluation for coronary artery disease. PROCEDURE IN DETAIL The patient was brought to the cardiac center. Cardiac images at rest were obtained in the parasternal long and short axis apical four and apical two views followed by starting with a d... | 33 Radiology |
CC Bilateral lower extremity numbness. HX 21 y/o RHM complained of gradual onset numbness and incoordination of both lower extremities beginning approximately 11/5/96. The symptoms became maximal over a 12-24 hour period and have not changed since. The symptoms consist of tingling in the distal lower extremities ap... | 27 Orthopedic |
PREOPERATIVE DIAGNOSIS Brain tumor left temporal lobe. POSTOPERATIVE DIAGNOSIS Brain tumor left temporal lobe - glioblastoma multiforme. OPERATIVE PROCEDURE 1. Left temporal craniotomy. 2. Removal of brain tumor. OPERATING MICROSCOPE Stealth. PROCEDURE The patient was placed in the supine position shoul... | 38 Surgery |
REASON FOR VISIT The patient is a 38-year-old woman with pseudotumor cerebri without papilledema who comes in because of new onset of headaches. She comes to clinic by herself. HISTORY OF PRESENT ILLNESS Dr. X has cared for her since 2002. She has a Codman-Hakim shunt set at 90 mmH2O. She last saw us in clinic... | 5 Consult - History and Phy. |
TITLE OF OPERATION Total laryngectomy right level 2 3 4 neck dissection tracheoesophageal puncture cricopharyngeal myotomy right thyroid lobectomy. INDICATION FOR SURGERY A 58-year-old gentleman who has had a history of a T3 squamous cell carcinoma of his glottic larynx having elected to undergo a laser exc... | 38 Surgery |
CHIEF COMPLAINT Followup diabetes mellitus type 1. SUBJECTIVE Patient is a 34-year-old male with significant diabetic neuropathy. He has been off on insurance for over a year. Has been using NPH and Regular insulin to maintain his blood sugars. States that he is deathly afraid of having a low blood sugar du... | 35 SOAP / Chart / Progress Notes |
PREOPERATIVE DIAGNOSIS Lumbar stenosis. POSTOPERATIVE DIAGNOSES Lumbar stenosis and cerebrospinal fluid fistula. TITLE OF THE OPERATION 1. Lumbar laminectomy for decompression with foraminotomies L3-L4 L4-L5 L5-S1 microtechniques. 2. Repair of CSF fistula microtechniques L5-S1 application of DuraSeal. INDIC... | 27 Orthopedic |
ADMISSION DIAGNOSIS Painful right knee status post total knee arthroplasty many years ago. The patient had gradual onset of worsening soreness and pain in this knee. X-ray showed that the poly seems to be worn out significantly in this area. DISCHARGE DIAGNOSIS Status post poly exchange right knee total knee ... | 10 Discharge Summary |
CHIEF COMPLAINT One-month followup. HISTORY OF PRESENT ILLNESS The patient is an 88-year-old Caucasian female. She comes here today with a friend. The patient has no complaints. She states she has been feeling well. Her knees are not hurting her at all anymore and she is not needing Bextra any longer. I thin... | 15 General Medicine |
PREOPERATIVE DIAGNOSIS Breast assymetry status post previous breast surgery. POSTOPERATIVE DIAGNOSIS Breast assymetry status post previous breast surgery. OPERATION Capsulotomy left breast flat advancement V to Y left breast for correction lower pole defect. ANESTHESIA LMA. FINDINGS AND PROCEDURE The ... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Right inguinal hernia. POSTOPERATIVE DIAGNOSIS Direct right inguinal hernia. TITLE OF PROCEDURE Marlex repair of right inguinal hernia. ANESTHESIA Spinal. PROCEDURE IN DETAIL The patient was taken to the operative suite placed on the table in the supine position and given a spina... | 39 Urology |
INDICATIONS Chest pain. PROCEDURE DONE Graded exercise treadmill stress test. STRESS ECG RESULTS The patient was stressed by continuous graded treadmill testing for nine minutes of the standard Bruce protocol. The heart rate increased from 68 beats per minute to 178 beats per minute which is 100 of the maxi... | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSES 1. Lumbar osteomyelitis. 2. Need for durable central intravenous access. POSTOPERATIVE DIAGNOSES 1. Lumbar osteomyelitis. 2. Need for durable central intravenous access. ANESTHESIA General. PROCEDURE Placement of left subclavian 4-French Broviac catheter. INDICATIONS The patient is... | 38 Surgery |
PREOPERATIVE DIAGNOSES 1. Extruded herniated disc left L5-S1. 2. Left S1 radiculopathy acute . 3. Morbid obesity. POSTOPERATIVE DIAGNOSES 1. Extruded herniated disc left L5-S1. 2. Left S1 radiculopathy acute . 3. Morbid obesity. PROCEDURE PERFORMED Microscopic lumbar discectomy left L5-S1. ANESTHESIA ... | 38 Surgery |
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