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PROCEDURES 1. Right frontal craniotomy with resection of right medial frontal brain tumor. 2. Stereotactic image-guided neuronavigation for resection of tumor. 3. Microdissection and micro-magnification for resection of brain tumor. ANESTHESIA General via endotracheal tube. INDICATIONS FOR THE PROCEDURE The p... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Cataract right eye. POSTOPERATIVE DIAGNOSIS Cataract right eye. PROCEDURE Cataract extraction with phacoemulsification and posterior chamber intraocular lens implantation. ME 30 AC 25.0 diopter lens was used. COMPLICATIONS None. ANESTHESIA Local 2 peribulbar lidocaine. PROCED... | 38 Surgery |
PROCEDURE Keller Bunionectomy. For informed consent the more common risks benefits and alternatives to the procedure were thoroughly discussed with the patient. An appropriate consent form was signed indicating that the patient understands the procedure and its possible complications. This 59 year-old female wa... | 38 Surgery |
PREPROCEDURE DIAGNOSIS Left leg claudication. POSTPROCEDURE DIAGNOSIS Left leg claudication. OPERATION PERFORMED Aortogram with bilateral segmental lower extremity run off. ANESTHESIA Conscious sedation. INDICATION FOR PROCEDURE The patient presents with lower extremity claudication. She is a 68-year-... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Lumbar spondylosis. POSTOPERATIVE DIAGNOSIS Lumbar spondylosis. OPERATION PERFORMED Lumbar facet injections done under fluoroscopic control. ANESTHESIA Local and IV. COMPLICATIONS None. DESCRIPTION OF PROCEDURE After proper consent was obtained the patient was taken to the fluo... | 28 Pain Management |
EXAM MRI RIGHT FOOT CLINICAL Pain and swelling in the right foot. FINDINGS Obtained for second opinion interpretation is an MRI examination performed on 11-04-05. There is a transverse fracture of the anterior superior calcaneal process of the calcaneus. The fracture is corticated however and there is an active mar... | 27 Orthopedic |
PRECATHETERIZATION DIAGNOSIS ES Hypoplastic left heart status post Norwood procedure and Glenn shunt. POSTCATHETERIZATION DIAGNOSIS ES 1. Hypoplastic left heart. A. Status post Norwood. B. Status post Glenn. 2. Left pulmonary artery hypoplasia. 3. Diminished right ventricular systolic function. 4. Trivial neo-a... | 38 Surgery |
HISTORY The patient is a 61-year-old male patient. I was asked to evaluate this patient because of the elevated blood urea and creatinine. The patient has ascites pleural effusion hematuria history of coronary artery disease pulmonary nodules history of congestive heart failure status post AICD. The patient ... | 21 Nephrology |
PROCEDURE Primary right shoulder arthroscopic rotator cuff repair with subacromial decompression. PATIENT PROFILE This is a 42-year-old female. Refer to note in patient chart for documentation of history and physical. Due to the nature of the patient s increasing pain surgery is recommended. The alternatives ... | 38 Surgery |
DISCHARGE SUMMARY SUMMARY OF TREATMENT PLANNING This discharge is at the family s request. IDENTIFIED PROBLEMS/OUTCOMES 1. | 10 Discharge Summary |
HISTORY Advanced maternal age and hypertension. FINDINGS There is a single live intrauterine pregnancy with a vertex lie posterior placenta and adequate amniotic fluid. The amniotic fluid index is 23.2 cm. Estimated gestational age based on prior ultrasound is 36 weeks 4 four days with an estimated date of de... | 24 Obstetrics / Gynecology |
CERVICAL FACET JOINT INJECTION WITH CONTRAST. PREPROCEDURE PREPARATION After being explained the risks and benefits of the procedure the patient signed the standard informed consent form. the patient was placed in the prone position and standard ASA monitors applied. Intravenous access was established and IV sedat... | 28 Pain Management |
PREOPERATIVE DIAGNOSES 1. Epidural hematoma cervical spine. 2. Status post cervical laminectomy C3 through C7 postop day #10. 3. Central cord syndrome. 4. Acute quadriplegia. POSTOPERATIVE DIAGNOSES 1. Epidural hematoma cervical spine. 2. Status post cervical laminectomy C3 through C7 postop day #10. 3. Ce... | 38 Surgery |
PREOPERATIVE DIAGNOSES 1. Pelvic mass. 2. Suspected right ovarian cyst. POSTOPERATIVE DIAGNOSES 1. Pelvic mass. 2. Suspected right ovarian cyst. PROCEDURES 1. Exploratory laparotomy. 2. Extensive lysis of adhesions. 3. Right salpingo-oophorectomy. ANESTHESIA General. ESTIMATED BLOOD LOSS 200 mL SPECIMENS ... | 24 Obstetrics / Gynecology |
PROCEDURE Gastroscopy. PREOPERATIVE DIAGNOSIS Gastroesophageal reflux disease. POSTOPERATIVE DIAGNOSIS Barrett esophagus. MEDICATIONS MAC. PROCEDURE The Olympus gastroscope was introduced into the oropharynx and passed carefully through the esophagus stomach and duodenum to the transverse duodenum. Th... | 38 Surgery |
XYZ RE ABC MEDICAL RECORD# 123 Dear Dr. XYZ I saw ABC back in Neuro-Oncology Clinic today. He comes in for an urgent visit because of increasing questions about what to do next for his anaplastic astrocytoma. Within the last several days he has seen you in clinic and once again discussed whether or not to underg... | 22 Neurology |
TECHNICAL SUMMARY The patient was recorded from 2 15 p.m. on 08/21/06 through 1 55 p.m. on 08/25/06. The patient was recorded digitally using the 10-20 system of electrode placement. Additional temporal electrodes and single channels of EOG and EKG were also recorded. The patient s medications valproic acid Zone... | 33 Radiology |
FINDINGS There is a well demarcated mass lesion of the deep lobe of the left parotid gland measuring approximately 2.4 X 3.9 X 3.0cm AP X transverse X craniocaudal in size. The lesion is well demarcated. There is a solid peripheral rim with a mean attenuation coefficient of 56.3. There is a central cystic appearing ... | 33 Radiology |
HISTORY The patient is a 71-year-old female who was referred for an outpatient modified barium swallow study to objectively evaluate her swallowing function and safety. The patient complained of globus sensation high in her throat particularly with solid foods and with pills. She denied history of coughing and ch... | 14 Gastroenterology |
CHIEF COMPLAINT Abdominal pain. HISTORY OF PRESENT ILLNESS The patient is an 89-year-old white male who developed lower abdominal pain which was constant onset approximately half an hour after dinner on the evening prior to admission. He described the pain as 8/10 in severity and the intensity varied. The sym... | 15 General Medicine |
SUBJECTIVE The patient is brought in by an assistant with some of his food diary sheets. They wonder if the patient needs to lose anymore weight. OBJECTIVE The patient s weight today is 186-1/2 pounds which is down 1-1/2 pounds in the past month. He has lost a total of 34-1/2 pounds. I praised this. I went o... | 5 Consult - History and Phy. |
CC Horizontal diplopia. HX This 67 y/oRHM first began experiencing horizontal binocular diplopia 25 years prior to presentation in the Neurology Clinic. The diplopia began acutely and continued intermittently for one year. During this time he was twice evaluated for myasthenia gravis details of evaluation not kno... | 22 Neurology |
PREOPERATIVE DIAGNOSIS Facial and neck skin ptosis. Cheek neck and jowl lipotosis. Facial rhytides. POSTOPERATIVE DIAGNOSIS Same. PROCEDURE Temporal cheek-neck facelift CPT 15825 . Submental suction assisted lipectomy CPT 15876 . ANESTHESIA General. DESCRIPTION OF PROCEDURE This patient is a 65-yea... | 6 Cosmetic / Plastic Surgery |
PREOPERATIVE DIAGNOSIS Suspicious microcalcifications left breast. POSTOPERATIVE DIAGNOSIS Suspicious microcalcifications left breast. PROCEDURE PERFORMED Needle-localized excisional biopsy left breast. ANESTHESIA Local with sedation. SPECIMEN Left breast with specimen mammogram. COMPLICATIONS None... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Internal derangement left knee. POSTOPERATIVE DIAGNOSIS Internal derangement left knee. PROCEDURE PERFORMED Arthroscopy of the left knee with medial meniscoplasty. ANESTHESIA LMA. GROSS FINDINGS Displaced bucket-handle tear of medial meniscus left knee. PROCEDURE After inform... | 27 Orthopedic |
ADMISSION DIAGNOSES 1. Severe menometrorrhagia unresponsive to medical therapy. 2. Severe anemia. 3. Fibroid uterus. DISCHARGE DIAGNOSES 1. Severe menometrorrhagia unresponsive to medical therapy. 2. Severe anemia. 3. Fibroid uterus. OPERATIONS PERFORMED 1. Hysteroscopy. 2. Dilatation and curettage D C . 3.... | 24 Obstetrics / Gynecology |
2-D STUDY 1. Mild aortic stenosis widely calcified minimally restricted. 2. Mild left ventricular hypertrophy but normal systolic function. 3. Moderate biatrial enlargement. 4. Normal right ventricle. 5. Normal appearance of the tricuspid and mitral valves. 6. Normal left ventricle and left ventricular systolic funct... | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSES 1. Bunion left foot. 2. Hammertoe left second toe. POSTOPERATIVE DIAGNOSES 1. Bunion left foot. 2. Hammertoe left second toe. PROCEDURE PERFORMED 1. Bunionectomy SCARF type with metatarsal osteotomy and internal screw fixation left. 2. Arthroplasty left second toe. HISTORY This 3... | 27 Orthopedic |
DIAGNOSIS Desires vasectomy. NAME OF OPERATION Vasectomy. ANESTHESIA General. HISTORY Patient 37 desires a vasectomy. PROCEDURE Through a midline scrotal incision the right vas was identified and separated from the surrounding tissues clamped transected and tied off with a 4-0 chromic. No bleeding... | 39 Urology |
CHIEF COMPLAINT Hip pain. HISTORY OF PRESENTING ILLNESS The patient is a very pleasant 41-year-old white female that is known to me previously from our work at the Pain Management Clinic as well as from my residency training program San Francisco. We have worked collaboratively for many years at the Pain Manage... | 4 Chiropractic |
SUBJECTIVE The patient is in with several medical problems. He complains his mouth being sore since last week and also some trouble with my eyes. He states that they feel funny but he is seeing okay. He denies any more diarrhea or abdominal pain. Bowels are working okay. He denies nausea or diarrhea. Eatin... | 15 General Medicine |
PREOPERATIVE DIAGNOSIS Squamous cell carcinoma on the right hand incompletely excised. POSTOPERATIVE DIAGNOSIS Squamous cell carcinoma on the right hand incompletely excised. NAME OF OPERATION Re-excision of squamous cell carcinoma site right hand. ANESTHESIA Local with monitored anesthesia care. INDICAT... | 16 Hematology - Oncology |
PROCEDURE Upper endoscopy with biopsy. PROCEDURE INDICATION This is a 44-year-old man who was admitted for coffee-ground emesis which has been going on for the past several days. An endoscopy is being done to evaluate for source of upper GI bleeding. Informed consent was obtained. Outlining the risks benefits... | 38 Surgery |
CHIEF COMPLAINT 1. Metastatic breast cancer. 2. Enrolled is clinical trial C40502. 3. Sinus pain. HISTORY OF PRESENT ILLNESS She is a very pleasant 59-year-old nurse with a history of breast cancer. She was initially diagnosed in June 1994. Her previous treatments included Zometa Faslodex and Aromasin. She ... | 16 Hematology - Oncology |
CC Fall and laceration. HPI Mr. B is a 42-year-old man who was running to catch a taxi when he stumbled fell and struck his face on the sidewalk. He denies loss of consciousness but says he was dazed for a while after it happened. He complains of pain over the chin and right forehead where he has abrasions. H... | 15 General Medicine |
HISTORY OF PRESENT ILLNESS The patient presents today as a consultation from Dr. ABC s office regarding the above. He has history of neurogenic bladder and on intermittent self-catheterization 3 times a day. However June 24 2008 he was seen in the ER and with fever weakness possible urosepsis. He had a blo... | 39 Urology |
PREOPERATIVE DIAGNOSIS Right pleural effusion and suspected malignant mesothelioma. POSTOPERATIVE DIAGNOSIS Right pleural effusion suspected malignant mesothelioma. PROCEDURE Right VATS pleurodesis and pleural biopsy. ANESTHESIA General double-lumen endotracheal. DESCRIPTION OF FINDINGS Right pleural ef... | 16 Hematology - Oncology |
HISTORY OF PRESENT ILLNESS The patient is a two-and-a-half-month-old male who has been sick for the past three to four days. His mother has described congested sounds with cough and decreased appetite. He has had no fever. He has had no rhinorrhea. Nobody else at home is currently ill. He has no cigarette smoke... | 12 Emergency Room Reports |
PREOPERATIVE DIAGNOSIS Visually significant cataract left eye. POSTOPERATIVE DIAGNOSIS Visually significant cataract left eye. ANESTHESIA Topical/MAC. PROCEDURE Phacoemulsification cataract extraction with intraocular lens implantation left eye Alcon AcrySof SN60AT 23.0 D serial # . COMPLICATIONS ... | 26 Ophthalmology |
PROCEDURE IN DETAIL Following premedication with Vistaril 50 mg and Atropine 0.4 mg IM the patient received Versed 5.0 mg intravenously after Cetacaine spray to the posterior palate. The Olympus video gastroscope was then introduced into the upper esophagus and passed by direct vision to the descending duodenum. ... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Cataract right eye. POSTOPERATIVE DIAGNOSIS Cataract right eye. TITLE OF OPERATION Phacoemulsification with intraocular lens insertion right eye. ANESTHESIA Topical. COMPLICATIONS None. PROCEDURE IN DETAIL The patient was brought to the operating room where tetracaine drops w... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Medial meniscal tear of the right knee. POSTOPERATIVE DIAGNOSES 1. Medial meniscal tear right knee. 2. Lateral meniscal tear right knee. 3. Osteochondral lesion medial femoral condyle right knee. 4. Degenerative joint disease right knee. 5. Patella grade-II chondromalacia. 6. Later... | 27 Orthopedic |
CHIEF COMPLAINT Diarrhea vomiting and abdominal pain. HISTORY OF PRESENT ILLNESS The patient is an 85-year-old female who presents with a chief complaint as described above. The patient is a very poor historian and is extremely hard of hearing and therefore very little history is available. She was found by EMS... | 5 Consult - History and Phy. |
PREOPERATIVE DIAGNOSIS Thyroid goiter with substernal extension on the left. POSTOPERATIVE DIAGNOSIS Thyroid goiter with substernal extension on the left. PROCEDURE PERFORMED Total thyroidectomy with removal of substernal extension on the left. THIRD ANESTHESIA General endotracheal. ESTIMATED BLOOD LOSS ... | 13 Endocrinology |
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... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Metopic synostosis with trigonocephaly. POSTOPERATIVE DIAGNOSIS Metopic synostosis with trigonocephaly. PROCEDURES PERFORMED 1. Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z-osteotomies. 2. Bone grafts. 3. Bilateral forehead reconstruction wit... | 38 Surgery |
SUBJECTIVE His brother although he is a vegetarian has elevated cholesterol and he is on medication to lower it. The patient started improving his diet when he received the letter explaining his lipids are elevated. He is consuming less cappuccino quiche crescents candy from vending machines etc. He has sta... | 35 SOAP / Chart / Progress Notes |
PREOPERATIVE DIAGNOSIS Left medial compartment osteoarthritis of the knee. POSTOPERATIVE DIAGNOSIS Left medial compartment osteoarthritis of the knee. PROCEDURE PERFORMED Left unicompartmental knee replacement. COMPONENTS USED Biomet size medium femoral component size B tibial tray and a 3 mm polyethylene ... | 38 Surgery |
REASON FOR REFERRAL The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X. She is presenting for a second opinion following a recent neuropsychological evaluation that was ordered by her former place of employment th... | 32 Psychiatry / Psychology |
S - This patient has reoccurring ingrown infected toenails. He presents today for continued care. O - On examination the left great toenail is ingrown on the medial and lateral toenail border. The right great toenail is ingrown on the lateral nail border only. There is mild redness and granulation tissue growing ... | 35 SOAP / Chart / Progress Notes |
PREOPERATIVE DIAGNOSIS Extremely large basal cell carcinoma right lower lid. POSTOPERATIVE DIAGNOSIS Extremely large basal cell carcinoma right lower lid. TITLE OF OPERATION Excision of large basal cell carcinoma right lower lid and repaired with used dorsal conjunctival flap in the upper lid and a large p... | 26 Ophthalmology |
SUBJECTIVE The patient is in complaining of headaches and dizzy spells as well as a new little rash on the medial right calf. She describes her dizziness as both vertigo and lightheadedness. She does not have a headache at present but has some intermittent headaches neck pains and generalized myalgias. She has... | 35 SOAP / Chart / Progress Notes |
HISTORY A is a 55-year-old who I know well because I have been taking care of her husband. She comes for discussion of a screening colonoscopy. Her last colonoscopy was in 2002 and at that time she was told it was essentially normal. Nonetheless she has a strong family history of colon cancer and it has been a... | 5 Consult - History and Phy. |
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 ... | 38 Surgery |
REASON FOR FOLLOWUP Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a patient with code last night with CPR and advanced cardiac life support. HISTORY OF PRESENT ILLNESS This is a 65-year-old patient ... | 15 General Medicine |
PREOPERATIVE DIAGNOSES 1. Clinical stage T2 NX MX transitional cell carcinoma of the urinary bladder status post chemotherapy and radiation therapy. 2. New right hydronephrosis. POSTOPERATIVE DIAGNOSES 1. Clinical stage T4a N3 M1 transitional cell carcinoma of the urinary bladder status post chemotherapy and... | 39 Urology |
PREOPERATIVE DIAGNOSIS Aqueductal stenosis. POSTOPERATIVE DIAGNOSIS Aqueductal stenosis. TITLE OF PROCEDURE Endoscopic third ventriculostomy. ANESTHESIA General endotracheal tube anesthesia. DEVICES Bactiseal ventricular catheter with an Aesculap burr hole port. SKIN PREPARATION ChloraPrep. COMPLICATI... | 23 Neurosurgery |
Pap smear in November 2006 showed atypical squamous cells of undetermined significance. She has a history of an abnormal Pap smear. At that time she was diagnosed with CIN 3 as well as vulvar intraepithelial neoplasia. She underwent a cone biopsy that per her report was negative for any pathology. She had no vulva... | 5 Consult - History and Phy. |
PREOPERATIVE DIAGNOSIS Right carpal tunnel syndrome. POSTOPERATIVE DIAGNOSIS Right carpal tunnel syndrome. TITLE OF THE PROCEDURE Right carpal tunnel release. COMPLICATIONS There were no complications during the procedure. SPECIMEN The specimen was sent to pathology. INSTRUMENTS All counts were correc... | 38 Surgery |
FINAL DIAGNOSIS I. Ligature strangulation. A. Circumferential ligature with associated ligature furrow of neck. B. Abrasions and petechial hemorrhages neck. C. Petechial hemorrhages conjunctival surfaces of eyes and skin of face. II. Craniocerebral injuries. A. Scalp contusion. B. Linear comminuted fracture of rig... | 1 Autopsy |
EXAM Lexiscan Nuclear Myocardial Perfusion Scan. INDICATION Chest pain. TYPE OF TEST Lexiscan unable to walk on a treadmill. INTERPRETATION Resting heart rate of 96 blood pressure of 141/76. EKG normal sinus rhythm nonspecific ST-T changes left bundle branch block. Post Lexiscan 0.4 mg injected intra... | 33 Radiology |
CHIEF COMPLAINT Head injury. HISTORY This 16-year-old female presents to Children s Hospital via paramedic ambulance with a complaint at approximately 6 p.m. while she was at band practice using her flag device. She struck herself in the head with the flag. There was no loss of consciousness. She did feel dizz... | 12 Emergency Room Reports |
CHIEF COMPLAINT Joints are hurting all over and checkup. HISTORY OF PRESENT ILLNESS A 77-year-old white female who is having more problems with joint pain. It seems to be all over decreasing her mobility hands and wrists. No real swelling but maybe just a little more uncomfortable than they have been. The Day... | 15 General Medicine |
EARS NOSE MOUTH AND THROAT EARS/NOSE The auricles are normal to palpation and inspection without any surrounding lymphadenitis. There are no signs of acute trauma. The nose is normal to palpation and inspection externally without evidence of acute trauma. Otoscopic examination of the auditory canals and tympani... | 15 General Medicine |
CHIEF COMPLAINT The patient comes for bladder instillation for chronic interstitial cystitis. SUBJECTIVE The patient is crying today when she arrives in the office saying that she has a lot of discomfort. These bladder instillations do not seem to be helping her. She feels anxious and worried. She does not thi... | 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... | 11 ENT - Otolaryngology |
CHIEF COMPLAINT Trouble breathing. HISTORY OF PRESENT ILLNESS A 37-year-old German woman was brought to a Shock Room at the General Hospital with worsening shortness of breath and cough. Over the year preceding admission the patient had begun to experience the insidious onset of shortness of breath. She had smok... | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSIS Plantar fascitis left foot. POSTOPERATIVE DIAGNOSIS Plantar fascitis left foot. PROCEDURE PERFORMED Partial plantar fasciotomy left foot. ANESTHESIA 10 cc of 0.5 Marcaine plain with TIVA. HISTORY This 35-year-old Caucasian female presents to ABCD General Hospital with above chi... | 31 Podiatry |
PROSTATE BRACHYTHERAPY - PROSTATE I-125 IMPLANTATION This patient will be treated to the prostate with ultrasound-guided I-125 seed implantation. The original consultation and treatment planning will be separately performed. At the time of the implantation special coordination will be required. Stepping ultrasound ... | 16 Hematology - Oncology |
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... | 38 Surgery |
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... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Prostate cancer. POSTOPERATIVE DIAGNOSIS Prostate cancer. OPERATION PERFORMED Radical retropubic nerve-sparing prostatectomy without lymph node dissection. ESTIMATED BLOOD LOSS 450 mL. REPLACEMENT 250 mL of Cell Saver and crystalloid. COMPLICATIONS None. INDICATIONS OF SURGERY ... | 39 Urology |
PREOPERATIVE DIAGNOSES 1. Chronic renal failure. 2. Thrombosed left forearm arteriovenous Gore-Tex bridge fistula. POSTOPERATIVE DIAGNOSIS 1. Chronic renal failure. 2. Thrombosed left forearm arteriovenous Gore-Tex bridge fistula. PROCEDURE PERFORMED 1. Fogarty thrombectomy left forearm arteriovenous Gore-Tex ... | 38 Surgery |
IDENTIFICATION OF PATIENT ABCD is an 8-year-old Hispanic male currently in the second grade. CHIEF COMPLAINT/HISTORY OF PRESENT ILLNESS ABCD presents to this visit with his mother Xyz and her significant other Pqr. Circumstances leading to this admission In the past ABCD has been diagnosed and treated for ... | 32 Psychiatry / Psychology |
PROCEDURES PERFORMED Esophagogastroduodenoscopy. PREPROCEDURE DIAGNOSIS Dysphagia. POSTPROCEDURE DIAGNOSIS Active reflux esophagitis distal esophageal stricture ring due to reflux esophagitis dilated with balloon to 18 mm. PROCEDURE Informed consent was obtained prior to the procedure with special attent... | 14 Gastroenterology |
PREOPERATIVE DIAGNOSES 1. Left neck pain with left upper extremity radiculopathy. 2. Left C6-C7 neuroforaminal stenosis secondary to osteophyte. POSTOPERATIVE DIAGNOSES 1. Left neck pain with left upper extremity radiculopathy. 2. Left C6-C7 neuroforaminal stenosis secondary to osteophyte. OPERATIVE PROCEDURE 1. A... | 38 Surgery |
CHIEF COMPLAINT Altered mental status. HISTORY OF PRESENT ILLNESS This is a 6-year-old white male who was sent from the Emergency Room with the diagnosis of intracranial bleeding. The patient was found by the 8-year-old sister in the bathroom. He was laying down on one side and he was crying and moaning. The... | 12 Emergency Room Reports |
CHIEF COMPLAINT Well-child check and school physical. HISTORY OF PRESENT ILLNESS This is a 9-year-old African-American male here with his mother for a well-child check. Mother has no concerns at the time of the visit. She states he had a pretty good school year. He still has some fine motor issues especially ... | 29 Pediatrics - Neonatal |
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... | 33 Radiology |
CHIEF COMPLAINT This 3-year-old female presents today for evaluation of chronic ear infections bilateral. ASSOCIATED SIGNS AND SYMPTOMS FOR OTITIS MEDIA Associated signs and symptoms include cough fever irritability and speech and language delay. Duration ENT Duration of symptom 12 rounds of antibiotic... | 5 Consult - History and Phy. |
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... | 5 Consult - History and Phy. |
HISTORY A 59-year-old male presents in followup after being evaluated and treated as an in-patient by Dr. X for acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis admitted on 05/23/2008 discharged on 05/24/2008. Please refer to chart for history and physical an... | 11 ENT - Otolaryngology |
SUBJECTIVE School reports continuing difficulties with repetitive questioning obsession with cleanness on a daily basis concerned about his inability to relate this well in the classroom. He appears confused and depressed at times. Mother also indicates that preservative questioning had come down but he started... | 35 SOAP / Chart / Progress Notes |
TITLE OF OPERATION Lateral and plantar condylectomy fifth left metatarsal. PREOPERATIVE DIAGNOSIS Prominent lateral and plantar condyle hypertrophy fifth left metatarsal. POSTOPERATIVE DIAGNOSIS Prominent lateral and plantar condyle hypertrophy fifth left metatarsal. ANESTHESIA Monitored anesthesia c... | 38 Surgery |
PREOPERATIVE DIAGNOSES 1. Left back skin nevus 2 cm. 2. Right mid back skin nevus 1 cm. 3. Right shoulder skin nevus 2.5 cm. 4. Actinic keratosis left lateral nasal skin 2.5 cm. POSTOPERATIVE DIAGNOSES 1. Left back skin nevus 2 cm. 2. Right mid back skin nevus 1 cm. 3. Right shoulder skin nevus 2.5 cm. 4. ... | 38 Surgery |
CONJUNCTIVITIS better known as Pink Eye is an infection of the inside of your eyelid. It is usually caused by allergies bacteria viruses or chemicals. WHAT ARE THE SIGNS AND SYMPTOMS 1. Red irritated eye. 2. Some burning and/or scratchy feeling. 3. There may be a purulent pus or a mucous type discharge. H... | 26 Ophthalmology |
TITLE OF OPERATION 1. Secondary scleral suture fixated posterior chamber intraocular lens implant with penetrating keratoplasty. 2. A concurrent vitrectomy and endolaser was performed by the vitreoretinal team. INDICATION FOR SURGERY The patient is a 62-year-old white male who underwent cataract surgery in 09/0... | 38 Surgery |
PREOPERATIVE DIAGNOSIS Acute cholecystitis. POSTOPERATIVE DIAGNOSIS Acute gangrenous cholecystitis with cholelithiasis. OPERATION PERFORMED Laparoscopic cholecystectomy with cholangiogram. FINDINGS The patient had essentially a dead gallbladder with stones and positive wide bile/pus coming from the gallblad... | 14 Gastroenterology |
INDICATIONS This is a 55-year-old female who is having a colonoscopy to screen for colon cancer. There is no family history of colon cancer and there has been no blood in the stool. PROCEDURE PERFORMED Colonoscopy. PREP Fentanyl 100 mcg IV and 3 mg Versed IV. PROCEDURE The tip of the endoscope was introduc... | 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 ... | 14 Gastroenterology |
EXAM CT head without contrast CT facial bones without contrast and CT cervical spine without contrast. REASON FOR EXAM A 68-year-old status post fall with multifocal pain. COMPARISONS None. TECHNIQUE Sequential axial CT images were obtained from the vertex to the thoracic inlet without contrast. Addition... | 22 Neurology |
HISTORY I had the pleasure of meeting and evaluating the patient today referred for evaluation of tracheostomy tube placement and treatment recommendations. As you are well aware he is a pleasant 64-year-old gentleman who unfortunately is suffering from end-stage COPD who required tracheostomy tube placement abo... | 3 Cardiovascular / Pulmonary |
PREOPERATIVE DIAGNOSES 1. Bilateral breast carcinoma. 2. Chemotherapy required. POSTOPERATIVE DIAGNOSES 1. Bilateral breast carcinoma. 2. Chemotherapy required. OPERATION Right subclavian Port-a-Cath insertion. FINDINGS AND PROCEDURE With the patient under satisfactory general orotracheal anesthesia and in... | 38 Surgery |
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... | 23 Neurosurgery |
REASON FOR CONSULTATION I was asked by Dr. X to see the patient in consultation for a new diagnosis of colon cancer. HISTORY OF PRESENT ILLNESS The patient presented to medical attention after she noticed mild abdominal cramping in February 2007. At that time she was pregnant and was unsure if her symptoms migh... | 14 Gastroenterology |
PREOPERATIVE DIAGNOSES 1. Chronic pelvic pain. 2. Hypermenorrhea. 3. Desire for future fertility. 4. Failed conservative medical therapy. POSTOPERATIVE DIAGNOSES 1. Chronic pelvic pain. 2. Hypermenorrhea. 3. Desire for future fertility. 4. Failed conservative medical therapy. 5. Possible adenomyosis. 6. Lef... | 24 Obstetrics / Gynecology |
REASON FOR THE VISIT Very high PT/INR. HISTORY The patient is an 81-year-old lady whom I met last month when she came in with pneumonia and CHF. She was noticed to be in atrial fibrillation which is a chronic problem for her. She did not want to have Coumadin started because she said that she has had it before... | 3 Cardiovascular / Pulmonary |
PROTOCOL Bruce. PERTINENT MEDICATION None. REASON FOR TEST Chest pain. PROCEDURE AND INTERPRETATION 1. Baseline heart rate 67. 2. Baseline blood pressure 150/86. 3. Total time 6 minute 51 seconds. 4. METs 10.1. 5. Peak heart rate 140. 6. Percent of maximum-predicted heart rate 90. 7. Peak ... | 3 Cardiovascular / Pulmonary |
She has a past ocular history including cataract extraction with lens implants in both eyes in 2001 and 2003. She also has a history of glaucoma diagnosed in 1990 and macular degeneration. She has been followed in her home country and is here visiting family. She had the above-mentioned observation and was brought i... | 26 Ophthalmology |
PROCEDURE PERFORMED Port-A-Cath insertion. ANESTHESIA MAC. COMPLICATIONS None. ESTIMATED BLOOD LOSS Minimal. PROCEDURE IN DETAIL Patient was prepped and draped in sterile fashion. The left subclavian vein was cannulated with a wire. Fluoroscopic confirmation of the wire in appropriate position was perf... | 38 Surgery |
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