Datasets:

hpe-ai

/

medical-cases-classification-tutorial

like 4

Follow

HPE AI Solutions 2

The Ahmed shunt was primed and placed in the superior temporal quadrant and it was sutured in place with two 8-0 nylon sutures. The knots were trimmed.

PROCEDURE IN DETAIL: ,While in the holding area, the patient received a peripheral IV from the nursing staff. In addition, pilocarpine 1% was placed into the operative eye, two times, separated by 10 minutes. The patient was wheeled to the operating suite where the anesthesia team established peripheral monitoring lines. Through the IV, the patient received IV sedation in the form of propofol and once somnolent from this, a retrobulbar block was administrated consisting of 2% Xylocaine plain. Approximately 3 mL were administered. The patient then underwent a Betadine prep with respect to the face, lens, lashes, and eye. During the draping process, care was taken to isolate the lashes. A Vicryl traction suture was placed through the superior cornea and the eye was reflected downward to expose the superior temporal conjunctiva. Approximately 8 to 10 mm posterior to limbus, the conjunctiva was incised and dissected forward to the limbus. Blunt dissection was carried out in the superotemporal quadrant. Next, a 2 x 3-mm scleral flap was outlined that was one-half scleral depth in thickness. This flap was cut forward to clear cornea using a crescent blade. The Ahmed shunt was then primed and placed in the superior temporal quadrant and it was sutured in place with two 8-0 nylon sutures. The knots were trimmed. The tube was then cut to an appropriate length to enter the anterior chamber. The anterior chamber was then entered after a paracentesis wound had been made temporally. A trabeculectomy was done and then the tube was threaded through the trabeculectomy site. The tube was sutured in place with a multi-wrapped 8-0 nylon suture. The scleral flap was then sutured in place with two 10-0 nylon sutures. The knots were trimmed, rotated and buried. A scleral patch was then placed of an appropriate size over the two. It was sutured in place with interrupted 8-0 nylon sutures. The knots were trimmed. The overlying conjunctiva was then closed with a running 8-0 Vicryl suture with a BV needle. The anterior chamber was filled with Viscoat to keep it deep as the eye was somewhat soft. A good flow was established with irrigation into the anterior chamber. Homatropine, Econopred, and Vigamox drops were placed into the eye. A patch and shield were placed over the eye after removing the draping and the speculum. The patient tolerated the procedure well. He was taken to the recovery in good condition. He will be seen in followup in the office tomorrow.

Ahmed Shunt Placement

Ophthalmology

ophthalmology, cornea, ahmed shunt, nylon sutures, trabeculectomy, conjunctiva, chamberNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

This is a 46-year-old gentleman with end-stage renal disease (ESRD) secondary to diabetes and hypertension, who had been on hemodialysis and is also status post cadaveric kidney transplant with chronic rejection.

ADMISSION DIAGNOSIS:, End-stage renal disease (ESRD).,DISCHARGE DIAGNOSIS: , End-stage renal disease (ESRD).,PROCEDURE:, Cadaveric renal transplant.,HISTORY OF PRESENT ILLNESS: , This is a 46-year-old gentleman with end-stage renal disease (ESRD) secondary to diabetes and hypertension, who had been on hemodialysis since 1993 and is also status post cadaveric kidney transplant in 1996 with chronic rejection.,PAST MEDICAL HISTORY: ,1. Diabetes mellitus diagnosed 12 years ago.,2. Hypertension.,3. Coronary artery disease with a myocardial infarct in September of 2006.,4. End-stage renal disease.,PAST SURGICAL HISTORY: , Coronary artery bypass graft x5 in 1995 and cadaveric renal transplant in 1996.,SOCIAL HISTORY: ,The patient denies tobacco or ethanol use.,FAMILY HISTORY:, Hypertension.,PHYSICAL EXAMINATION: ,GENERAL: The patient was alert and oriented x3 in no acute distress, healthy-appearing male.,VITAL SIGNS: Temperature 96.6, blood pressure 166/106, heart rate 83, respiratory rate 18, and saturations 96% on room air.,CARDIOVASCULAR: Regular rate and rhythm.,PULMONARY: Clear to auscultation bilaterally.,ABDOMEN: Soft, nontender, and nondistended with positive bowel sounds.,EXTREMITIES: No clubbing, cyanosis, or edema.,PERTINENT LABORATORY DATA: , White blood cell count 6.4, hematocrit 34.6, and platelet count 182. Sodium 137, potassium 5.4, BUN 41, creatinine 7.9, and glucose 295. Total protein 6.5, albumin 3.4, AST 51, ALT 51, alk phos 175, and total bilirubin 0.5.,COURSE IN HOSPITAL: , The patient was admitted postoperatively to the surgical intensive care unit. Initially, the patient had a decrease in hematocrit from 30 to 25. The patient's hematocrit stabilized at 25. During the patient's stay, the patient's creatinine progressively decreased from 8.1 to a creatinine at the time of discharge of 2.3. The patient was making excellent urine throughout his stay. The patient's Jackson-Pratt drain was removed on postoperative day #1 and he was moved to the floor. The patient was advanced in diet appropriately. The patient was started on Prograf by postoperative day #2. Initial Prograf levels came back high at 18. The patient's Prograf doses were changed accordingly and today, the patient is deemed stable to be discharged home. During the patient's stay, the patient received four total doses of Thymoglobulin. Today, he will complete his final dose of Thymoglobulin prior to being discharged. In addition, today, the patient has an elevated blood pressure of 198/96. The patient is being given an extra dose of metoprolol for this blood pressure. In addition, the patient has an elevated glucose of 393 and for this reason he has been given an extra dose of insulin. These labs will be rechecked later today and once his blood pressure has decreased to systolic blood pressure less than 116 and his glucose has come down to a more normal level, he will be discharged to home.,DISCHARGE INSTRUCTIONS: , The patient is discharged with instructions to seek medical attention in the event if he develops fevers, chills, nausea, vomiting, decreased urine output, or other concerns. He is discharged on a low-potassium diet with activity as tolerated. He is instructed that he may shower; however, he is to undergo no underwater soaking activities for approximately two weeks. The patient will be followed up in the Transplant Clinic at ABCD tomorrow, at which time, his labs will be rechecked. The patient's Prograf levels at the time of discharge are pending; however, given that his Prograf dose was decreased, he will be followed tomorrow at the Renal Transplant Clinic.

ESRD - Discharge Summary

Nephrology

Endotracheal intubation. The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather. PCO2 was 29 and pO2 was 66 on the 15 liters.

PROCEDURE PERFORMED: , Endotracheal intubation.,INDICATION FOR PROCEDURE: ,The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather. PCO2 was 29 and pO2 was 66 on the 15 liters.,NARRATIVE OF PROCEDURE: , The patient was given a total of 5 mg of Versed, 20 mg of etomidate, and 10 mg of vecuronium. He was intubated in a single attempt. Cords were well visualized, and a #8 endotracheal tube was passed using a curved blade. Fiberoptically, a bronchoscope was passed for lavage and the tube was found to be in good position 3 cm above the main carina where it was kept there and the right lower lobe was lavaged with trap A lavage with 100 mL of normal sterile saline for cytology, AFB, and fungal smear and culture. A separate trap B was then lavaged for bacterial C&S and Gram stain and was sent for those purposes. The patient tolerated the procedure well.

Endotracheal Intubation - 2

Cardiovascular / Pulmonary

cardiovascular / pulmonary, nonrebreather, respiratory distress, falling saturation, endotracheal intubation, lavage, breathingNOTE

Bilateral knee degenerative arthritis. Bilateral knee arthroplasty. The Zimmer NexGen total knee system was utilized.

PREOPERATIVE DIAGNOSIS: , Bilateral knee degenerative arthritis.,POSTOPERATIVE DIAGNOSIS: , Bilateral knee degenerative arthritis.,PROCEDURE PERFORMED: , Bilateral knee arthroplasty.,Please note this procedure was done by Dr. X for the left total knee and Dr. Y for the right total knee. This operative note will discuss the right total knee arthroplasty.,ANESTHESIA: ,General.,COMPLICATIONS: , None.,BLOOD LOSS: , Approximately 150 cc.,HISTORY:, This is a 79-year-old female who has disabling bilateral knee degenerative arthritis. She has been unresponsive to conservative measures. All risks, complications, anticipated benefits, and postoperative course were discussed. The patient has agreed to proceed with surgery as described below.,GROSS FINDINGS: , There was noted to be eburnation and wear along the patellofemoral joint and femoral tibial articulation medially and laterally with osteophyte formation and sclerosis.,SPECIFICATIONS: , The Zimmer NexGen total knee system was utilized.,PROCEDURE: , The patient was taken to the operating room #2 and placed in supine position on the operating room table. She was administered spinal anesthetic by Dr. Z.,The tourniquet was placed about the proximal aspect of the right lower extremity. The right lower extremity was then sterilely prepped and draped in the usual fashion. An Esmarch bandage was used to exsanguinate the right lower extremity and the tourniquet was inflated to 325 mmHg. Longitudinal incision was made over the anterior aspect of the right knee. Subcutaneous tissue was carefully dissected. A medial parapatellar retinacular incision was made. The patella was then everted and the above noted gross findings were appreciated. A drill hole was placed in the distal aspect of the femur and the distal femoral cutting guides were positioned in place. The appropriate cuts were made at the distal femur as well as with use of the chamfer guide. The trial femoral component was then positioned in place and noted to have good fit. Attention was then directed to proximal tibia, the external tibial alignment guide was positioned in place and the proximal tibial cut was made demonstrating satisfactory cut. The medial and lateral collateral ligaments remained intact throughout the procedure as well as the posterior cruciate ligaments. The remnants of the anterior cruciate ligament and menisci were resected. The tibial trial was positioned in place. Intraoperative radiographs were taken, demonstrating satisfactory alignment of the tibial cut. The tibial holes were then drilled. The patella was then addressed with the Bovie used to remove the soft tissue around the perimeter of the patella. The patellar cutting guide was positioned in place and the posterior aspect of the patella was resected to the appropriate thickness. Three drill holes were made within the patella after it was determined that 35 mm patella would be most appropriate. The knee was placed through range of motion with the trial components marked and then the appropriate components obtained. The tibial tray was inserted with cement, backed it into place, excess methylmethacrylate was removed. The femoral component was inserted with methylmethacrylate. Any excessive methylmethacrylate and bony debris were removed from the joint. Trial Poly was positioned in place and the knee was held in full extension while the methylmethacrylate became firm. The methylmethacrylate was also used at the patella. The prosthesis was positioned in place. The patellar clamp held securely till the methylmethacrylate was firm. After all three components were in place, the knee was then again in placed range of motion and there appeared to be some torsion to the proximal tibial component and concerned regarding the alignment. This component was removed and revised to a stemmed component with better alignment and position. The previous component removed, the methylmethacrylate was removed. Further irrigation was performed and then a stemmed template was positioned in place with the intramedullary alignment guide positioned and the tibia drilled and broached. The trial tibial stemmed component was positioned in place. Knee was placed through range of motion and the tracking was better. Actual component was then obtained, methyl methacrylate was placed within the tibia. The stemmed tibial component was impacted into place with good fit. The Poly was then positioned in place. Knee held in full extension with compression longitudinally after methylmethacrylate was solidified. The trial Poly was removed. Wound was irrigated and the joint was inspected. There was no debris. Collateral ligaments and posterior cruciate ligaments remained intact. Soft tissue balancing was done and a 17 mm Poly was then inserted with the knee and tibial and femoral components with good tracking as well as the patellar component. The tourniquet was deflated. Hemostasis was satisfactory. A drain was placed into the depths of the wound. The medial retinacular incision was closed with one Ethibond suture in interrupted fashion. The knee was placed through range of motion and there was no undue tissue tension, good patellar tracking, no excessive soft tissue laxity or constrain. The subcutaneous tissue was closed with #2-0 undyed Vicryl in interrupted fashion. The skin was closed with surgical clips. The exterior of the wound was cleansed as well padded dressing ABDs and ace wrap over the right lower extremity. At the completion of the procedure, distal pulses were intact. Toes were pink, warm, with good capillary refill. Distal neurovascular status was intact. Postoperative x-ray demonstrated satisfactory alignment of the prosthesis. Prognosis is good in this 79-year-old female with a significant degenerative arthritis.

Knee Arthroplasty - Bilateral

Orthopedic

orthopedic, patellofemoral, eburnation, osteophyte, articulation, tibial, femoral, bilateral knee arthroplasty, knee degenerative arthritis, zimmer nexgen, lower extremity, arthroplasty, patella, methylmethacrylate,

Botulinum toxin injection bilateral rectus femoris, medial hamstrings, and gastrocnemius soleus muscles, phenol neurolysis of bilateral obturator nerves, application of bilateral short leg fiberglass casts.

PROCEDURE CODES: 64640 times two, 64614 time two, 95873 times two, 29405 times two.,PREOPERATIVE DIAGNOSIS: Spastic diplegic cerebral palsy, 343.0.,POSTOPERATIVE DIAGNOSIS: Spastic diplegic cerebral palsy, 343.0.,ANESTHESIA: MAC.,COMPLICATIONS: None.,DESCRIPTION OF TECHNIQUE: Informed consent was obtained from the patient's mom. The patient was brought to minor procedures and sedated per their protocol. The patient was positioned lying supine. Skin overlying all areas injected was prepped with chlorhexidine.,The obturator nerves were identified lateral to the adductor longus tendon origin and below the femoral pulse with active EMG stimulation. Approximately 4 mL of 5% phenol was injected in this location bilaterally. Phenol injections were done at the site of maximum hip adduction contraction with least amount of stimulus. Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified with active EMG stimulation. Approximately 50 units was injected in the rectus femoris bilaterally, 75 units in the medial hamstrings bilaterally and 100 units in the gastrocnemius soleus muscles bilaterally. Total amount of botulinum toxin injected was 450 units diluted 25 units to 1 mL. After injections were performed, bilateral short leg fiberglass casts were applied. The patient tolerated the procedure well and no complications were encountered.

Phenol Neurolysis & Botulinum Toxin Injection - 3

Neurosurgery

neurosurgery, botulinum toxin injection bilateral, toxin injection bilateral rectus, neurolysis of bilateral obturator, short leg fiberglass casts, muscles phenol neurolysis, botulinum toxin injection, gastrocnemius soleus muscles, short leg fiberglass, femoris medial, cerebral palsy, active emg, emg stimulation, phenol neurolysis, toxin injection, rectus femoris, gastrocnemius soleus, soleus muscles, obturator nerves, leg fiberglass, fiberglass casts, botulinum toxin, hamstrings, gastrocnemius, obturator, nerves, fiberglass, casts, muscles, botulinum, phenol, bilateral, injection, toxin

Anterior cervical discectomy with decompression of spinal cord. Anterior cervical fusion. Anterior cervical instrumentation. Insertion of intervertebral device. Use of operating microscope.

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 intervertebral device, C7-T1.,5. Use of operating microscope.,ANESTHESIOLOGY: , General endotracheal.,ESTIMATED BLOOD LOSS: ,A 30 mL.,PROCEDURE IN DETAIL: ,The patient was taken to the operating room where he was orally intubated by The Anesthesiology Service. He was placed in the supine position on an OR table. His arms were carefully taped down. He was sterilely prepped and draped in the usual fashion.,A 4-cm incision was made obliquely over the left side of his neck. Subcutaneous tissue was dissected down to the level of the platysma. The platysma was incised using electrocautery. Blunt dissection was done to create a plane between the strap muscles and the sternoclavicular mastoid muscle. This allowed us to get right down on to the anterior cervical spine. Blunt dissection was done to sweep off the longus colli. We isolated the C7-T1 interspace. An x-ray was taken to verify; we were indeed at the C7-T1 interspace.,Shadow-Line retractor was placed as well as Caspar pins. This provided very, very good access to the C7-T1 disk.,At this point, the operating microscope was brought into the decompression.,A thorough and aggressive C7-T1 discectomy was done using a succession of curettes, pituitary rongeur, 4-mm cutting bur and a #2 Kerrison rongeur. At the end of the discectomy, the cartilaginous endplates were carefully removed using 4-mm cutting burr. The posterior longitudinal ligament was carefully resected using #2 Kerrison rongeur. Left-sided C8 foraminotomy was accomplished using nerve hook and a 2-mm Kerrison rongeur. At the end of the decompression, there was no further compression on the left C8 nerve root.,A Synthes cortical cancellous ____________ bone was placed in the interspace. Sofamor Danek Atlantis plate was then placed over the interspace and four screws were placed, two in the body of C7 and two in the body of T1. An x-ray was taken. It showed good placement of the plate and screws.,A deep drain was placed. The platysma layer was closed in running fashion using #1 Vicryl. Subcutaneous tissue was closed in an interrupted fashion using 2-0 Vicryl. Skin was closed in a running fashion using 4-0 Monocryl. Steri-Strips and dressings were applied. All counts were correct. There were no complications.

Anterior Cervical Discectomy & Fusion - 6

Orthopedic

orthopedic, disk herniation, cervical discectomy, decompression, spinal cord, anterior cervical fusion, anterior cervical discectomy, kerrison rongeur, anterior cervical, instrumentation, cervical, anterior, platysma, kerrison, fashion, interspace, rongeur, discectomy, herniation,

Revision laminectomy L5-S1, discectomy L5-S1, right medial facetectomy, preparation of disk space and arthrodesis with interbody graft with BMP. Status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain, failed conservative therapy.

TITLE OF OPERATION: , Revision laminectomy L5-S1, discectomy L5-S1, right medial facetectomy, preparation of disk space and arthrodesis with interbody graft with BMP.,INDICATIONS FOR SURGERY: ,Please refer to medical record, but in short, the patient is a 43-year-old male known to me, status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain, failed conservative therapy. Risks and benefits of surgery were explained in detail including risk of bleeding, infection, stroke, heart attack, paralysis, need for further surgery, hardware failure, persistent symptoms, and death. This list was inclusive, but not exclusive. An informed consent was obtained after all patient's questions were answered.,PREOPERATIVE DIAGNOSIS: ,Severe lumbar spondylosis L5-S1, collapsed disk space, hypermobility, and herniated disk posteriorly.,POSTOPERATIVE DIAGNOSIS: , Severe lumbar spondylosis L5-S1, collapsed disk space, hypermobility, and herniated disk posteriorly.,ANESTHESIA: , General anesthesia and endotracheal tube intubation.,DISPOSITION: , The patient to PACU with stable vital signs.,PROCEDURE IN DETAIL: ,The patient was taken to the operating room. After adequate general anesthesia with endotracheal tube intubation was obtained, the patient was placed prone on the Jackson table. Lumbar spine was shaved, prepped, and draped in the usual sterile fashion. An incision was carried out from L4 to S1. Hemostasis was obtained with bipolar and Bovie cauterization. A Weitlaner was placed in the wound and a subperiosteal dissection was carried out identifying the lamina of L4, L5, and sacrum. At this time, laminectomy was carried out of L5-S1. Thecal sac was retracted rightward and the foramen was opened and unilateral medial facetectomy was carried out in the disk space. At this time, the disk was entered with a #15 blade and bipolar. The disk was entered with straight up and down-biting pituitaries, curettes, and the high speed drill and we were able to takedown calcified herniated disk. We were able to reestablish the disk space, it was very difficult, required meticulous dissection and then drilling with a diamond bur in the disk space underneath the spinal canal, very carefully holding the spinal canal out of harm's way as well as the exiting nerve root. Once this was done, we used rasps to remove more disk material anteriorly and under the midline to the left side and then we put in interbody graft of BMP 8 mm graft from Medtronic. At this time, Dr. X will dictate the posterolateral fusion, pedicle screw fixation to L4 to S1 with compression and will dictate the closure of the wound. There were no complications.

Laminectomy & Discectomy & Facetectomy

Neurosurgery

neurosurgery, revision laminectomy, discectomy, facetectomy, arthrodesis, lumbar spondylosis, hypermobility, collapsed disk space, medial facetectomy, interbody graft, herniated disk, interbody, laminectomy, disk, therapy, lumbar, herniated, space,

Ultrasound OB - followup for fetal growth.

REASON FOR EXAM: , Followup for fetal growth. , ,INTERPRETATION: , Real-time exam demonstrates a single intrauterine fetus in cephalic presentation with a regular cardiac rate of 147 beats per minute documented. ,FETAL BIOMETRY: ,BPD = 8.3 cm = 33 weeks, 4 days,HC = 30.2 cm = 33 weeks, 4 days,AC = 27.9 cm = 32 weeks, 0 days,FL = 6.4 cm = 33 weeks, 1 day,The head to abdomen circumference ratio is normal at 1.08, and the femur length to abdomen circumference ratio is normal at 23.0%. Estimated fetal weight is 2,001 grams. ,The amniotic fluid volume appears normal, and the calculated index is normal for the age at 13.7 cm. ,A detailed fetal anatomic exam was not performed at this setting, this being a limited exam for growth. The placenta is posterofundal and grade 2., ,IMPRESSION: , Single viable intrauterine pregnancy in cephalic presentation with a composite gestational age of 32 weeks, 5 days, plus or minus 17 days, giving and estimated date of confinement of 8/04/05. There has been normal progression of fetal growth compared to the two prior exams of 2/11/05 and 4/04/05. The examination of 4/04/05 questioned an echogenic focus within the left ventricle. The current examination does not demonstrate any significant persistent echogenic focus involving the left ventricle.

Ultrasound OB

Obstetrics / Gynecology

obstetrics / gynecology, amniotic fluid volume, placenta, posterofundal, intrauterine pregnancy, followup for fetal growth, ultrasound ob, cephalic presentation, abdomen circumference, circumference ratio, echogenic focus, fetal growth, fetal,

Colonoscopy. History of colon polyps and partial colon resection, right colon. Mild diverticulosis of the sigmoid colon. Hemorrhoids.

PREPROCEDURE DIAGNOSIS: , History of colon polyps and partial colon resection, right colon.,POSTPROCEDURE DIAGNOSES: ,1. Normal operative site. ,2. Mild diverticulosis of the sigmoid colon. ,3. Hemorrhoids.,PROCEDURE: ,Total colonoscopy.,PROCEDURE IN DETAIL: ,The patient is a 60-year-old of Dr. ABC's being evaluated for the above. The patient also apparently had an x-ray done at the Hospital and it showed a dark spot, and because of this, a colonoscopy was felt to be needed. She was prepped the night before and on the morning of the test with oral Fleet's, brought to the second floor and sedated with a total of 50 mg of Demerol and 3.75 mg of Versed IV push. Digital rectal exam was done, unremarkable. At that point, the Pentax video colonoscope was inserted. The rectal vault appeared normal. The sigmoid showed diverticula throughout, mild to moderate in nature. The scope was then passed through the descending and transverse colon over to the hepatic flexure area and then the anastomosis site was visualized. The scope was passed a short distance up the ileum, which appeared normal. The scope was then withdrawn through the transverse, descending, sigmoid, and rectal vault area. The scope was then retroflexed, and anal verge visualized showed some hemorrhoids. The scope was then removed. The patient tolerated the procedure well.,RECOMMENDATIONS: ,Repeat colonoscopy in three years.

Colonoscopy - 14

Gastroenterology

gastroenterology, partial colon resection, diverticulosis, colon polyps, rectal vault, colonoscopy, polyps, hemorrhoids, sigmoid

Thromboendarterectomy of right common, external, and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure. Coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending, and reverse autogenous saphenous vein graft to the obtuse marginal, posterior descending branch of the right coronary artery.

OPERATIVE PROCEDURE,1. Thromboendarterectomy of right common, external, and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure.,2. Coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending, and reverse autogenous saphenous vein graft to the obtuse marginal, posterior descending branch of the right coronary artery. Total cardiopulmonary bypass,cold blood potassium cardioplegia, antegrade and retrograde, for myocardial protection, placement of temporary pacing wires.,DESCRIPTION:, The patient was brought to the operating room, placed in supine position. Adequate general endotracheal anesthesia was induced. Appropriate monitoring lines were placed. The chest, abdomen and legs were prepped and draped in a sterile fashion. The greater saphenous vein was harvested from the right upper leg through interrupted skin incisions and was prepared by ligating all branches with 4-0 silk and flushing with vein solution. The leg was closed with running 3-0 Dexon subcu, and running 4-0 Dexon subcuticular on the skin, and later wrapped. A median sternotomy incision was made and the left internal mammary artery was dissected free from its takeoff at the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze. The sternum was closed. A right carotid incision was made along the anterior border of the sternocleidomastoid muscle and carried down to and through the platysma. The deep fascia was divided. The facial vein was divided between clamps and tied with 2-0 silk. The common carotid artery, takeoff of the external and internal carotid arteries were dissected free, with care taken to identify and preserve the hypoglossal and vagus nerves. The common carotid artery was double-looped with umbilical tape, takeoff of the external was looped with a heavy silk, distal internal was double-looped with a heavy silk. Shunts were prepared. A patch was prepared. Heparin 50 mg was given IV. Clamp was placed on the beginning of the takeoff of the external and the proximal common carotid artery. Distal internal was held with a forceps. Internal carotid artery was opened with 11-blade. Potts scissors were then used to extend the aortotomy through the lesion into good internal carotid artery beyond. The shunt was placed and proximal and distal snares were tightened. Endarterectomy was carried out under direct vision in the common carotid artery and the internal reaching a fine, feathery distal edge using eversion on the external. All loose debris was removed and Dacron patch was then sutured in place with running 6-0 Prolene suture, removing the shunt just prior to completing the suture line. Suture line was completed and the neck was packed.,The pericardium was opened. A pericardial cradle was created. The patient was heparinized for cardiopulmonary bypass, cannulated with a single aortic and single venous cannula. A retrograde cardioplegia cannula was placed with a pursestring of 4-0 Prolene into the coronary sinus, and secured to a Rumel tourniquet. An antegrade cardioplegia needle sump was placed in the ascending aorta and cardiopulmonary bypass was instituted. The ascending aorta was cross-clamped and cold blood potassium cardioplegia was given antegrade, a total of 5 cc per kg. This was followed sumping of the ascending aorta and retrograde cardioplegia, a total of 5 cc per kg to the coronary sinus. The obtuse marginal 1 coronary was identified and opened, and an end-to-side anastomosis was then performed with running 7-0 Prolene suture. The vein was cut to length. Antegrade and retrograde cold blood potassium cardioplegia was given. The obtuse marginal 2 was not felt to be suitable for bypass, therefore, the posterior descending of the right coronary was identified and opened, and an end-to-side anastomosis was then performed with running 7-0 Prolene suture to reverse autogenous saphenous vein. The vein was cut to length. The mammary was clipped distally, divided and spatulated for anastomosis. Antegrade and retrograde cold blood potassium cardioplegia was given. The anterior descending was identified and opened. the mammary was then sutured to this with running 8-0 Prolene suture. Warm blood potassium cardioplegia was given, and the cross-clamp was removed. A partial-occlusion clamp was placed. Two aortotomies were made. The veins were cut to fit these and sutured in place with running 5-0 Prolene suture. The partial- occlusion clamp was removed. All anastomoses were inspected and noted to be patent and dry. Atrial and ventricular pacing wires were placed. Ventilation was commenced. The patient was fully warmed. The patient was weaned from cardiopulmonary bypass and de-cannulated in a routine fashion. Protamine was given. Good hemostasis was noted. A single mediastinal chest tube and bilateral pleural Blake drains were placed. The sternum was closed with figure-of-eight stainless steel wire, the linea alba with figure-of-eight #1 Vicryl, the sternal fascia with running #1 Vicryl, the subcu with running 2-0 Dexon and the skin with a running 4-0 Dexon subcuticular stitch.

Thromboendarterectomy

Cardiovascular / Pulmonary

cardiovascular / pulmonary, cabg, thromboendarterectomy, carotid artery, coronary artery bypass, mammary, obtuse, papaverine-soaked, running prolene suture, cardiopulmonary bypass, internal carotid, running prolene, prolene suture, carotid, sutured, artery, prolene, coronary, bypass, veinNOTE

Right nodular malignant mesothelioma.

PREOPERATIVE DIAGNOSIS:, Right mesothelioma.,POSTOPERATIVE DIAGNOSIS: , Right lung mass invading diaphragm and liver.,FINDINGS: , Right lower lobe lung mass invading diaphragm and liver.,PROCEDURES:,1. Right thoracotomy.,2. Right lower lobectomy with en bloc resection of diaphragm and portion of liver.,SPECIMENS: , Right lower lobectomy with en bloc resection of diaphragm and portion of liver.,BLOOD LOSS: , 600 mL.,FLUIDS: , Crystalloid 2.7 L and 1 unit packed red blood cells.,ANESTHESIA: , Double-lumen endotracheal tube.,CONDITION:, Stable, extubated, to PACU.,PROCEDURE IN DETAIL:, Briefly, this is a gentleman who was diagnosed with a B-cell lymphoma and then subsequently on workup noted to have a right-sided mass seeming to arise from the right diaphragm. He was presented at Tumor Board where it was thought upon review that day that he had a right nodular malignant mesothelioma. Thus, he was offered a right thoracotomy and excision of mass with possible reconstruction of the diaphragm. He was explained the risks, benefits, and alternatives to this procedure. He wished to proceed, so he was brought to the operating room.,An epidural catheter was placed. He was put in a supine position where SCDs and Foley catheter were placed. He was put under general endotracheal anesthesia with a double-lumen endotracheal tube. He was given preoperative antibiotics, then he was placed in the left decubitus position, and the area was prepped and draped in the usual fashion.,A low thoracotomy in the 7th interspace was made using the skin knife and then Bovie cautery onto the middle of the rib and then with the Alexander instrument, the chest was entered. Upon entering the chest, the chest wall retractor was inserted and the cavity inspected. It appeared that the mass actually arose more from the right lower lobe and was involving the diaphragm. He also had some marked lymphadenopathy. With these findings, which were thought at that time to be more consistent with a bronchogenic carcinoma, we proceeded with the intent to perform a right lower lobectomy and en bloc diaphragmatic resection. Thus, we mobilized the inferior pulmonary ligament and made our way around the hilum anteriorly and posteriorly. We also worked to open the fissure and tried to identify the arteries going to the superior portion of the right lower lobe and basilar arteries as well as the artery going to the right middle lobe. The posterior portion of the fissure ultimately divided with the single firing of a GIA stapler with a blue load and with the final portion being divided between 2-0 ties. Once we had clearly delineated the arterial anatomy, we were able to pass a right angle around the artery going to the superior segment. This was ligated in continuity with an additional stick tie in the proximal portion of 3-0 silk. This was divided thus revealing a branched artery going to the basilar portion of the right lower lobe. This was also ligated in continuity and actually doubly ligated. Care was taken to preserve the artery to the right and middle lobe.,We then turned our attention once again to the hilum to dissect out the inferior pulmonary vein. The superior pulmonary vein was visualized as well. The right angle was passed around the inferior pulmonary vein, and this was ligated in continuity with 2-0 silk and a 3-0 stick tie. Upon division of this portion, the specimen site had some bleeding, which was eventually controlled using several 3-0 silk sutures. The bronchial anatomy was defined. Next, we identified the bronchus going to the right lower lobe as well as the right middle lobe. A TA-30 4.8 stapler was then closed. The lung insufflated. The right middle lobe and right upper lobe were noted to inflate well. The stapler was fired, and the bronchus was cut with a 10-blade.,We then turned our attention to the diaphragm. There was a small portion of the diaphragm of approximately 4 to 5 cm has involved with tumor, and we bovied around this with at least 1 cm margin. Upon going through the diaphragm, it became clear that the tumor was also involving the dome of the liver, so after going around the diaphragm in its entirety, we proceeded to wedge out the portion of liver that was involved. It seemed that it would be a mucoid shallow portion. The Bovie was set to high cautery. The capsule was entered, and then using Bovie cautery, we wedged out the remaining portion of the tumor with a margin of normal liver. It did leave quite a shallow defect in the liver. Hemostasis was achieved with Bovie cautery and gentle pressure. The specimen was then taken off the table and sent to Pathology for permanent. The area was inspected for hemostasis. A 10-flat JP was placed in the abdomen at the portion of the wedge resection, and 0 Prolene was used to close the diaphragmatic defect, which was under very little tension. A single 32 straight chest tube was also placed. The lung was seen to expand. We also noted that the incomplete fissure between the middle and upper lobes would prevent torsion of the right middle lobe. Hemostasis was observed at the end of the case. The chest tube was irrigated with sterile water, and there was no air leak observed from the bronchial stump. The chest was then closed with Vicryl at the level of the intercostal muscles, staying above the ribs. The 2-0 Vicryl was used for the latissimus dorsi layer and the subcutaneous layer, and 4-0 Monocryl was used to close the skin. The patient was then brought to supine position, extubated, and brought to the recovery room in stable condition.,Dr. X was present for the entirety of the procedure, which was a right thoracotomy, right lower lobectomy with en bloc resection of diaphragm and a portion of liver.

Mesothelioma - Thoracotomy & Lobectomy

Hematology - Oncology

hematology - oncology, double lumen endotracheal, en bloc resection, malignant mesothelioma, lung mass, endotracheal tube, chest tube, bovie cautery, en bloc, diaphragm, lobectomy, mesothelioma, thoracotomy,

Bilateral temporal artery biopsy. Rule out temporal arteritis.

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 out temporal arteritis. I explained fully the procedure to the patient.,PROCEDURE: , Both sides were done exactly the same way. After 1% Xylocaine infiltration, a 2 to 3-cm incision was made over the temporal artery. The temporal artery was identified and was grossly normal on both sides. Proximal and distal were ligated with both of 3-0 silk suture and Hemoccult. The specimen of temporal artery was taken from both sides measuring at least 2 to 3 cm. They were sent as separate specimens, right and left labeled. The wound was then closed with interrupted 3-0 Monocryl subcuticular sutures and Dermabond. She tolerated the procedure well.

Temporal Artery Biopsy

Neurology

neurology, headaches, bilateral temporal artery, temporal artery biopsy, temporal arteritis, temporal artery, temporal, biopsy, arteritis

CT Brain - arachnoid cyst Arachnoid cyst diagnosed by CT brain.

CC:, Seizures.,HX: ,The patient was initially evaluated at UIHC at 7 years of age. He had been well until 7 months prior to evaluation when he started having spells which were described as "dizzy spells" lasting from several seconds to one minute in duration. They occurred quite infrequently and he was able to resume activity immediately following the episodes. The spell became more frequent and prolonged, and by the time of initial evaluation were occurring 2-3 times per day and lasting 2-3 minutes in duration. In addition, in the 3 months prior to evaluation, the right upper extremity would become tonic and flexed during the episodes, and he began to experience post ictal fatigue.,BIRTH HX:, 32 weeks gestation to a G4 mother and weighed 4#11oz. He was placed in an incubator for 3 weeks. He was jaundiced, but there was no report that he required treatment.,PMH: ,Single febrile convulsion lasting "3 hours" at age 2 years.,MEDS: ,none.,EXAM:, Appears healthy and in no acute distress. Unremarkable general and neurologic exam.,Impression: Psychomotor seizures.,Studies: Skull X-Rays were unremarkable.,EEG showed "minimal spike activity during hyperventilation, as well as random sharp delta activity over the left temporal area, in drowsiness and sleep. This record also showed moderate amplitude asymmetry ( left greater than right) over the frontal central and temporal areas, which is a peculiar finding.",COURSE:, The patient was initially treated with Phenobarbital; then Dilantin was added (early 1970's); then Depakene was added ( early 1980's) due to poor seizure control. An EEG on 8/22/66 showed "Left mid-temporal spike focus with surrounding slow abnormality, especially posterior to the anterior temporal areas (sparing the parasagittal region). In addition, the right lateral anterior hemisphere voltage is relatively depressed. ...this suggests two separate areas of cerebral pathology." He underwent his first HCT scan in Sioux City in 1981, and this revealed an right temporal arachnoid cyst. The patient had behavioral problems throughout elementary/junior high/high school. He underwent several neurosurgical evaluations at UIHC and Mayo Clinic and was told that surgery was unwarranted. He was placed on numerous antiepileptic medication combinations including Tegretol, Dilantin, Phenobarbital, Depakote, Acetazolamide, and Mysoline. Despite this he averaged 2-3 spells a month. He was last seen, 6/19/95, and was taking Dilantin and Tegretol. His typical spells were described as sudden in onset and without aura. He frequently becomes tonic or undergoes tonic-clonic movement and falls with associated loss of consciousness. He usually has rapid recovery and can return to work in 20 minutes. He works at a Turkey packing plant. Serial HCT scans showed growth in the arachnoid cyst until 1991, when growth arrest appeared to have occurred.

Arachnoid Cyst

Neurology

neurology, arachnoid cyst, hct scan, seizures, serial hct scans, dizzy spells, drowsiness, hyperventilation, loss of consciousness, moderate amplitude asymmetry, temporal area, tonic-clonic movement, phenobarbital, dilantin, cyst, temporal, arachnoid

Increasing oxygen requirement. Baby boy has significant pulmonary hypertension.

INDICATION FOR CONSULTATION: , Increasing oxygen requirement.,HISTORY: , Baby boy, XYZ, is a 29-3/7-week gestation infant. His mother had premature rupture of membranes on 12/20/08. She then presented to the Labor and Delivery with symptoms of flu. The baby was then induced and delivered. The mother had a history of premature babies in the past. This baby was doing well, and then, we had a significant increasing oxygen requirement from room air up to 85%. He is now on 60% FiO2.,PHYSICAL FINDINGS,GENERAL: He appears to be pink, well perfused, and slightly jaundiced.,VITAL SIGNS: Pulse 156, 56 respiratory rate, 92% sat, and 59/28 mmHg blood pressure.,SKIN: He was pink.,He was on the high-frequency ventilator with good wiggle.,His echocardiogram showed normal structural anatomy. He has evidence for significant pulmonary hypertension. A large ductus arteriosus was seen with bidirectional shunt. A foramen ovale shunt was also noted with bidirectional shunt. The shunting for both the ductus and the foramen ovale was equal left to right and right to left.,IMPRESSION: , My impression is that baby boy, XYZ, has significant pulmonary hypertension. The best therapy for this is to continue oxygen. If clinically worsens, he may require nitric oxide. Certainly, Indocin should not be used at this time. He needs to have lower pulmonary artery pressures for that to be considered.,Thank you very much for allowing me to be involved in baby XYZ's care.

Pulmonary Hypertension - Pediatric Consult

Cardiovascular / Pulmonary

cardiovascular / pulmonary, high-frequency ventilator, structural anatomy, foramen ovale, oxygen requirement, hypertension, pulmonary

Left neck dissection. Metastatic papillary cancer, left neck. The patient had thyroid cancer, papillary cell type, removed with a total thyroidectomy and then subsequently recurrent disease was removed with a paratracheal dissection.

PREOPERATIVE DIAGNOSIS: , Metastatic papillary cancer, left neck.,POSTOPERATIVE DIAGNOSIS: , Metastatic papillary cancer, left neck.,OPERATION PERFORMED: , Left neck dissection.,ANESTHESIA: ,General endotracheal.,INDICATIONS: , The patient is a very nice gentleman, who has had thyroid cancer, papillary cell type, removed with a total thyroidectomy and then subsequently recurrent disease was removed with a paratracheal dissection. He now has evidence of lesion in the left mid neck and the left superior neck on ultrasound, which are suspicious for recurrent cancer. Left neck dissection is indicated.,DESCRIPTION OF OPERATION: , The patient was placed on the operating room table in the supine position. After adequate general endotracheal anesthesia was administered, the table was then turned. A shoulder roll placed under the shoulders and the face was placed in an extended fashion. The left neck, chest, and face were prepped with Betadine and draped in a sterile fashion. A hockey stick skin incision was performed, extending a previous incision line superiorly towards the mastoid cortex through skin, subcutaneous tissue and platysma with Bovie electrocautery on cut mode. Subplatysmal superior and inferior flaps were raised. The dissection was left lateral neck dissection encompassing zones 1, 2A, 2B, 3, and the superior portion of 4. The sternocleidomastoid muscle was unwrapped at its fascial attachment and this was taken back posterior to the XI cranial nerve into the superior posterior most triangle of the neck. This was carried forward off of the deep rooted muscles including the splenius capitis and anterior and middle scalenes taken medially off of these muscles including the fascia of the muscles, stripped from the carotid artery, the X cranial nerve, the internal jugular vein and then carried anteriorly to the lateral most extent of the dissection previously done by Dr. X in the paratracheal region. The submandibular gland was removed as well. The X, XI, and XII cranial nerves were preserved. The internal jugular vein and carotid artery were preserved as well. Copious irrigation of the wound bed showed no identifiable bleeding at the termination of the procedure. There were two obviously positive nodes in this neck dissection. One was left medial neck just lateral to the previous tracheal dissection and one was in the mid region of zone 2. A #10 flat fluted Blake drain was placed through a separate stab incision and it was secured to the skin with a 2-0 silk ligature. The wound was closed in layers using a 3-0 Vicryl in a buried knot interrupted fashion for the subcutaneous tissue and the skin was closed with staples. A fluff and Kling pressure dressing was then applied. The patient was extubated in the operating room, brought to the recovery room in satisfactory condition. There were no intraoperative complications.

Neck Dissection

ENT - Otolaryngology

ent - otolaryngology, metastatic papillary cancer, thyroidectomy, thyroid cancer, papillary cell type, dissection, neck, metastatic, paratracheal, papillary, cancer

CT chest with contrast.

EXAM: , CT chest with contrast.,REASON FOR EXAM: , Pneumonia, chest pain, short of breath, and coughing up blood.,TECHNIQUE: , Postcontrast CT chest 100 mL of Isovue-300 contrast.,FINDINGS: , This study demonstrates a small region of coalescent infiltrates/consolidation in the anterior right upper lobe. There are linear fibrotic or atelectatic changes associated with this. Recommend followup to ensure resolution. There is left apical scarring. There is no pleural effusion or pneumothorax. There is lingular and right middle lobe mild atelectasis or fibrosis.,Examination of the mediastinal windows disclosed normal inferior thyroid. Cardiac and aortic contours are unremarkable aside from mild atherosclerosis. The heart is not enlarged. There is no pathologic adenopathy identified in the chest including the bilateral axillary and hilar regions.,Very limited assessment of the upper abdomen demonstrates no definite abnormalities.,There are mild degenerative changes in the thoracic spine.,IMPRESSION:,1.Anterior small right upper lobe infiltrate/consolidation. Recommend followup to ensure resolution given its consolidated appearance.,2.Bilateral atelectasis versus fibrosis.

CT Chest - 1

Cardiovascular / Pulmonary

cardiovascular / pulmonary, pneumonia, chest pain, short of breath, coughing up blood, upper lobe infiltrate, ct chest, ct, chest, isovue,

Dysphagia and hematemesis while vomiting. Diffuse esophageal dilatation/hematemesis

CHIEF COMPLAINT: , Dysphagia and hematemesis while vomiting.,HISTORY OF PRESENT ILLNESS: , This is a 53-year-old African American female with 15 years known history of HIV and hepatitis B, and known history of compensated heart failure, COPD, who presented today with complaint of stuck food in her esophagus, bloody cough, and bloody vomiting since 4 o'clock this vomiting, when she ate eggplant parmigiana meal. The back and chest pain is 8/10, no radiation and is constant. She denied fever, abdominal pain, or dysphagia before current event eating bones or fish. This is the first episode of hematemesis and feeling of globus pallidus. In the emergency room, the patient was treated with nitropaste, morphine, and Lopressor with positive results for chest pain. CAT scan of the chest showed diffuse esophageal dilatation with residual food in it, no mediastinal air was identified.,REVIEW OF SYSTEMS: , The patient denied diarrhea, abdominal pain, fever, weight loss, dysphagia before this event. Denied any exertional chest pain or shortness of breath. No headache, limb weakness. No joint pain or muscle ache. No dysuria.,PAST MEDICAL HISTORY: ,Remarkable for:,1. Asthma.,2. Hepatitis C - 1995.,3. HIV, known since 1995 and followed up by Dr. X, ABCD Medical Center, the last visit was 08/09. The patient does not take HIV medications against medical advice.,4. Hypertension, known since 2008.,5. Negative PPD test, 10/08.,PAST SURGICAL HISTORY: , Remarkable for hysterectomy in 2001, pilonidal cyst surgery in 2005.,FAMILY HISTORY: , Mother deceased at age 68 of cirrhosis. She had history of alcohol abuse. Father deceased at age 45, also has a history of alcohol abuse, cardiac disease, and hypertension.,ALLERGIES: , Not known allergies.,MEDICATIONS AT HOME: , Lisinopril 5 mg daily; metoprolol 25 mg twice daily; furosemide 40 mg once daily; Isentress 400 mg once daily, the patient does not take this medication for the last 3 months; Norvir 100 mg once daily; Prezista 400 mg once daily. The patient does not take her HIV medications for the last 2 to 3 months. Occasionally, she takes inhalation of albuterol and Ambien 10 mg once daily.,SOCIAL HISTORY: , She is single, lives with her 21-year-old daughter, works as CNA, smokes one pack per day for the last 8 years. She had periods when she quit smoking and started again 2-1/2 years ago. She denied alcohol abuse and she was using cocaine in the past, last time she used cocaine 10 years ago.,PHYSICAL EXAMINATION: , Temperature 99.8, pulse 106, respiratory rate 18, blood pressure 162/97, saturation 99 on room air. African American female, not in acute respiratory distress, but uncomfortable, and showing some signs of back discomfort. Oriented x3, mildly drowsy, calm and cooperative. Eyes, EOMI, PERRLA. Tympanic membranes normal appearance bilaterally. External canal, no erythema or discharge. Nose, no erythema or discharge. Throat, dry mucous, no exudates. No ulcers in oral area. Full upper denture and extensive decayed lower teeth. No cervical lymphadenopathy, no carotid bruits bilaterally. Heart: RRR, S1 and S2 appreciated. No additional sounds or murmurs were auscultated. Lung: Good air entrance bilaterally. No rales or rhonchi. Abdomen: Soft, nontender, nondistended. No masses or organomegaly were palpated. Legs: No signs of DVT, peripheral pulses full, posterior dorsalis pedis 2+. Skin: No rashes or other lesions, warm and well perfused. Nails: No clubbing. No other signs of skin infection. Neurological exam: Cranial nerves II through XII grossly intact. No motor or sensory deficit was found.,CAT scan of the chest, which was done at 8 o'clock in the morning on 01/12/10. Impression: Cardiomegaly, normal aorta, large distention of esophagus containing food. Chest x-ray: Cardiomegaly, no evidence of CHF or pneumonia. EKG: Normal sinus rhythm, no signs of ischemia.,LABORATORY DATA: , Hemoglobin 10.4, hematocrit 30.6, white blood cells 7.3, neutrophils 75, platelets 197. Sodium 140, potassium 3.1, chloride 104, bicarb 25, glucose 113, BUN 19, creatinine 1.1, GFR 55, calcium 8.8, total protein 8.1, albumin 3.1, globulin 5.0, bilirubin 0.3, alk phos 63, GOT 23, GPT 22, lipase 104, amylase 85, protime 10.2, INR 1, PTT 25.8. Urine: Negative for ketones, protein, glucose, blood, and nitrite, bacteria 2+. Troponin 0.040. BNP 1328.,PLAN:,1. Diffuse esophageal dilatation/hematemesis. We will put her n.p.o., we will give IV fluid, half normal saline D5 100 mL per hour. I discussed the case with Dr. Y, gastroenterologist. The patient planned for EGD starting today. Differential diagnosis may include foreign body, achalasia, Candida infection, or CMV esophagitis. We will treat according to the EGD findings. We will give IV Nexium 40 mg daily for GI prophylaxis. We will hold all p.o. medication.,2. CHF. Cardiomegaly on x-ray. She is clinically stable. Lungs are clear. No radiological sign of CHF exacerbation. We will restart lisinopril and metoprolol after EGD study will be completed.,3. HIV - follow up by Dr. X, (ABCD Medical Center). The last visit was on 08/08. The patient was not taking her HIV medications for the last 3 months and does not know her CD4 number or viral load. We will check CD4 number and viral load. We will contact Dr. X (ID specialist in ABCD Med).,4. Hypertension. We will control blood pressor with Lopressor 5 mg IV p.r.n. If blood pressure more than 160/90, we will hold metoprolol and lisinopril.,5. Hepatitis C, known since 1995. The patient does not take any treatment.,6. Tobacco abuse. The patient refused nicotine patch.,7. GI prophylaxis as stated above; and DVT prophylaxis, compression socks. We will restrain from using heparin or Lovenox.,ADDENDUM: , The patient was examined by Dr. Y, gastroenterologist, who ordered a CAT scan with oral contrast, which showed persistent distention of the esophagus with elementary debris within the lumen of the esophagus. There is no evidence of leakage of the oral contrast. There is decrease in size of periaortic soft tissue density around the descending aorta, this is associated with increase in very small left pleural effusion in the intervening time. There is no evidence of pneumomediastinum or pneumothorax, lungs are clear, contrast is present in stomach. After procedure, the patient had profuse vomiting with bloody content and spiked fever 102. The patient felt relieved after vomiting. The patient was started on aztreonam 1 g IV every 8 hours, Flagyl 500 mg IV every 8 hours. ID consult was called and thoracic surgeon consult was ordered.

Dysphagia & Hematemesis

Gastroenterology

Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy. Posterior cervical fusion C4-C5. Songer wire. Right iliac bone graft.

PREOPERATIVE DIAGNOSES,1. Post anterior cervical discectomy and fusion at C4-C5 and C5-C6 with possible pseudoarthrosis at C4-C5.,2. Cervical radiculopathy involving the left arm.,3. Disc degeneration at C3-C4 and C6-C7.,POSTOPERATIVE DIAGNOSES,1. Post anterior cervical discectomy and fusion at C4-C5 and C5-C6 with possible pseudoarthrosis at C4-C5.,2. Cervical radiculopathy involving the left arm.,3. Disc degeneration at C3-C4 and C6-C7.,OPERATIVE PROCEDURES,1. Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy.,2. Posterior cervical fusion C4-C5.,3. Songer wire.,4. Right iliac bone graft.,TECHNIQUE: ,The patient was brought to the operating room. Preoperative evaluations included previous cervical spine surgery. The patient initially had some relief; however, his left arm pain did recur and gradually got worse. Repeat studies including myelogram and postspinal CTs revealed some blunting of the nerve root at C4-C5 and C5-C6. There was also noted to be some annular bulges at C3-C4, and C6-C7. The CT scan in March revealed that the fusion was not fully solid. X-rays were done in November including flexion and extension views, it appeared that the fusion was solid.,The patient had been on pain medication. The patient had undergone several nonoperative treatments. He was given the option of surgical intervention. We discussed Botox, I discussed with the patient and posterior cervical decompression. I explained to the patient this will leave a larger scar on his neck, and that no guarantee would help, there would be more bleeding and more pain from the posterior surgery than it was from the anterior surgery. If at the time of surgery there was some motion of the C4-C5 level, I would recommend a fusion. The patient was a smoker and had been advised to quit smoking but has not quit smoking. I have therefore recommended that he use iliac bone graft. I explained to the patient that this would give him a scar over the back of the right pelvis and could be a source of chronic pain for the patient for the rest of his life. Even if this type of bone graft was used, there was no guarantee that it will fuse and he should stop smoking completely.,The patient also was advised that if I did a fusion, I would also use post instrumentation, which was a wire. The wire would be left permanently.,Even with all these procedures, there was no guarantee that his symptoms would improve. His numbness, tingling, and weakness could get worse rather than better, his neck pain and arm pain could persist. He still had some residual bursitis in his left shoulder and this would not be cured by this procedure. Other procedures may be necessary later. There is still with a danger of becoming quadriplegic or losing total control of bowel or bladder function. He could lose total control of his arms or legs and end up in the bed for the rest of his life. He could develop chronic regional pain syndromes. He could get difficulty swallowing or eating. He could have substantial weakness in the arm. He was advised that he should not undergo the surgery unless the pain is persistent, severe, and unremitting.,He was also offered his records if he would like any other pain medications or seek other treatments, he was advised that Dr. X would continue to prescribe pain medication if he did not wish to proceed with surgery.,He stated he understood all the risks. He did not wish to get any other treatments. He said the pain has reached the point that he wished to proceed with surgery.,PROCEDURE IN DETAIL: , In the operating room, he was given general endotracheal anesthesia.,I then carefully rolled the patient on thoracic rolls. His head was controlled by a horseshoe holder. The anesthesiologist checked the eye positions to make sure there was no pressure on the orbits and the anesthesiologist continued to check them every 15 minutes. The arms, the right hip, and the neck was then prepped and draped. Care was taken to position both arms and both legs. Pulses were checked.,A midline incision was made through the skin and subcutaneous tissue on the cervical spine. A loupe magnification and headlamp illumination was used. Bleeding vessels were cauterized. Meticulous hemostasis was carried out throughout the procedure. Gradually and carefully I exposed the spinous process of the C6, C5, and C4. A lateral view was done after an instrument in place. This revealed the C6-C7 level. I therefore did a small laminotomy opening at C4-C5. I placed an instrument and x-rays confirmed C4-C5 level.,I stripped the muscles from the lamina and then moved them laterally and held with a self-retaining retractor.,Once I identified the level, I then used a bur to thin the lamina of C5. I used a 1-mm, followed by a 2-mm Kerrison rongeur to carefully remove the lamina off C5 on the left. I removed some of the superior lamina of C6 and some of the inferior lamina of C4. This allowed me to visualize the dura and the nerve roots and gradually do neural foraminotomies for both the C5 and C6 nerve roots. There was some bleeding from the epidural veins and a bipolar cautery was used. Absolutely no retractors were ever placed in the canal. There was no retraction. I was able to place a small probe underneath the nerve root and check the disc spaces to make sure there was no fragments of disc or herniation disc and none were found.,At the end of the procedure, the neuroforamen were widely patent. The nerve roots had been fully decompressed.,I then checked stability. There was micromotion at the C4-C5 level. I therefore elected to proceed with a fusion.,I debrided the interspinous ligament between C4 and C5. I used a bur to roughen up the surface of the superior portion of the spinous process of C5 and the inferior portion of C4. Using a small drill, I opened the facet at C4-C5. I then used a very small curette to clean up the articular cartilage. I used a bur then to roughen up the lamina at C4-C5.,Attention was turned to the right and left hip, which was also prepped. An incision made over the iliac crest. Bleeding vessels were cauterized. I exposed just the posterior aspect of the crest. I removed some of the bone and then used the curette to remove cancellous bone.,I placed the Songer wire through the base of the spinous process of C4 and C5. Drill holes made with a clip. I then packed cancellous bone between the decorticated spinous process. I then tightened the Songer wire to the appropriate tension and then cut off the excess wire.,Prior to tightening the wire, I also packed cancellous bone with facet at C4-C5. I then laid bone upon the decorticated lamina of C4 and C5.,The hip wound was irrigated with bacitracin and Kantrex. Deep structures were closed with #1 Vicryl, subcutaneous suture and subcuticular tissue was closed.,No drain was placed in the hip.,A drain was left in the posterior cervical spine. The deep tissues were closed with 0 Vicryl, subcutaneous tissue and skin were then closed. The patient was taken to the recovery room in good condition.

Laminectomy & Foraminotomy & Cervical Fusion

Neurosurgery

Microscopic suspension direct laryngoscopy with biopsy of left true vocal cord stripping. Hoarseness, bilateral true vocal cord lesions, and leukoplakia.

PREOPERATIVE DIAGNOSES:,1. Hoarseness.,2. Bilateral true vocal cord lesions.,3. Leukoplakia.,POSTOPERATIVE DIAGNOSES:,1. Hoarseness.,2. Bilateral true vocal cord lesions.,3. Leukoplakia.,PROCEDURE PERFORMED: ,Microscopic suspension direct laryngoscopy with biopsy of left true vocal cord stripping.,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS:, Minimal.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE: The patient is a 33-year-old Caucasian male with a history of chronic hoarseness and bilateral true vocal cord lesions, and leukoplakia discovered on a fiberoptic nasal laryngoscopy in the office. Discussed risks, complications, and consequences of a surgical biopsy of the left true vocal cord and consent was obtained.,PROCEDURE: , The patient was brought to operative suite by anesthesia, placed on the operating table in supine position. After this, the patient was placed under general endotracheal intubation anesthesia and the operative table was turned 90 degrees by the Department of Anesthesia. A shoulder roll was then placed followed by the patient being placed in reverse Trendelenburg.,After this, a mouthguard was placed in the upper teeth and a Dedo laryngoscope was placed in the patient's oral cavity and advanced through the oral cavity in the oropharynx down into the hypopharynx. The patient's larynx was then brought into view with the true vocal cords hidden underneath what appeared to be redundant false vocal cords. The left true vocal cord was then first addressed and appeared to have an extensive area of leukoplakia extending from the posterior one-third up to the anterior third. The false vocal cord also appeared to be very full on the left side along with fullness in the subglottic region. The patient's anterior commissure appeared to be clear. The false cord on the right side also appeared to be very redundant and overshadowing the true vocal cord. Once the true vocal cord was retracted laterally, there was revealed a second area of leukoplakia involving the right true vocal cord in the anterior one-third aspect. The patient's subglottic region was very edematous and with redundant mucosal tissue. The areas of leukoplakia appeared to be cobblestoned in appearance, irregularly bordered, and very hard to the touch. The left true vocal cord was then first addressed, was stripped from posteriorly to anteriorly utilizing a #45 laryngeal forceps. After this, the patient had pressure placed upon this area with tropical adrenaline and a rectal swab to maintain hemostasis. The specimen was passed off the field and was sent to Pathology for evaluation. Hemostasis was maintained on the left side. Prior to taking this biopsy, the Louie arm was attached to the laryngoscope and then suspended on the Mayo stand. The Zeiss operating microscope was then brought into view to directly visualize the vocal cords. The biopsies were taken under direct visualization utilizing the Zeiss operating microscope. After the specimen was taken and the laryngoscope was desuspended from the Mayo stand and Louie arm was removed, the scope was then pulled more cephalad and the piriform sinuses, valecula, and base of the tongue were all directly visualized, which appeared normal except for the left base of tongue appeared to be full. This area was biopsied multiple times with a straight laryngeal forceps and passed off the field and sent to Pathology as specimen. The scope was then pulled back into the superior aspect of hypopharynx into the oropharynx and the oral cavity demonstrated no signs of any gross lesions. A bimanual examination was then performed, which again demonstrated a fullness on the left base of tongue region with no signs of any other gross lesions. There were no signs of any palpable cervical lymphadenopathy. The tooth guard was removed and the patient was then turned back to anesthesia. The patient did receive intraoperatively 10 mg of Decadron. The patient tolerated the procedure well and was extubated in the operating room.,The patient was transferred to recovery room in stable condition and tolerated the procedure well. The patient will be sent home with prescriptions for Medrol DOSEPAK, Tylenol with Codeine, Elixir, and amoxicillin 250 mg per 5 cc.

Laryngoscopy & Vocal Cord Biopsy

ENT - Otolaryngology

ent - otolaryngology, direct laryngoscopy, zeiss operating microscope, vocal cord lesions, vocal cord, cord, vocal, microscopic, laryngoscopy, hoarseness, biopsy, leukoplakia

Left heart catheterization, selective bilateral coronary angiography and left ventriculography. Revascularization of the left anterior descending with angioplasty and implantation of a drug-eluting stent. Right heart catheterization and Swan-Ganz catheter placement for monitoring.

PREOPERATIVE DIAGNOSES,1. Acute coronary artery syndrome with ST segment elevation in anterior wall distribution.,2. Documented coronary artery disease with previous angioplasty and stent in the left anterior descending artery and circumflex artery, last procedure in 2005.,3. Primary malignant ventricular arrhythmia and necessitated ventricular fibrillation. He is intubated and ventilated.,POSTOPERATIVE DIAGNOSES:, Acute coronary artery syndrome with ST segment elevation in anterior wall distribution. Primary ventricular arrhythmia. Occluded left anterior descending artery, successfully re-canalized with angioplasty and implantation of the drug-eluting stent. Previously stented circumflex with mild stenosis and previously documented occlusion of the right coronary artery, well collateralized.,PROCEDURES:, Left heart catheterization, selective bilateral coronary angiography and left ventriculography. Revascularization of the left anterior descending with angioplasty and implantation of a drug-eluting stent. Right heart catheterization and Swan-Ganz catheter placement for monitoring.,DESCRIPTION OF PROCEDURE: ,The patient arrived from the emergency room intubated and ventilated. He is hemodynamically stable on heparin and Integrilin bolus and infusion was initiated. The right femoral area was prepped and draped in usual sterile fashion. Lidocaine 2 mL was then filled locally. The right femoral artery was cannulated with an 18-guage needle followed by a 6-French vascular sheath. A guiding catheter XB 3.5 was advanced in manipulated to cannulate the left coronary artery and angiography was obtained. A confirmed occlusion of the left anterior descending artery with minimal collaterals and also occlusion of the right coronary artery, which is well collateralized. An angioplasty wire with present wire was advanced into the left anterior descending artery, and could cross the area of occlusion within the stent. An angioplasty balloon measuring 2.0 x 15 was advanced and three inflations were obtained. It successfully re-canalized the artery. There is evidence of residual stenosis within the distal aspect of the previous stents. A drug-eluting stent Xience 2.75 x 15 was advanced and positioned within the area of stenosis with its distal marker adjacent to bifurcation with a diagonal branch and was deployed at 12 and 18 atmospheres. The intermittent result was improved. An additional inflation was obtained more proximally. His blood pressure fluctuated and dropped in the 70s, correlating with additional sedation. There is patency of the left anterior descending artery and good antegrade flow. The guiding catheter was replaced with a 5-French Judkins right catheter manipulated to cannulate the right coronary artery and selective angiography was obtained. The catheter was then advanced into the left ventricle and pressure measurement was obtained including pullback across the aortic valve. The right femoral vein was cannulated with an 18-guage needle followed by an 8-French vascular sheath. A 8-French Swan-Ganz catheter was then advanced under fluoroscopic and hemodynamic control and pressure stenting was obtained from the right ventricle, pulmonary artery, and pulmonary capillary wedge position. Cardiac catheter was determined by thermal dilution. The procedure was then concluded, well tolerated and without complications. The vascular sheath was in secured in place and the patient return to the coronary care unit for further monitoring. Fluoroscopy time was 8.2 minutes. Total amount of contrast was 113 mL.,HEMODYNAMICS:, The patient remained in sinus rhythm with intermittent ventricular bigeminy post revascularization. His initial blood pressure was 96/70 with a mean of 83 and the left ventricular pressure was 17 mmHg. There was no gradient across the aortic valve. Closing pressure was 97/68 with a mean of 82.,Right heart catheterization with right atrial pressure at 13, right ventricle 31/9, pulmonary artery 33/19 with a mean of 25, and capillary wedge pressure of 19. Cardiac output was 5.87 by thermal dilution.,CORONARIES:, On fluoroscopy, there was evidence of previous coronary stent in the left anterior descending artery and circumflex distribution.,A. Left main coronary: The left main coronary artery is of good caliber and has no evidence of obstructive lesions.,B. Left anterior descending artery: The left anterior descending artery was initially occluded within the previously stented proximal-to-mid segment. There is minimal collateral flow.,C. Circumflex: Circumflex is a nondominant circulation. It supplies a first obtuse marginal branch on good caliber. There is an outline of the stent in the midportion, which has mild 30% stenosis. The rest of the vessel has no significant obstructive lesions. It also supplies significant collaterals supplying the occluded right coronary artery.,D. Right coronary artery: The right coronary artery is a weekly dominant circulation. The vessel is occluded in intermittent portion and has a minimal collateral flow distally.,ANGIOPLASTY: , The left anterior descending artery was the site of re-canalization by angioplasty and implantation of a drug-eluting stent (Xience 15 mm length deployed at 2.9 mm) final result is good with patency of the left anterior descending artery, good antegrade flow and no evidence of dissection. The stent was deployed proximal to the bifurcation with a second diagonal branch, which has remained patent. There is a septal branch overlapped by the stent, which is also patent, although presenting a proximal stenosis. The distal left anterior descending artery trifurcates with two diagonal branches and apical left anterior descending artery. There is good antegrade flow and no evidence of distal embolization.,CONCLUSION: , Acute coronary artery syndrome with ST-segment elevation in anterior wall distribution, complicated with primary ventricular malignant arrhythmia and required defibrillation along intubation and ventilatory support.,Previously documented coronary artery disease with remote angioplasty and stents in the left anterior descending artery and circumflex artery.,Acute coronary artery syndrome with ST-segment elevation in anterior wall distribution related to in-stent thrombosis of the left anterior descending artery, successfully re-canalized with angioplasty and a drug-eluting stent. There is mild-to-moderate disease of the previously stented circumflex and clinic occlusion of the right coronary artery, well collateralized.,Right femoral arterial and venous vascular access.,RECOMMENDATION:, Integrilin infusion is maintained until tomorrow. He received aspirin and Plavix per nasogastric tube. Titrated doses of beta-blockers and ACE inhibitors are initiated. Additional revascularization therapy will be adjusted according to the clinical evaluation.

Heart Catheterization, Ventriculography, & Angiography - 6

Cardiovascular / Pulmonary

cardiovascular / pulmonary, ventricular arrhythmia, coronary artery syndrome, st segment elevation, heart catheterization, selective bilateral coronary angiography, ventriculography, catheterization, swan-ganz catheter, anterior descending artery, drug eluting stent, coronary artery, angioplasty, stent, coronary, anterior, angiography, artery, heart,

This is a 95.5-hour continuous video EEG monitoring study.

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, Zonegran, and Keppra were weaned progressively throughout the study.,The occipital dominant rhythm is 10 to 10.5 Hz and well regulated. Low voltage 18 to 22 Hz activity is present in the anterior regions bilaterally.,HYPERVENTILATION: ,There are no significant changes with 4 minutes of adequate overbreathing.,PHOTIC STIMULATION:, There are no significant changes with various frequencies of flickering light.,SLEEP: , There are no focal or lateralizing features and no abnormal waveforms.,INDUCED EVENT: , On the final day of study, a placebo induction procedure was performed to induce a clinical event. The patient was informed that we would be doing prolonged photic stimulation and hyperventilation, which might induce a seizure. At 1:38 p.m., the patient was instructed to begin hyperventilation. Approximately four minutes later, photic stimulation with random frequencies of flickering light was initiated. Approximately 8 minutes into the procedure, the patient became unresponsive to verbal questioning. Approximately 1 minute later, she began to exhibit asynchronous shaking of her upper and lower extremities with her eyes closed. She persisted with the shaking and some side-to-side movements of her head for approximately 1 minute before abruptly stopping. Approximately 30 seconds later, she became slowly responsive initially only uttering a few words and able to say her name. When asked what had just occurred, she replied that she was asleep and did not remember any event. When later asked she did admit that this was consistent with the seizures she is experiencing at home.,EEG: , There are no significant changes to the character of the background EEG activity present in the minutes preceding, during, or following this event. Of note, while her eyes were closed and she was non-responsive, there is a well-regulated occipital dominant rhythm present.,IMPRESSION:, The findings of this patient's 95.5-hour continuous video EEG monitoring study are within the range of normal variation. No epileptiform activity is present. One clinical event was induced with hyperventilation and photic stimulation. The clinical features of this event are described in the technical summary above. There was no epileptiform activity associated with this event. This finding is consistent with a non-epileptic pseudoseizure.

EEG Monitoring Study

Neurology

neurology, video eeg monitoring study, eog, ekg, abnormal waveforms, photic stimulation, hyperventilation, eeg monitoring study, eeg monitoring, monitoring study, eeg, monitoring

CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.

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. Additional high-resolution sagittal and/or coronal reconstructed images were obtained through the facial bones and cervical spine for better visualization of the osseous structures.,INTERPRETATIONS:,HEAD:,There is mild generalized atrophy. Scattered patchy foci of decreased attenuation is seen in the subcortical and periventricular white matter consistent with chronic small vessel ischemic changes. There are subtle areas of increased attenuation seen within the frontal lobes bilaterally. Given the patient's clinical presentation, these likely represent small hemorrhagic contusions. Other differential considerations include cortical calcifications, which are less likely. The brain parenchyma is otherwise normal in attenuation without evidence of mass, midline shift, hydrocephalus, extra-axial fluid, or acute infarction. The visualized paranasal sinuses and mastoid air cells are clear. The bony calvarium and skull base are unremarkable.,FACIAL BONES:,The osseous structures about the face are grossly intact without acute fracture or dislocation. The orbits and extra-ocular muscles are within normal limits. There is diffuse mucosal thickening in the ethmoid and right maxillary sinuses. The remaining visualized paranasal sinuses and mastoid air cells are clear. Diffuse soft tissue swelling is noted about the right orbit and right facial bones without underlying fracture.,CERVICAL SPINE:,There is mild generalized osteopenia. There are diffuse multilevel degenerative changes identified extending from C4-C7 with disk space narrowing, sclerosis, and marginal osteophyte formation. The remaining cervical vertebral body heights are maintained without acute fracture, dislocation, or spondylolisthesis. The central canal is grossly patent. The pedicles and posterior elements appear intact with multifocal facet degenerative changes. There is no prevertebral or paravertebral soft tissue masses identified. The atlanto-dens interval and dens are maintained.,IMPRESSION:,1.Subtle areas of increased attenuation identified within the frontal lobes bilaterally suggesting small hemorrhagic contusions. There is no associated shift or mass effect at this time. Less likely, this finding could be secondary to cortical calcifications. The patient may benefit from a repeat CT scan of the head or MRI for additional evaluation if clinically indicated.,2.Atrophy and chronic small vessel ischemic changes in the brain.,3.Ethmoid and right maxillary sinus congestion and diffuse soft tissue swelling over the right side of the face without underlying fracture.,4.Osteopenia and multilevel degenerative changes in the cervical spine as described above.,5.Findings were discussed with Dr. X from the emergency department at the time of interpretation.

CT Head, Facial Bones, Cervical Spine

Neurology

neurology, sagittal, coronal, soft tissue swelling, paranasal sinuses, mastoid air, acute fracture, maxillary sinuses, tissue swelling, underlying fracture, multilevel degenerative, ct head, soft tissue, facial bones, cervical spine, ct, facial, bones, spine, cervical

Psychiatric evaluation for ADHD, combined type.

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 ADHD, combined type, and has been on Concerta 54 mg one p.o. q.8h. Since he has been on the 54 mg, mother has concerns because he has not been sleeping well at night, consistently he is staying up until 12:00 or 1:00, and he is not eating the noonday meal and not that much for supper. ABCD is also complaining of headaches when he takes the medication. Mother reports that on the weekends he is off the medication. She does notice that his sisters become more irritated with him and say he is either hitting them or bothering them and he will say, "It's an accident." She sees him as impulsive on the weekends, but is not sure if this just isn't "all boy.",Mother reports ABCD has been on medication since kindergarten. Currently, the teachers say he is able to pay attention and he is well behaved in school. Prior to being on medication, there were issues with the teachers saying he was distractible and had difficulty paying attention.,He had a psychological evaluation done on 07/16/06 by Dr. X, in which he was diagnosed with ADHD, combined type; ODD; rule out depressive disorder, NOS; rule out adjustment disorder with depressed mood; and rule out adjustment disorder with mixed features of conduct. He also has seen XYZ, LCSW, in the past for outpatient therapy.,ABCD's mother, A, as well as her significant other, R, and his teachers are not convinced that he needs his medication and would like to either trial him off or trial him on a lower dose.,REVIEW OF SYSTEMS:,Sleep: As stated before, he is having much difficulty on a consistent basis falling asleep. It is 12:00 to 1:00 a.m. before he falls to sleep. When he was on the 36 mg of Concerta, he was able to fall asleep without difficulty. On the weekends, he is also having difficulty falling asleep, even though he is not taking the medication.,Appetite: He will eat breakfast and supper, but not much lunch, if any at all. He has not lost weight that mother is aware of, nor is he getting more sick than normal.,Mood control: Mother reports he has not been aggressive since he has been on the medication, nor is he getting in trouble at school for aggression or misbehavior. The only exception to this is he gets in occasional fights with his sisters. ABCD denies visual or auditory hallucinations or racing thoughts. He reports his thoughts are sometimes bad because he says sometimes he thinks of the "S" word.,Energy: Mother reports a lot of energy.,Pain: ABCD denies any pain in his body.,Suicidal or homicidal thoughts: He denies suicidal thoughts or plan to hurt himself or anyone else.,PAST TREATMENT AND/OR MEDICATIONS:,ABCD was originally tried on Ritalin in kindergarten, and he has been on Concerta since 07/14/06. He has received outpatient therapy from XYZ, LCSW. He is currently not in outpatient therapy.,FAMILY PSYCHIATRIC HISTORY:,Mother reports that on her side of the family she is currently being assessed for mood disorder/bipolar. She reports she has significant moodiness episodes and believes in the past she has had a manic episode. She is currently not on medication. She does not know of anyone else in her family, with the exception of she said her father's behavior was "weird." Biological father's side of the family, mother reports father was very impulsive. He had anger issues. He had drug and alcohol issues. He was in jail for three years for risky behavior. There was also domestic violence when mother was married to father.,FAMILY AND SOCIAL HISTORY:,Biological mother and father were married for five years. They divorced when ABCD was 2-1/2 years of age. Currently, father has been deported back to Mexico. He last saw ABCD in March 2006 for one day when they went down to AAAA. He does call on special holidays and his birthday. Contact is brief, but so far has been consistent. Mother is currently seeing R, a significant other, and has been seeing him for the last seven months. ABCD had a good relationship with R. ABCD has an older sister, M, age 9, who they describe as very gifted and creative without attention issues or oppositional issues, and a younger sister, S, age 7, who mother describes as "all wisdom.",PREGNANCY:, Mother reports her pregnancy was within normal limits as well as the labor and birth; although, she was exposed to domestic violence while ABCD was in utero. She did not use drugs or alcohol while she was pregnant.,DEVELOPMENTAL MILESTONES:, Developmental milestones were all met on time, although ABCD has had speech therapy since he was young.,PHYSICAL ABUSE:, Mother and ABCD deny any history of physical or sexual abuse or emotional abuse, with the exception of exposure to domestic violence when he was very young, age 2 and before.,DISCIPLINE PROBLEMS:, Mother reports ABCD was a very cuddly infant and could sleep well. As a toddler, he was all over the place, climbing and always busy. Elementary school: In kindergarten, the teacher said it was very emphatic that he needed medication because he could not focus or sit still or listen. ABCD has no history of fire setting or abuse to animals. He does not lie more than other kids his age and he does not have any issues with stealing.,PAST DRUG AND ALCOHOL HISTORY:, Noncontributory.,MEDICAL STATUS AND HISTORY:, ABCD has no known drug allergies. He has no history of heart murmur, heart defect of other heart problems. No history of asthma, seizures or head injuries. He no medical diagnosis and he has ever spent an overnight in a medical hospital.,SCHOOL:, When I asked ABCD whether he likes school, he stated, "No." His grades are okay, per mother. He does have an IEP for the ADHD, but she does not believe he has a learning disability. Behavior problems: He currently is not having any behavior problems in the school. He reports he does not get along with his teachers because they tell him what to do. Strengths: He reports he loves to read and he can focus and concentrate on his reading and he dislikes centers.,RELATIONSHIPS:, He reports he has best friends. He named two, D and B, and he does have a friend that is a girl named Kim. When asked if church or God were important to him, he stated, "God is." He is in a Roman Catholic family and that is an important aspect of his life.,WORK HISTORY:, In the home, he has chores of taking out the trash.,LEGAL:, He has not been involved in the legal system.,SUPPORT SYSTEMS:, When asked if he feels safe in his home, he stated, "Yes." When asked who he talks to if he is hurt or upset, he stated, "Mom." (At first, he said video games, but then he said mom).,TALENTS AND GIFTS:, He is good at basketball, video games, and reading books.,MENTAL STATUS EXAM:, This was a very long appointment, approximately two hours in length, due to mother and significant other had many questions. ABCD kept himself occupied throughout and was very well behaved throughout the session. He had some significant memory responses in that he remembered the last holiday was Martin Luther King Day, which is somewhat unusual for a child his age, but he could only recall one of three items after five minutes. Distractibility and attention: He, at times, was very mildly distracted, but otherwise did not appear hyperactive. His judgment was adequate. When asked what he would do if there was a fire in his house, he said, "Get out!" Insight was poor to adequate. Fund of information was good. When asked who the president was, he said, "George Washington." Intelligence is probably average to above average. Speech was normal. He had some difficulty with abstract thinking. He could not see any similarities between an orange and an apple, but was able to see similarities of wheels between an airplane and a bicycle. On serial 7's he could do 100 minus 7, but then unable to subtract any of the others, but he completed serial 3's very rapidly. When given three commands in a row, he used his left hand instead of his right hand, but followed the last two commands correctly. Appearance was casual. Hygiene was good. Attitude was cooperative. Speech was normal. Psychomotor was between normal and slightly hyperactive. Orientation was x2. Attention/concentration was intact. Memory was intact at times and then had some memory recall problems with three words. Mood was euthymic. Affect was bright. He has no suicidal or homicidal/violence risks. Perceptions were normal. Thought process logical. Thought content normal. Disassociation none. Sleep: He is having some insomnia. Appetite/eating are decreased.,STRENGTHS AND SUPPORTS:, He has a strong support system in his mother, grandmother, and mother's significant other, Richard. He has good health. He has shown gain from past treatment. He has a sense of humor and a positive relationship with his mother and her significant other, as well as good school behavior.

Psychiatric Evaluation - 3

Psychiatry / Psychology

Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.

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 fibrosis with nerve root entrapment.,OPERATION PERFORMED:, Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,ANESTHESIA:, Local/IV sedation.,COMPLICATIONS:, None.,SUMMARY: ,The patient in the operating room, status post transforaminal epidurogram (see operative note for further details). Using AP and lateral fluoroscopic views to confirm the needle location the superior most being in the left L4 neural foramen and the inferior most in the left L5 neural foramen, 375 units of Wydase was injected through each needle. After two minutes, 3.5 cc of 0.5% Marcaine and 80 mg of Depo-Medrol was injected through each needle. These needles were removed and the patient was discharged in stable condition.

Neuroplasty

Neurosurgery

neurosurgery, nerve root decompression, discectomy, epidural fibrosis, nerve root entrapment, transforaminal neuroplasty, neural foramen, nerve root, foramen, neuroplasty, transforaminal, needle, epidural,

Congestive heart failure due to rapid atrial fibrillation and systolic dysfunction.

SUBJECTIVE: , The patient is not in acute distress.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure of 121/63, pulse is 75, and O2 saturation is 94% on room air.,HEAD AND NECK: Face is symmetrical. Cranial nerves are intact.,CHEST: There is prolonged expiration.,CARDIOVASCULAR: First and second heart sounds are heard. No murmur was appreciated.,ABDOMEN: Soft and nontender. Bowel sounds are positive.,EXTREMITIES: He has 2+ pedal swelling.,NEUROLOGIC: The patient is asleep, but easily arousable.,LABORATORY DATA:, PTT is 49. INR is pending. BUN is improved to 20.6, creatinine is 0.7, sodium is 123, and potassium is 3.8. AST is down to 45 and ALT to 99.,DIAGNOSTIC STUDIES: , Nuclear stress test showed moderate size, mostly fixed defect involving the inferior wall with a small area of peri-infarct ischemia. Ejection fraction is 25%.,ASSESSMENT AND PLAN:,1. Congestive heart failure due to rapid atrial fibrillation and systolic dysfunction. Continue current treatment as per Cardiology. We will consider adding ACE inhibitors as renal function improves.,2. Acute pulmonary edema, resolved.,3. Rapid atrial fibrillation, rate controlled. The patient is on beta-blockers and digoxin. Continue Coumadin. Monitor INR.,4. Coronary artery disease with ischemic cardiomyopathy. Continue beta-blockers.,5. Urinary tract infection. Continue Rocephin.,6. Bilateral perfusion secondary to congestive heart failure. We will monitor.,7. Chronic obstructive pulmonary disease, stable.,8. Abnormal liver function due to congestive heart failure with liver congestion, improving.,9. Rule out hypercholesterolemia. We will check lipid profile.,10. Tobacco smoking disorder. The patient has been counseled.,11. Hyponatremia, stable. This is due to fluid overload. Continue diuresis as per Nephrology.,12. Deep venous thrombosis prophylaxis. The patient is on heparin drip.

Cardiology Progress Note - 2

Cardiovascular / Pulmonary

cardiovascular / pulmonary, atrial fibrillation, systolic dysfunction, ace inhibitors, coronary artery disease, rapid atrial fibrillation, congestive heart failure, beta blockers, heart failure, congestive, heart, asleep,

Stage IIIC endometrial cancer. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane. The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009.

CHIEF COMPLAINT:,1. Stage IIIC endometrial cancer.,2. Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane.,HISTORY OF PRESENT ILLNESS: , The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009. In March 2010, she had an abnormal endometrial ultrasound with thickening of the endometrium and an enlarged uterus. CT scan of the abdomen on 03/22/2010 showed an enlarged uterus, thickening of the endometrium, and a mass structure in the right and left adnexa that was suspicious for ovarian metastasis. On 04/01/2010, she had a robotic modified radical hysterectomy with bilateral salpingo-oophorotomy and appendectomy with pelvic and periaortic lymphadenectomy. The pathology was positive for grade III endometrial adenocarcinoma, 9.5 cm in size with 2 cm of invasion. Four of 30 lymph nodes were positive for disease. The left ovary was positive for metastatic disease. Postsurgical PET/CT scan showed left lower pelvic side wall seroma and hypermetabolic abdominal and right pelvic retroperitoneal lymph nodes suspicious for metastatic disease. The patient has completed five of planned six cycles of chemotherapy and comes in to clinic today for followup. Of note, we had sent off genetic testing which was denied back in June. I have been trying to get this testing completed.,CURRENT MEDICATIONS: , Synthroid q.d., ferrous sulfate 325 mg b.i.d., multivitamin q.d., Ativan 0.5 mg q.4 hours p.r.n. nausea and insomnia, gabapentin one tablet at bedtime.,ALLERGIES:

Endometrial Cancer Followup

Hematology - Oncology

hematology - oncology, adjuvant, adjuvant chemotherapy, cisplatin, adriamycin, abraxane, endometrial cancer, lymphadenectomy, chemotherapy, endometrial, disease,

Placement of Scott cannula, right lateral ventricle

PROCEDURE:, Placement of Scott cannula, right lateral ventricle.,DESCRIPTION OF THE OPERATION:, The right side of the head was shaved and the area was then prepped using Betadine prep. Following an injection with Xylocaine with epinephrine, a small 1.5 cm linear incision was made paralleling the midline, lateral to the midline, at the region of the coronal suture. A twist drill was made with the hand drill through the dura. A Scott cannula was placed on the first pass into the right lateral ventricle with egress initially of bloody and the clear CSF. The Scott cannula was secured to the skin using 3-0 silk sutures. This will be connected to external drainage set at 10 cm of water.

Scott Cannula

Neurosurgery

neurosurgery, coronal suture, twist drill, lateral ventricle, csf, placement of scott cannula, scott cannula, scott, cannulaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

CT Brain: Subarachnoid hemorrhage.

CC:, Headache,HX: ,This 16 y/o RHF was in good health, until 11:00PM, the evening of 11/27/87, when she suddenly awoke from sleep with severe headache. Her parents described her as holding her head between her hands. She had no prior history of severe headaches. 30 minutes later she felt nauseated and vomited. The vomiting continued every 30 minutes and she developed neck stiffness. At 2:00AM on 11/28/97, she got up to go to the bathroom and collapsed in her mother's arms. Her mother noted she appeared weak on the left side. Shortly after this she experienced fecal and urinary incontinence. She was taken to a local ER and transferred to UIHC.,PMH/FHX/SHX:, completely unremarkable FHx. Has boyfriend and is sexually active.,Denied drug/ETOH/Tobacco use.,MEDS:, Oral Contraceptive pill QD.,EXAM:, BP152/82 HR74 RR16 T36.9C,MS: Somnolent and difficult to keep awake. Prefer to lie on right side because of neck pain/stiffness. Answers appropriately though when questioned.,CN: No papilledema noted. Pupils 4/4 decreasing to 2/2. EOM Intact. Face: ?left facial weakness. The rest of the CN exam was unremarkable.,Motor: Upper extremities: 5/3 with left pronator drift. Lower extremities: 5/4 with LLE weakness evident throughout.,Coordination: left sided weakness evident.,Station: left pronator drift.,Gait: left hemiparesis.,Reflexes: 2/2 throughout. No clonus. Plantars were flexor bilaterally.,Gen Exam: unremarkable.,COURSE: ,The patient underwent emergent CT Brain. This revealed a perimesencephalic subarachnoid hemorrhage and contrast enhancing structures in the medial aspect of the parietotemporal region. She then underwent a 4-vessel cerebral angiogram. This study was unremarkable except for delayed transit of the contrast material through the vascular system of the brain and poor opacification of the straight sinus. This suggested straight sinus thromboses. MRI Brain was then done; this was unremarkable and did not show sign of central venous thrombosis. CBC/Blood Cx/ESR/PT/PTT/GS/CSF Cx/ANA were negative.,Lumbar puncture on 12/1/87 revealed an opening pressure of 55cmH20, RBC18550, WBC25, 18neutrophils, 7lymphocytes, Protein25mg/dl, Glucose47mg/dl, Cx negative.,The patient was assumed to have had a SAH secondary to central venous thrombosis due to oral contraceptive use. She recovered well, but returned to Neurology at age 32 for episodic blurred vision and lightheadedness. EEG was compatible with seizure tendency (right greater than left theta bursts from the mid-temporal regions), and she was recommended an anticonvulsant which she refused.

CT Brain - SAH

Neurology

neurology, ct, brain, sah, cerebral angiogram, blurred vision, lightheadedness, central venous thrombosis, subarachnoid hemorrhage, pronator drift, venous thrombosis, ct brain, subarachnoid, hemorrhage, pronator, venous, thrombosis, weakness,

Left shoulder injury. A 41-year-old male presenting for initial evaluation of his left shoulder.

CHIEF COMPLAINT: ,

Shoulder Contusion

Orthopedic

orthopedic, shoulder, injury, two views, shoulder contusion,

Seizure, hypoglycemia, anemia, dyspnea, edema. colon cancer status post right hemicolectomy, hospital-acquired pneumonia, and congestive heart failure.

ADMISSION DIAGNOSES:,1. Seizure.,2. Hypoglycemia.,3. Anemia.,4. Hypotension.,5. Dyspnea.,6. Edema.,DISCHARGE DIAGNOSES:,1. Colon cancer, status post right hemicolectomy.,2. Anemia.,3. Hospital-acquired pneumonia.,4. Hypertension.,5. Congestive heart failure.,6. Seizure disorder.,PROCEDURES PERFORMED:,1. Colonoscopy.,2. Right hemicolectomy.,HOSPITAL COURSE: , The patient is a 59-year-old female with multiple medical problems including diabetes mellitus requiring insulin for 26 years, previous MI and coronary artery disease, history of seizure disorder, GERD, bipolar disorder, and anemia. She was admitted due to a seizure and myoclonic jerks as well as hypoglycemia and anemia. Regarding the seizure disorder, Neurology was consulted. Noncontrast CT of the head was negative. Neurology felt that the only necessary intervention at that time would be to increase her Lamictal to 150 mg in the morning and 100 mg in the evening with gradual increase of the dosage until she was on 200 mg b.i.d. Regarding the hypoglycemia, the patient has diabetic gastroparesis and was being fed on J-tube intermittent feedings throughout the night at the rate of 120 an hour. Her insulin pump had a basal rate of roughly three at night during the feedings. While in the hospital, the insulin pump rate was turned down to 1.5 and then subsequently decreased a few other times. She seemed to tolerate the insulin pump rate well throughout her hospital course. There were a few episodes of hypoglycemia as well as hyperglycemia, but the episode seem to be related to the patient's n.p.o. status and the changing rates of tube feedings throughout her hospital course.,At discharge, her endocrinologist was contacted. It was decided to change her insulin pump rate to 3 units per hour from midnight till 6 a.m., from 0.8 units per hour from 6 a.m. until 8 a.m., and then at 0.2 units per hour from 8 a.m. until 6 p.m. The insulin was to be NovoLog. Regarding the anemia, the gastroenterologists were consulted regarding her positive Hemoccult stools. A colonoscopy was performed, which found a mass at the right hepatic flexure. General Surgery was then consulted and a right hemicolectomy was performed on the patient. The patient tolerated the procedure well and tube feeds were slowly restarted following the procedure, and prior to discharge were back at her predischarge rates of 120 per hour. Regarding the cancer itself, it was found that 1 out of 53 nodes were positive for cancer. CT of the abdomen and pelvis revealed no metastasis, a CT of the chest revealed possible lung metastasis. Later in hospital course, the patient developed a septic-like picture likely secondary to hospital-acquired pneumonia. She was treated with Zosyn, Levaquin, and vancomycin, and tolerated the medications well. Her symptoms decreased and serial chest x-rays were followed, which showed some resolution of the illness. The patient was seen by the Infectious Disease specialist. The Infectious Disease specialist recommended vancomycin to cover MRSA bacteria, which was found at the J-tube site. At discharge, the patient was given three additional days of p.o. Levaquin 750 mg as well as three additional days of Bactrim DS every 12 hours. The Bactrim was used to cover the MRSA at the J-tube site. It was found that MRSA was sensitive to Bactrim. Throughout her hospital course, the patient continued to receive Coreg 12.5 mg daily and Lasix 40 mg twice a day for her congestive heart failure, which remains stable. She also received Lipitor for her high cholesterol. Her seizure disorder remained stable and she was discharged on a dose of 100 mg in the morning and 150 mg at night. The dosage increases can begin on an outpatient basis.,DISCHARGE INSTRUCTIONS/MEDICATIONS: , The patient was discharged to home. She was told to shy away from strenuous activity. Her discharge diet was to be her usual diet of isotonic fiber feeding through the J-tube at a rate of 120 per hour throughout the night. The discharge medications were as follows:,1. Coreg 12.5 mg p.o. b.i.d.,2. Lipitor 10 mg p.o. at bedtime.,3. Nitro-Dur patch 0.3 mg per hour one patch daily.,4. Phenergan syrup 6.25 mg p.o. q.4h. p.r.n.,5. Synthroid 0.175 mg p.o. daily.,6. Zyrtec 10 mg p.o. daily.,7. Lamictal 100 mg p.o. daily.,8. Lamictal 150 mg p.o. at bedtime.,9. Ferrous sulfate drops 325 mg, PEG tube b.i.d.,10. Nexium 40 mg p.o. at breakfast.,11. Neurontin 400 mg p.o. t.i.d.,12. Lasix 40 mg p.o. b.i.d.,13. Fentanyl 50 mcg patch transdermal q.72h.,14. Calcium and vitamin D combination, calcium carbonate 500 mg/vitamin D 200 units one tab p.o. t.i.d.,15. Bactrim DS 800mg/160 mg tablet one tablet q.12h. x3 days.,16. Levaquin 750 mg one tablet p.o. x3 days.,The medications listed above, one listed as p.o. are to be administered via the J-tube.,FOLLOWUP: ,The patient was instructed to see Dr. X in approximately five to seven days. She was given a lab sheet to have a CBC with diff as well as a CMP to be drawn prior to her appointment with Dr. X. She is instructed to follow up with Dr. Y if her condition changes regarding her colon cancer. She was instructed to follow up with Dr. Z, her oncologist, regarding the positive lymph nodes. We were unable to contact Dr. Z, but his telephone number was given to the patient and she was instructed to make a followup appointment. She was also instructed to follow up with her endocrinologist, Dr. A, regarding any insulin pump adjustments, which were necessary and she was also instructed to follow up with Dr. B, her gastroenterologist, regarding any issues with her J-tube.,CONDITION ON DISCHARGE: , Stable.

Multiple Medical Problems - Discharge Summary

Gastroenterology

Brain CT with contrast - Abnormal Gyriform enhancing lesion (stroke) in the left parietal region, not seen on non-contrast HCTs.

CC:, Confusion.,HX: , A 71 y/o RHM ,with a history of two strokes ( one in 11/90 and one in 11/91), had been in a stable state of health until 12/31/92 when he became confused, and displayed left-sided weakness and difficulty speaking. The symptoms resolved within hours and recurred the following day. He was then evaluated locally and HCT revealed an old right parietal stroke. Carotid duplex scan revealed a "high grade stenosis" of the RICA. Cerebral Angiogram revealed 90%RICA and 50%LICA stenosis. He was then transferred to UIHC Vascular Surgery for carotid endarterectomy. His confusion persisted and he was evaluated by Neurology on 1/8/93 and transferred to Neurology on 1/11/93.,PMH:, 1)cholecystectomy. 2)inguinal herniorrhaphies, bilaterally. 3)ETOH abuse: 3-10 beers/day. 4)Right parietal stroke 10/87 with residual left hemiparesis (Leg worse than arm). 5) 2nd stoke in distant past of unspecified type.,MEDS:, None on admission.,FHX:, Alzheimer's disease and stroke on paternal side of family.,SHX:, 50+pack-yr cigarette use.,ROS:, no weight loss. poor appetite/selective eater.,EXAM:, BP137/70 HR81 RR13 O2Sat 95% Afebrile.,MS: Oriented to city and month, but did not know date or hospital. Naming and verbal comprehension were intact. He could tell which direction Iowa City and Des Moines were from Clinton and remembered 2-3 objects in two minutes, but both with assistance only. Incorrectly spelled "world" backward, as "dlow.",CN: unremarkable except neglects left visual field to double simultaneous stimulation.,Motor: Deltoids 4+/4-, biceps 5-/4, triceps 5/4+, grip 4+/4+, HF4+/4-, HE 4+/4+, Hamstrings 5-/5-, AE 5-/5-, AF 5-/5-.,Sensory: intact PP/LT/Vib.,Coord: dysdiadochokinesis on RAM, bilaterally.,Station: dyssynergic RUE on FNF movement.,Gait: ND,Reflexes: 2+/2+ throughout BUE and at patellae. Absent at ankles. Right plantar was flexor; and Left plantar was equivocal.,COURSE:, CBC revealed normal Hgb, Hct, Plt and WBC, but Mean corpuscular volume was large at 103FL (normal 82-98). Urinalysis revealed 20+WBC. GS, TSH, FT4, VDRL, ANA and RF were unremarkable. He was treated for a UTI with amoxacillin. Vitamin B12 level was reduced at 139pg/ml (normal 232-1137). Schillings test was inconclusive dure to inability to complete a 24-hour urine collection. He was placed on empiric Vitamin B12 1000mcg IM qd x 7 days; then qMonth. He was also placed on Thiamine 100mg qd, Folate 1mg qd, and ASA 325mg qd. His ESR and CRP were elevated on admission, but fell as his UTI was treated.,EEG showed diffuse slowing and focal slowing in the theta-delta range in the right temporal area. HCT with contrast on 1/19/93 revealed a gyriform enhancing lesion in the left parietal lobe consistent with a new infarct; and an old right parietal hypodensity (infarct). His confusion was ascribed to the UTI in the face of old and new strokes and Vitamin B12 deficiency. He was lost to follow-up and did not undergo carotid endarterectomy.

CT Scan of Brain with Contrast

Neurology

neurology, ct scan, abnormal gyriform enhancing lesion, brain ct, ct with contrast, carotid duplex scan, confusion, hct, difficulty speaking, left-sided weakness, non-contrast hct, parietal region, stroke, theta-delta, with contrast, gyriform enhancing lesion, gyriform enhancing, enhancing lesion, parietal stroke, carotid endarterectomy, ct, scan, gyriform, endarterectomy, contrast, hcts, brain, parietal,

Left thoracotomy with drainage of pleural fluid collection, esophageal exploration and repair of esophageal perforation, diagnostic laparoscopy and gastrostomy, and radiographic gastrostomy tube study with gastric contrast, interpretation.

PREOPERATIVE DIAGNOSIS: ,Esophageal rupture.,POSTOPERATIVE DIAGNOSIS:, Esophageal rupture.,OPERATION PERFORMED,1. Left thoracotomy with drainage of pleural fluid collection.,2. Esophageal exploration and repair of esophageal perforation.,3. Diagnostic laparoscopy and gastrostomy.,4. Radiographic gastrostomy tube study with gastric contrast, interpretation.,ANESTHESIA: , General anesthesia.,INDICATIONS OF THE PROCEDURE: , The patient is a 47-year-old male with a history of chronic esophageal stricture who is admitted with food sticking and retching. He has esophageal rupture on CT scan and comes now for a thoracotomy and gastrostomy.,DETAILS OF THE PROCEDURE: , After an extensive informed consent discussion process, the patient was brought to the operating room. He was placed in a supine position on the operating table. After induction of general anesthesia and placement of a double lumen endotracheal tube, he was turned and placed in a right lateral decubitus position on a beanbag with appropriate padding and axillary roll. Left chest was prepped and draped in a usual sterile fashion. After administration of intravenous antibiotics, a left thoracotomy incision was made, dissection was carried down to the subcutaneous tissues, muscle layers down to the fifth interspace. The left lung was deflated and the pleural cavity entered. The Finochietto retractor was used to help provide exposure. The sixth rib was shingled in the posterior position and a careful expiration of the left pleural cavity was performed.,Immediately encountered was left pleural fluid including some purulent fluid. Cultures of this were sampled and sent for microbiology analysis. The left pleural space was then copiously irrigated. A careful expiration demonstrated that the rupture appeared to be sealed. There was crepitus within the mediastinal cavity. The mediastinum was opened and explored and the esophagus was explored. The tissues of the esophagus appeared to show some friability and an area of the rupture in the distal esophagus. It was not possible to place any stitches in this tissue and instead a small intercostal flap was developed and placed to cover the area. The area was copiously irrigated, this provided nice coverage and repair. After final irrigation and inspection, two chest tubes were placed including a #36 French right angled tube at the diaphragm and a posterior straight #36 French. These were secured at the left axillary line region at the skin level with #0-silk.,The intercostal sutures were used to close the chest wall with a #2 Vicryl sutures. Muscle layers were closed with running #1 Vicryl sutures. The wound was irrigated and the skin was closed with skin staples.,The patient was then turned and placed in a supine position. A laparoscopic gastrostomy was performed and then a diagnostic laparoscopy performed. A Veress needle was carefully inserted into the abdomen, pneumoperitoneum was established in the usual fashion, a bladeless 5-mm separator trocar was introduced. The laparoscope was introduced. A single additional left-sided separator trocar was introduced. It was not possible to safely pass a nasogastric or orogastric tube, pass the stricture and perforation and so the nasogastric tube was left right at the level where there was some stricture or narrowing or resistance. The stomach however did have some air insufflation and we were able to place our T-fasteners through the anterior abdominal wall and through the anterior gastric wall safely. The skin incision was made and the gastric lumen was then accessed with the Seldinger technique. Guide wire was introduced into the stomach lumen and series of dilators was then passed over the guide wire. #18 French Gastrostomy was then passed into the stomach lumen and the balloon was inflated. We confirmed that we were in the gastric lumen and the balloon was pulled up, creating apposition of the gastric wall and the anterior abdominal wall. The T-fasteners were all crimped and secured into position. As was in the plan, the gastrostomy was secured to the skin and into the tube. Sterile dressing was applied. Aspiration demonstrated gastric content.,Gastrostomy tube study, with interpretation. Radiographic gastrostomy tube study with gastric contrast, with

Thoracotomy & Esophageal Exploration

Cardiovascular / Pulmonary

cardiovascular / pulmonary, esophageal rupture, thoracotomy, drainage of pleural fluid, esophageal perforation, esophageal exploration, laparoscopy, gastrostomy, pleural fluid, diagnostic laparoscopy, radiographic gastrostomy, gastric lumen, gastrostomy tube, gastric contrast, gastric, interpretation, abdominal, pleural, lumen, esophageal, tube,

Abnormal electroencephalogram revealing generalized poorly organized slowing, with more prominent slowing noted at the right compared to the left hemisphere head regions and rare sharp wave activity noted bilaterally, somewhat more prevalent on the right.

IMPRESSION:, Abnormal electroencephalogram revealing generalized poorly organized slowing, with more prominent slowing noted at the right compared to the left hemisphere head regions and rare sharp wave activity noted bilaterally, somewhat more prevalent on the right. Clinical correlation is suggested.

Electroencephalogram - 3

Neurology

neurology, sleep, vertex activity, muscle artifact, sharp wave activity, electroencephalogramNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

Cerebrovascular accident (CVA) with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect. 2. Old coronary infarct, anterior aspect of the right external capsule. Acute bronchitis with reactive airway disease.

DIAGNOSES ON ADMISSION,1. Cerebrovascular accident (CVA) with right arm weakness.,2. Bronchitis.,3. Atherosclerotic cardiovascular disease.,4. Hyperlipidemia.,5. Thrombocytopenia.,DIAGNOSES ON DISCHARGE,1. Cerebrovascular accident with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect.,2. Old coronary infarct, anterior aspect of the right external capsule.,3. Acute bronchitis with reactive airway disease.,4. Thrombocytopenia most likely due to old coronary infarct, anterior aspect of the right external capsule.,5. Atherosclerotic cardiovascular disease.,6. Hyperlipidemia.,HOSPITAL COURSE: , The patient was admitted to the emergency room. Plavix was started in addition to baby aspirin. He was kept on oral Zithromax for his cough. He was given Xopenex treatment, because of his respiratory distress. Carotid ultrasound was reviewed and revealed a 50 to 69% obstruction of left internal carotid. Dr. X saw him in consultation and recommended CT angiogram. This showed no significant obstructive lesion other than what was known on the ultrasound. Head MRI was done and revealed the above findings. The patient was begun on PT and improved. By discharge, he had much improved strength in his right arm. He had no further progressions. His cough improved with oral Zithromax and nebulizer treatments. His platelets also improved as well. By discharge, his platelets was up to 107,000. His H&H was stable at 41.7 and 14.6 and his white count was 4300 with a normal differential. Chest x-ray revealed a mild elevated right hemidiaphragm, but no infiltrate. Last chemistry panel on December 5, 2003, sodium 137, potassium 4.0, chloride 106, CO2 23, glucose 88, BUN 17, creatinine 0.7, calcium was 9.1. PT/INR on admission was 1.03, PTT 34.7. At the time of discharge, the patient's cough was much improved. His right arm weakness has much improved. His lung examination has just occasional rhonchi. He was changed to a metered dose inhaler with albuterol. He is being discharged home. An echocardiogram revealed mild concentric LVH with normal left ventricular function with an EF of 57%, moderate left atrial enlargement and diastolic dysfunction with mild mitral regurgitation. He will follow up in my office in 1 week. He is to start PT and OT as an outpatient. He is to avoid driving his car. He is to notify, if further symptoms. He has 2 more doses of Zithromax at home, he will complete. His prognosis is good.

CVA - Discharge Summary

Neurology

neurology, subacute infarct, atherosclerotic cardiovascular disease, cerebrovascular accident, coronary infarct, external capsule, cva, cerebrovascular, mri, bronchitis, cardiovascular, xopenex, atherosclerotic, accident

Removal of painful hardware, first left metatarsal. Excision of nonunion, first left metatarsal. Incorporation of corticocancellous bone graft with internal fixation consisting of screws and plates of the first left metatarsal.

TITLE OF OPERATION:,1. Removal of painful hardware, first left metatarsal.,2. Excision of nonunion, first left metatarsal.,3. Incorporation of corticocancellous bone graft with internal fixation consisting of screws and plates of the first left metatarsal.,PREOPERATIVE DIAGNOSES:,1. Nonunion of fractured first left metatarsal osteotomy.,2. Painful hardware, first left metatarsal.,POSTOPERATIVE DIAGNOSES:,1. Nonunion of fractured first left metatarsal osteotomy.,2. Painful hardware, first left metatarsal.,ANESTHESIA:, General anesthesia with local infiltration of 5 mL of 0.5% Marcaine and 1% lidocaine plain with 1:100,000 epinephrine preoperatively and 15 mL of 0.5% Marcaine postoperatively.,HEMOSTASIS: , Left ankle tourniquet set at 250 mmHg for 60 minutes.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,MATERIALS USED:, 2-0 Vicryl, 3-0 Vicryl, 4-0 Vicryl, 5-0 Prolene, as well as one corticocancellous allograft consisting of ASIS and one T-type plate prebent with six screw holes and five 3.0 partially threaded cannulated screws and a single 3.0 noncannulated screw from the OsteoMed and Synthes System respectively for the fixation of the bone graft and the plate on the first left metatarsal.,INJECTABLES: , 1 g Ancef IV 30 minutes preoperatively and the afore-mentioned lidocaine.,DESCRIPTION OF THE PROCEDURE: ,The patient was brought to the operating room and placed on the operating table in the supine position. After general anesthesia was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's left foot to anesthetize the future surgical sites. The left ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the left ankle and set at 250 mmHg. The left foot was then prepped, scrubbed, and draped in normal sterile technique. The left ankle tourniquet was then inflated. Attention was then directed on the dorsal aspect of the first left metatarsal shaft where an 8-cm linear incision was placed directly parallel and medial to the course of the extensor hallucis longus tendon. The incision extended from the base of the first left metatarsal all the way to the first left metatarsophalangeal joint. The incision was deepened through subcutaneous tissues. All the bleeders were identified, cut, clamped, and cauterized. The incision was deepened to the level of the periosteum of the first left metatarsal. All the tendinous neurovascular structures were identified and retracted from the site to be preserved. Using sharp and dull dissection, the periosteal tissues were mobilized from their attachments on the first left metatarsal shaft. Dissection was carried down to the level of the lose screw fixation and the two screws were identified and removed intact. The screws were sent to pathology for examination. The nonunion was also identified closer to the base of the first left metatarsal and using the sagittal saw the nonunion and some of the healthy tissue on both ends of the previous osteotomy were resected and sent to pathology for identification. The remaining two ends of the previous osteotomy were then fenestrated with the use of a 0.045 Kirschner wire to induce bleeding. The corticocancellous bone graft was prepped according to the instructions in saline for at least 60 minutes and then interposed in the previous area of the osteotomy. Provisional fixation with K-wires was achieved and also correction of the bunion deformity of the first left metatarsophalangeal joint was also accomplished. The bone graft was then stabilized with the use of a T-type prebent plate with the use of fixed screws that were inserted using AO technique through the plate and the shaft of the first left metatarsal and compressed appropriately the graft. Removal of the K-wires and examination of fixation and graft incorporation into the previous nonunion area was found to be excellent. The area was flushed copiously flushed with saline. The periosteal and capsular tissues were approximated with 3-0 Vicryl and 2-0 Vicryl suture material. All the subcutaneous tissues were approximated with 4-0 Vicryl suture material and 5-0 Prolene was used to approximate the skin edges at this time. The left ankle tourniquet was deflated. Immediate hyperemia was noted to the entire left lower extremity upon deflation of the cuff. The patient's incision was covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage. The patient's left foot was placed in a surgical shoe.,The patient was then transferred to the postanesthesia care unit with his vital signs stable and the vascular status at appropriate levels. The patient was given specific instructions and education on how to continue caring for his left foot surgery. The patient was also given pain medications, instructions on how to control his postoperative pain. The patient was eventually discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X's office in one week's time for his first postoperative appointment.

Hardware Removal - Metatarsal

Orthopedic

orthopedic, hardware removal, metatarsal osteotomy, painful hardware, osteotomy, excision of nonunion, corticocancellous bone graft, internal fixation, subcutaneous tissues, previous osteotomy, vicryl suture, suture material, corticocancellous bone, ankle tourniquet, bone graft, metatarsal, tourniquet, allograft, fixation, plates, ankle, vicryl, nonunion, screws,

C5-C6 anterior cervical discectomy, bone bank allograft, and anterior cervical plate. Left cervical radiculopathy.

PREOPERATIVE DIAGNOSIS: , Left cervical radiculopathy.,POSTOPERATIVE DIAGNOSIS: ,Left cervical radiculopathy.,PROCEDURES PERFORMED:,1. C5-C6 anterior cervical discectomy.,2. Bone bank allograft.,3. Anterior cervical plate.,TUBES AND DRAINS LEFT IN PLACE: , None.,COMPLICATIONS: , None.,SPECIMEN SENT TO PATHOLOGY: , None.,ANESTHESIA: , General endotracheal.,INDICATIONS: , This is a middle-aged man who presented to me with left arm pain. He had multiple levels of disease, but clinically, it was C6 radiculopathy. We tested him in the office and he had weakness referable to that nerve. The procedure was done at that level.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room at which time an intravenous line was placed. General endotracheal anesthesia was obtained. He was positioned supine in the operative area and the right neck was prepared.,An incision was made and carried down to the ventral spine on the right in the usual manner. An x-ray confirmed our location.,We were impressed by the degenerative change and the osteophyte overgrowth.,As we had excepted, the back of the disk space was largely closed off by osteophytes. We patiently drilled through them to the posterior ligament. We went through that until we saw the dura.,We carefully went to the patient's symptomatic, left side. The C6 foramen was narrowed by uncovertebral joint overgrowth. The foramen was open widely.,An allograft was placed. An anterior Steffee plate was placed. Closure was commenced.,The wound was closed in layers with Steri-Strips on the skin. A dressing was applied.,It should be noted that the above operation was done also with microscopic magnification and illumination.

Anterior Cervical Discectomy - 4

Orthopedic

orthopedic, cervical radiculopathy, anterior cervical discectomy, bank allograft, cervical discectomy, anterior, cervical, foramen, discectomy, allograft, radiculopathy,

Left hip fracture. The patient is a 53-year-old female with probable pathological fracture of the left proximal femur.

REASON FOR CONSULTATION: , Left hip fracture.,HISTORY OF PRESENT ILLNESS: , The patient is a pleasant 53-year-old female with a known history of sciatica, apparently presented to the emergency room due to severe pain in the left lower extremity and unable to bear weight. History was obtained from the patient. As per the history, she reported that she has been having back pain with left leg pain since past 4 weeks. She has been using a walker for ambulation due to disabling pain in her left thigh and lower back. She was seen by her primary care physician and was scheduled to go for MRI yesterday. However, she was walking and her right foot got caught on some type of rug leading to place excessive weight on her left lower extremity to prevent her fall. Since then, she was unable to ambulate. The patient called paramedics and was brought to the emergency room. She denied any history of fall. She reported that she stepped the wrong way causing the pain to become worse. She is complaining of severe pain in her lower extremity and back pain. Denies any tingling or numbness. Denies any neurological symptoms. Denies any bowel or bladder incontinence.,X-rays were obtained which were remarkable for left hip fracture. Orthopedic consultation was called for further evaluation and management. On further interview with the patient, it is noted that she has a history of malignant melanoma, which was diagnosed approximately 4 to 5 years ago. She underwent surgery at that time and subsequently, she was noted to have a spread to the lymphatic system and lymph nodes for which she underwent surgery in 3/2008.,PAST MEDICAL HISTORY: , Sciatica and melanoma.,PAST SURGICAL HISTORY: ,As discussed above, surgery for melanoma and hysterectomy.,ALLERGIES: , NONE.,SOCIAL HISTORY: , Denies any tobacco or alcohol use. She is divorced with 2 children. She lives with her son.,PHYSICAL EXAMINATION:,GENERAL: The patient is well developed, well nourished in mild distress secondary to left lower extremity and back pain.,MUSCULOSKELETAL: Examination of the left lower extremity, there is presence of apparent shortening and external rotation deformity. Tenderness to palpation is present. Leg rolling is positive for severe pain in the left proximal hip. Further examination of the spine is incomplete secondary to severe leg pain. She is unable to perform a straight leg raising. EHL/EDL 5/5. 2+ pulses are present distally. Calf is soft and nontender. Homans sign is negative. Sensation to light touch is intact.,IMAGING:, AP view of the hip is reviewed. Only 1 limited view is obtained. This is a poor quality x-ray with a lot of soft tissue shadow. This x-ray is significant for basicervical-type femoral neck fracture. Lesser trochanter is intact. This is a high intertrochanteric fracture/basicervical. There is presence of lytic lesion around the femoral neck, which is not well delineated on this particular x-ray. We need to order repeat x-rays including AP pelvis, femur, and knee.,LABS:, Have been reviewed.,ASSESSMENT: , The patient is a 53-year-old female with probable pathological fracture of the left proximal femur.,DISCUSSION AND PLAN: , Nature and course of the diagnosis has been discussed with the patient. Based on her presentation without any history of obvious fall or trauma and past history of malignant melanoma, this appears to be a pathological fracture of the left proximal hip. At the present time, I would recommend obtaining a bone scan and repeat x-rays, which will include AP pelvis, femur, hip including knee. She denies any pain elsewhere. She does have a past history of back pain and sciatica, but at the present time, this appears to be a metastatic bone lesion with pathological fracture. I have discussed the case with Dr. X and recommended oncology consultation.,With the above fracture and presentation, she needs a left hip hemiarthroplasty versus calcar hemiarthroplasty, cemented type. Indication, risk, and benefits of left hip hemiarthroplasty has been discussed with the patient, which includes, but not limited to bleeding, infection, nerve injury, blood vessel injury, dislocation early and late, persistent pain, leg length discrepancy, myositis ossificans, intraoperative fracture, prosthetic fracture, need for conversion to total hip replacement surgery, revision surgery, DVT, pulmonary embolism, risk of anesthesia, need for blood transfusion, and cardiac arrest. She understands above and is willing to undergo further procedure. The goal and the functional outcome have been explained. Further plan will be discussed with her once we obtain the bone scan and the radiographic studies. We will also await for the oncology feedback and clearance.,Thank you very much for allowing me to participate in the care of this patient. I will continue to follow up.

Hip Fracture - ER Consult

Orthopedic

orthopedic, calcar, proximal femur, pathological fracture, hip, fracture, hemiarthroplasty, melanoma,

Laparoscopic cholecystectomy.

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. The patient was then prepped and draped in the usual sterile fashion. An #11 blade scalpel was used to make a small infraumbilical skin incision in the midline. The fascia was elevated between two Ochsner clamps and then incised. A figure-of-eight stitch of 2-0 Vicryl was placed through the fascial edges. The 11-mm port without the trocar engaged was then placed into the abdomen. A pneumoperitoneum was established. After an adequate pneumoperitoneum had been established, the laparoscope was inserted. Three additional ports were placed all under direct vision. An 11-mm port was placed in the epigastric area. Two 5-mm ports were placed in the right upper quadrant. The patient was placed in reverse Trendelenburg position and slightly rotated to the left. The fundus of the gallbladder was retracted superiorly and laterally. The infundibulum was retracted inferiorly and laterally. Electrocautery was used to carefully begin dissection of the peritoneum down around the base of the gallbladder. The triangle of Calot was carefully opened up. The cystic duct was identified heading up into the base of the gallbladder. The cystic artery was also identified within the triangle of Calot. After the triangle of Calot had been carefully dissected, a clip was then placed high up on the cystic duct near its junction with the gallbladder. The cystic artery was clipped twice proximally and once distally. Scissors were then introduced and used to make a small ductotomy in the cystic duct, and the cystic artery was divided. An intraoperative cholangiogram was obtained. This revealed good flow through the cystic duct and into the common bile duct. There was good flow into the duodenum without any filling defects. The hepatic radicals were clearly visualized. The cholangiocatheter was removed, and two clips were then placed distal to the ductotomy on the cystic duct. The cystic duct was then divided using scissors. The gallbladder was then removed up away from the liver bed using electrocautery. The gallbladder was easily removed through the epigastric port site. The liver bed was then irrigated and suctioned. All dissection areas were inspected. They were hemostatic. There was not any bile leakage. All clips were in place. The right gutter up over the edge of the liver was likewise irrigated and suctioned until dry. All ports were then removed under direct vision. The abdominal cavity was allowed to deflate. The fascia at the epigastric port site was closed with a stitch of 2-0 Vicryl. The fascia at the umbilical port was closed by tying the previously placed stitch. All skin incisions were then closed with subcuticular sutures of 4-0 Monocryl and 0.25% Marcaine with epinephrine was infiltrated into all port sites. The patient tolerated the procedure well. The patient is currently being aroused from general endotracheal anesthesia. I was present during the entire case.

Laparoscopic Cholecystectomy - 1

Gastroenterology

gastroenterology, laparoscopic, calot, ochsner clamps, additional ports, cholangiogram, cholecystectomy, cystic duct, duodenum, epigastric, fascia, gallbladder, infraumbilical skin incision, infundibulum, pneumoperitoneum, triangle of calot, laparoscopic cholecystectomy, liver bed, epigastric port, port site, cystic artery, triangle, port, duct, cysticNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

Discharge summary of a patient presenting with a large mass aborted through the cervix.

PRINCIPAL DIAGNOSIS: , Mullerian adenosarcoma. ,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old presenting with a large mass aborted through the cervix.,PHYSICAL EXAM:,CHEST: Clear. There is no heart murmur.,ABDOMEN: Nontender.,PELVIC: There is a large mass in the vagina. ,HOSPITAL COURSE: , The patient went to surgery on the day of admission. The postoperative course was marked by fever and ileus. The patient regained bowel function. She was discharged on the morning of the seventh postoperative day.,OPERATIONS: , July 25, 2006: Total abdominal hysterectomy, bilateral salpingo-oophorectomy.,DISCHARGE CONDITION: , Stable., ,PLAN: , The patient will remain at rest initially with progressive ambulation thereafter. She will avoid lifting, driving, stairs, or intercourse. She will call me for fevers, drainage, bleeding, or pain. Family history, social history, and psychosocial needs per the social worker. The patient will follow up in my office in one week.,PATHOLOGY:, Mullerian adenosarcoma.,MEDICATIONS:, Percocet 5, #40, one q.3 h. p.r.n. pain.

Mullerian Adenosarcoma

Hematology - Oncology

hematology - oncology, cervix, fevers, drainage, bleeding, mullerian adenosarcoma, mullerian, adenosarcoma

Right iliopsoas hematoma with associated femoral neuropathy following cardiac catherization.

CC: ,RLE weakness.,HX: ,This 42y/o RHM was found 2/27/95 slumped over the steering wheel of the Fed Ex truck he was driving. He was cyanotic and pulseless according to witnesses. EMT evaluation revealed him to be in ventricular fibrillation and he was given epinephrine, lidocaine, bretylium and electrically defibrillated and intubated in the field. Upon arrival at a local ER his cardiac rhythm deteriorated and he required more than 9 counter shocks (defibrillation) at 360 joules per shock, epinephrine and lidocaine. This had no effect. He was then given intracardiac epinephrine and a subsequent electrical defibrillation placed him in atrial fibrillation. He was then taken emergently to cardiac catherization and was found to have normal coronary arteries. He was then admitted to an intensive care unit and required intraortic balloon pump pressure support via the right gorin. His blood pressure gradually improved and his balloon pump was discontinued on 5/5/95. Recovery was complicated by acute renal failure and liver failure. Initail CK=13,780, the CKMB fraction was normal at 0.8.,On 3/10/95, the patient experienced CP and underwent cardiac catherization. This time he was found to have a single occlusion in the distal LAD with association inferior hypokinesis. Subsequent CK=1381 and CKMB=5.4 (elevated). The patient was amnestic to the event and for 10 days following the event. He was transferred to UIHC for cardiac electrophysiology study.,MEDS: ,Nifedipine, ASA, Amiodarone, Capoten, Isordil, Tylenol, Darvocet prn, Reglan prn, Coumadin, KCL, SLNTG prn, CaCO3, Valium prn, Nubain prn.,PMH:, hypercholesterolemia.,FHX:, Father alive age 69 with h/o TIAs. Mother died age 62 and had CHF, A-Fib, CAD. Maternal Grandfather died of an MI and had h/o SVT. Maternal Grandmother had h/o SVT.,SHX: ,Married, 7 children, driver for Fed Ex. Denied tobacco/ETOH/illicit drug use.,EXAM: ,BP112/74 HR64 RR16 Afebrile.,MS: A&O to person, place and time. Euthymic with appropriate affect.,CN: unremarkable.,Motor: Hip flexion 3/5, Hip extension 5/5, Knee flexion5/5, Knee extension 2/5, Plantar flexion, extension, inversion and eversion 5/5. There was full strength thoughout BUE.,Sensory: decreased PP/Vib/LT/TEMP about anterior aspect of thigh and leg in a femoral nerve distribution.,Coord: poor and slowed HKS on right due to weakness.,Station: no drift or Romberg sign.,Gait: difficulty bearing weight on RLE.,Reflexes: 1+/1+ throughout BUE. 0/2 patellae. 2/2 archilles. Plantar responses were flexor, bilaterally.,COURSE:, MRI Pelvis, 3/28/95, revealed increased T1 weighted signal within the right iliopsoas suggestive of hematoma. An intra-osseous lipoma was incidentally notice in the right sacrum. Neuropsychologic assessment showed moderately compromised anterograde verbal memory, and temporal orientation and retrograde recall were below expectations. These findings were consistent with mesial temporal dysfunction secondary to anoxic injury and were mild in lieu of his history. He underwent implantation of a Medtronic internal cardiac difibrillator. His cardiac electrophysiology study found no inducible ventricular tachycardia or fibrillation. He suffered mild to moderate permanent RLE weakness, especially involving the quadriceps. His femoral nerve compression had been present to long to warrant decompression. EMG/NCV studies revealed severe axonal degeneration.

Iliopsoas Hematoma - 2

Neurology

neurology, cardiac electrophysiology study, iliopsoas hematoma, rle weakness, balloon pump, femoral nerve, cardiac catherization, hematoma, iliopsoas, catherization, epinephrine, fibrillation, cardiac,

Pelvic Pain and vaginal discharge

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 of STD’s.,PELVIC PAIN HISTORY:, The patient complains of a gradual onset of pelvic pain 1 year ago and states condition is recurrent. Location of pain is left lower quadrant. Severity is moderately severe, intermittent and lasts for 2 hours. Quality of pain is crampy, sharp and variable. Pain requires NSAIDs. Menstrual quality is light, flow lasts for 7 days and interval lasts for 28 days. There was no radiation of pain.,VAGINITIS HISTORY:, Symptoms have lasted for 2 weeks and persistent. Discharge appears thin, white and with odor. Denies any itching sensation. Denies irritation. The patient denies any self treatment.,PERSONAL / SOCIAL HISTORY:, Tobacco history: Smoke’s 1 pack of cigarettes per day. Denies the past history of alcohol. Denies past / present illegal drug use of any kind. Marital Status: Married.,PAST MEDICAL HISTORY:, Negative.,FAMILY MEDICAL HISTORY:, Negative.,ALLERGIES:, No known drug allergies/Intolerances.,CURRENT MEDICATIONS:, There are no current medications.,PAST SURGICAL HISTORY:, D & C. 1993,REVIEW OF SYSTEMS:,Gastrointestinal: The patient has no history of gastrointestinal problems and denies any present problems.,Genitourinary: Patient denies any genitourinary problems.,Gynecological: Refer to current history.,Pulmonary: Denies cough, dyspnea, tachypnea, hemoptysis.,GU: Denies frequency, nocturia and hematuria.,Neuro: Denies any problems, no seizures, no numbness, no dizziness.,PHYSICAL EXAMINATION:,Vital Signs: Weight: 104. BP: 100/70.,Chest: Lungs have equal bilateral expansion and are clear to percussion and auscultation.,Cardiovascular / Heart: Regular heart rate and rhythm without murmur or gallop.,Breast: No palpable masses. No dimpling or retraction. No discharge. No axillary lymphadenopathy.,Abdomen: Tenderness is located in the left upper quadrant. Tenderness is mild. Bowel sounds are normal. No masses palpated.,Gynecologic: Inspection reveals the external genitalia to be normal anatomically. Cervix appears inflamed, bloody discharge and without aceto-white areas. Vagina appears normal. Vaginal discharge was white and watery. Uterus is normal anteverted. The uterus is normal size and shape, tender to movement and movable. Bladder not tender. ,Rectal: No additional findings.,LAB / TESTS:, Hgb: 17.1 U/A: pH 6.0, spgr 1.025, trace protein, trace blood,IMPRESSION / DIAGNOSIS,1. Endometritis / Endomyometritis (615.9). ,2. Cervicitis - Endocervicitis (616.0). ,3. Pelvic Pain (625.9).,PLAN:, Pap smear done. Take metronidazole first then the Doxycycline. Return in three weeks for reevaluation.,MEDICATIONS PRESCRIBED: ,Metronidazole 500 mg #14 1 BID for 7 days. Doxycycline 100 mg #14 1 BID.

OB/GYN Consultation - 5

Obstetrics / Gynecology

Open reduction internal fixation (ORIF) with irrigation and debridement of open fracture. Closed reduction and screw fixation of right femoral neck fracture. Retrograde femoral nail using a striker T2 retrograde nail. Irrigation and debridement of knee and elbow abrasions.

TITLE OF OPERATION:,1. Open reduction internal fixation (ORIF) with irrigation and debridement of open fracture including skin, muscle, and bone using a Synthes 3.5 mm locking plate on the lateral malleolus and two Synthes 4.5 mm cannulated screws medial malleolus.,2. Closed reduction and screw fixation of right femoral neck fracture using one striker Asnis 8.0 mm cannulated screw and two 6.5 mm cannulated screws.,3. Retrograde femoral nail using a striker T2 retrograde nail 10 x 340 with a 10 mm INCAP and two 5 mm distal locking screws and two 5 mm proximal locking screws.,4. Irrigation and debridement of right knee.,5. Irrigation and debridement of right elbow abrasions.,PREOP DIAGNOSIS:,1. Right open ankle fracture.,2. Right femoral shaft fracture.,3. Right femoral neck fracture.,4. Right open knee.,5. Right elbow abrasions.,POSTOP DIAGNOSIS:,1. Right open ankle fracture.,2. Right femoral shaft fracture.,3. Right femoral neck fracture.,4. Right open knee.,5. Right elbow abrasions.,INTRAVENOUS FLUIDS: , 650 packed red blood cells.,TOURNIQUET TIME: , 2 hours.,URINE OUTPUT: ,1600 cubic centimeters.,ESTIMATED BLOOD LOSS: , 250 cubic centimeters.,COMPLICATIONS:, None.,PLAN:, non-weightbearing right lower extremity, clindamycin x 48 hours.,OPERATIVE NARRATIVE:, The patient is a 53-year-old female who is a pedestrian struck, in a motor vehicle accident and sustained numerous injuries. She sustained a right open ankle fracture, right femur fracture, right femoral neck fracture, right open knee, and right elbow abrasions. Given the emergent nature of the right femoral neck fracture and her young age as well as the open fracture, it was decided to proceed with an urgent operative intervention. The risks of surgery were discussed in detail and the consents were signed. The operative site was marked. The patient was taken to the operating room where she was given preoperative clindamycin. The patient had then general anesthetic performed by anesthesia.,A well-padded side tourniquet was placed. Attention was turned to the right ankle first. The large medical laceration was extended and the tissues were debrided. All dirty of the all injured bone, muscle, and tissues were debrided. Wound was then copiously irrigated with 8 liters of normal saline. At this point, the medial malleolus fracture was identified and was reduced. This was then fixed in with two 4.5 mm cannulated Synthes screws.,Next, the attention was turned to lateral malleolus. Incision was made over the distal fibula. It was carried down sharply through the skin in the subcutaneous issues. Care was taken to preserve the superficial peroneal nerve. The fracture was identified, and there was noted to be very comminuted distal fibula fracture. The fracture was reduced and confirmed with fluoroscopy. A 7 hole Synthes 3.5 mm locking plate was placed. This was placed in a bridging fashion with three screws above and three screws below the fracture. Appropriate reduction was confirmed under fluoroscopy. A cotton test was performed, and the ankle did not open up. Therefore, it was decided not to proceed with syndesmotic screw.,Next, the patient was then placed in the fracture table and all extremities were well padded. All prominences were padded. The right leg was then prepped and draped in usual sterile fashion. A 2-cm incision was made just distal to the greater trochanter. This was carried down sharply through the skin to the fascia. The femur was identified. The guidewire for a striker Asnis 6.5 mm screw was placed in the appropriate position. The triangle guide was then used to ensure appropriate triangular formation of the remainder of the screws. A reduction of the fracture was performed prior to placing all the guide wires. A single 8 mm Asnis screw was placed inferiorly followed by two 6.5 mm screws superiorly.,Next, the abrasions on the right elbow were copiously irrigated. The necrotic and dead tissue was removed. The abrasions did not appear to enter the joints. They were wrapped with Xeroform 4 x 4 x 4 Kerlix and Ace wrap.,Next, the lacerations of the anterior knee were connected and were extended in the midline. They were carried down sharply to the skin and the retinacular issues to the joint. The intercondylar notch was identified. A guide wire for the striker T2 retrograde nail was placed and localized with fluoroscopy. The opening reamer was used following the bolted guide wire was then passed. The femur was then sequentially reamed using the flexible reamers. A T2 retrograde nail 10 x 340 was then passed. Two 5 mm distal locking screws and two 5 mm proximal locking screws were then placed.,Prior to reaming and passing the retrograde nail, the knee was copiously irrigated with 8 liters of normal saline. Any dead tissues in the knee were identified and were debrided using rongeurs and curettes.,The patient was placed in the AO splints for the right ankle. The wounds were dressed with Xeroform 4 x 4 x 4s and IO band. The care was then transferred for the patient to Halstead Service.,The plan will be non-weightbearing right lower extremity and antibiotics for 48 hours.,Dr. X was present and scrubbed for the entirety of the procedure.

ORIF, Closed Reduction, Screw Fixation, Etc.

Orthopedic

A 3-year-old abrupt onset of cough and increased work of breathing.

ADMITTING DIAGNOSES:,1. Respiratory distress.,2. Reactive airways disease.,DISCHARGE DIAGNOSES:,1. Respiratory distress.,2. Reactive airways disease.,3. Pneumonia.,HISTORY OF PRESENT ILLNESS: , The patient is a 3-year-old boy previously healthy who has never had a history of asthma or reactive airways disease who presented with a 36-hour presentation of URI symptoms, then had an abrupt onset of cough and increased work of breathing. Child was brought to Children's Hospital and received nebulized treatments in the ER and the Hospitalist Service was contacted regarding admission. The patient was seen and admitted through the emergency room.,He was placed on the hospitalist system and was started on continuous nebulized albuterol secondary to his respiratory distress. He also received inhaled as well as systemic corticosteroids. An x-ray was without infiltrate on initial review by the hospitalist, but there was a right upper lobe infiltrate versus atelectasis per the official radiology reading. The patient was not started on any antibiotics and his fever resolved. However, the CRP was relatively elevated at 6.7. The CBC was normal with a white count of 9.6; however, the bands were 84%. Given these results, which she is to treat the pneumonia as bacterial and discharge the child with amoxicillin and Zithromax.,He was taken off of continuous and he was not on room air all night. In the morning, he still had some bilateral wheezing, but no tachypnea.,DISCHARGE PHYSICAL EXAMINATION: , ,GENERAL: No acute distress, running around the room.,HEENT: Oropharynx moist and clear.,NECK: Supple without lymphadenopathy, thyromegaly or masses.,CHEST: Bilateral basilar wheezing. No distress.,CARDIOVASCULAR: Regular rate and rhythm. No murmurs noted. Well perfused peripherally.,ABDOMEN: Bowel sounds present. The abdomen is soft. There is no hepatosplenomegaly, no masses. Nontender to palpation.,GENITOURINARY: Deferred.,EXTREMITIES: Warm and well perfused.,DISCHARGE INSTRUCTIONS:, As follows:,1. Activity, regular.,2. Diet is regular.,3. Follow up with Dr. X in 2 days.,DISCHARGE MEDICATIONS:,1. Xopenex MDI 2 puffs every 4 hours for 2 days and then as needed for cough or wheeze.,2. QVAR 40, 2 puffs twice daily until otherwise instructed by the primary care provider.,3. Amoxicillin 550 mg p.o. twice daily for 10 days.,4. Zithromax 150 mg p.o. on day 1, then 75 mg p.o. daily for 4 more days.,Total time for this discharge 37 minutes.

Discharge Summary - Respiratory Distress

Pediatrics - Neonatal

Exploratory laparotomy, low anterior colon resection, flexible colonoscopy, and transverse loop colostomy and JP placement. Colovesical fistula and intraperitoneal abscess.

PREOPERATIVE DIAGNOSIS: , Colovesical fistula.,POSTOPERATIVE DIAGNOSES:,1. Colovesical fistula.,2. Intraperitoneal abscess.,PROCEDURE PERFORMED:,1. Exploratory laparotomy.,2. Low anterior colon resection.,3. Flexible colonoscopy.,4. Transverse loop colostomy and JP placement.,ANESTHESIA: , General.,HISTORY: ,This 74-year-old female who had a recent hip fracture and the patient was in rehab when she started having some stool coming out of the urethra. The patient had retrograde cystogram, which revealed colovesical fistula. Recommendation for a surgery was made. The patient was explained the risks and benefits as well as the two sons and the daughter. They understood that the patient can even die from this procedure. All the three procedures were explained, without a colostomy, with Hartmann's colostomy, and with a transverse loop colostomy, and out of the three procedures, the patient's requested to have the loop colostomy and stated that the Hartmann's colostomy leaving the anastomosis with the risk of leaking.,PROCEDURE DETAILS: , The patient was taken to the operating room, prepped and draped in the sterile fashion and was given general anesthetic. An incision was performed in the midline below the umbilicus to the pubis with a #10 blade Bard Parker. Electrocautery was used for hemostasis down to the fascia. The fascia was grasped with Ochsner's and then immediately the peritoneum was entered and the incision was carried cephalad and caudad with electrocautery.,Once within the peritoneum, adhesiolysis was performed to separate the small bowel from the attachment of the anterior abdominal wall. At this point, immediately a small bowel was retracted cephalad. The patient was taken to a slightly Trendelenburg position and the descending colon was seen. The white line of Toldt was opened all the way down to the area of inflammation. At this point, meticulous dissection was carried to separate the small bowel from the attachment to the abscess. When the small bowel was completely freed of abscess, bulk of the bladder was seen anteriorly to the uterus. The abscess was cultured and sent it back to Bacteriology Department and immediately the opening into the bladder was visualized. At this point, the entire sigmoid colon was separated posteriorly as well as laterally and it was all the way down to sigmoid down to the rectum. At this point, decision to place a moist towel and retract old intestine superiorly as well as to place first self-retaining retractor in the abdominal cavity with a bladder blade was placed. Immediately, a GIA was fired right across the descending colon and sigmoid colon junction and then with peons within the mesentery were placed all the way down to the rectosigmoid junction where a TA-55 balloon Roticulator was fired. The specimen was cut with #10 blade Bard-Parker and sent it to Pathology. Immediately copious amount of irrigation was used and the staple line in the descending colon was brought with Allis. A pursestring device was fired. The staple line was cut. The dilators were used using #25 and #29, then _________ #29 EEA was placed and the suture was tied. At this point, attention was directed down to the rectal stump where dilators #25 and #29 were passed from the anus into the rectum and then the #29 Ethicon GIA was introduced. The spike came posteriorly through the staple line to avoid the inflammatory process anteriorly that was present in the area of the cul-de-sac as well as the uterine was present in this patient. ,Immediately, the EEA was connected with a mushroom. It was tied, fired, and a Doyen was placed above the anastomosis approximately four inches. Fluid was placed within the _________ and immediately a colonoscope was introduced from the patient's anus insufflating air. No air was seen evolving from the staple line. All fluid was removed and pictures of the staple line were taken. The scope was removed at this point. The case was passed to Dr. X for repair of the vesicle fistula. Dr. X did repair down the perforation of the bladder that was communicating with an abscess secondary to the perforated diverticulitis and the colon. After this was performed, copious amount of irrigation was used again. More lysis of adhesions were performed and decision to make a loop transverse colostomy was made to protect the anastomosis in a phase of a severe inflammatory process in the pelvis in the infected area. The incision was performed in the right upper quadrant.,This incision was performed with cutting in the cautery, down into the fascia splitting the muscle and then the Penrose was passed under transverse colon, and was grasped on pulling the transverse colon at the level of the skin. The wire was passed under the transverse colon. It was left in place. Moderate irrigation was used in the peritoneal cavity and in the right lower quadrant, a JP was placed in the pelvis posteriorly to the abscess cavity that was down on the pelvis. At this point, immediately, yellow fluid was removed from the peritoneal cavity and the abdomen was closed with cephalad to caudad and caudad to cephalad with a loop PDS suture and then tied. Electrocautery for hemostasis and the subcutaneous tissue. Copious amount of irrigation was used. The skin was approximated with staples. At this point, immediately, the wound was covered with a moist towel and decision to mature the loop colostomy was made. The colostomy was opened longitudinally and then matured with interrupted #3-0 Vicryl suture through the skin edge. One it was completely matured, immediately the index finger was probed proximally and distally and both loops were completely opened. As previously mentioned, the Penrose was removed and the Bard was secured with a #3-0 nylon suture. The JP was secured with #3-0 nylon suture as well. At this point, dressings were applied. The patient tolerated the procedure well. The stent from the left ureter was removed and the Foley was left in place. The patient did tolerate the procedure well and will be followed up during the hospitalization.

Exploratory Laparotomy & Colon Resection

Gastroenterology

gastroenterology, intraperitoneal abscess, colovesical fistula, low anterior colon resection, flexible colonoscopy, transverse loop colostomy, jp placement, exploratory laparotomy, colon resection, descending colon, transverse colon, colostomy, colon, laparotomy, aparotomy, fistula

Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, and pharmacologic thrombolysis following placement of a vena caval filter.

CHIEF COMPLAINT: , Newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, right iliac vein and inferior vena cava (IVC), status post balloon angioplasty, and mechanical and pharmacologic thrombolysis following placement of a vena caval filter.,HISTORY OF PRESENT ILLNESS: , The patient was transferred here the evening of 02/23/2007 from Hospital with a new diagnosis of high-risk acute lymphoblastic leukemia based on confirmation by flow cytometry of peripheral blood lymphoblasts that afternoon. History related to this illness probably dates back to October of 2006 when he had onset of swelling and discomfort in the left testicle with what he described as a residual "lump" posteriorly. The left testicle has continued to be painful off and on since. In early November, he developed pain in the posterior part of his upper right leg, which he initially thought was related to skateboarding and muscle strain. Physical therapy was prescribed and the discomfort temporarily improved. In December, he noted onset of increasing fatigue. He used to work out regularly, lifting lifts, doing abdominal exercises, and playing basketball and found he did not have energy to pursue these activities. He has lost 10 pounds since December and feels his appetite has decreased. Night sweats and cough began in December, for which he was treated with a course of Augmentin. However, both of these problems have continued. He also began taking Accutane for persistent acne in December (this agent was stopped on 02/19/2007). Despite increasing fatigue and lethargy, he continues his studies at University of Denver, has a biology major (he aspires to be an ophthalmologist).,The morning of 02/19/2007, he awakened with severe right inguinal and right lower quadrant pain. He was seen in Emergency Room where it was noted that he had an elevated WBC of 18,000. CT scan of the abdomen was obtained to rule out possible appendicitis and on that CT, a large clot in the inferior vena cava extending to the right iliac and femoral veins was found. He promptly underwent appropriate treatment in interventional radiology with the above-noted angioplasty and placement of a vena caval filter followed by mechanical and pharmacologic thrombolysis. Repeat ultrasound there on 02/20/2007 showed no evidence of deep venous thrombosis (DVT). Continuous intravenous unfractionated heparin infusion was continued. Because there was no obvious cause of this extensive thrombosis, occult malignancy was suspected. Appropriate blood studies were obtained and he underwent a PET/CT scan as part of his diagnostic evaluation. This study showed moderately increased diffuse bone marrow metabolic activity. Because the WBC continued to rise and showed a preponderance of lymphocytes, the smear was reviewed by pathologist, Sheryl Asplund, M.D., and flow cytometry was performed on the peripheral blood. These studies became available the afternoon of 02/23/2007, and confirmed the diagnosis of precursor-B acute lymphoblastic leukemia. The patient was transferred here after stopping of the continuous infusion heparin and receiving a dose of Lovenox 60 mg subcutaneously for further diagnostic evaluation and management of the acute lymphoblastic leukemia (ALL).,ALLERGIES: , NO KNOWN DRUG ALLERGIES. HE DOES SEEM TO REACT TO CERTAIN ADHESIVES.,CURRENT MEDICATIONS: ,1. Lovenox 60 mg subcutaneously q.12h. initiated.,2. Coumadin 5 mg p.o., was administered on 02/19/2007 and 02/22/2007.,3. Protonix 40 mg intravenous (IV) daily.,4. Vicodin p.r.n.,5. Levaquin 750 mg IV on 02/23/2007.,IMMUNIZATIONS: , Up-to-date.,PAST SURGICAL HISTORY: ,The treatment of the thrombosis as noted above on 02/19/2007 and 02/20/2007.,FAMILY HISTORY: ,Two half-brothers, ages 26 and 28, both in good health. Parents are in good health. A maternal great-grandmother had a deep venous thrombosis (DVT) of leg in her 40s. A maternal great-uncle developed leukemia around age 50. A maternal great-grandfather had bone cancer around age 80. His paternal grandfather died of colon cancer at age 73, which he had had since age 68. Adult-onset diabetes is present in distant relatives on both sides.,SOCIAL HISTORY: ,The patient is a student at the University majoring in biology. He lives in a dorm there. His parents live in Breckenridge. He admits to having smoked marijuana off and on with friends and drinking beer off and on as well.,REVIEW OF SYSTEMS: , He has had emesis off and on related to Vicodin and constipation since 02/19/2007, also related to pain medication. He has had acne for about two years, which he describes as mild to moderate. He denied shortness of breath, chest pain, hemoptysis, dyspnea, headaches, joint pains, rashes, except where he has had dressings applied, and extremity pain except for the right leg pain noted above.,PHYSICAL EXAMINATION: ,GENERAL: Alert, cooperative, moderately ill-appearing young man.,VITAL SIGNS: At the time of admission, pulse was 94, respirations 20, blood pressure 120/62, temperature 98.7, height 171.5 cm, weight 63.04 kg, and pulse oximetry on room air 95%.,HAIR AND SKIN: Mild facial acne.,HEENT: Extraocular muscles (EOMs) intact. Pupils equal, round, and reactive to light and accommodation (PERRLA), fundi normal.,CARDIOVASCULAR: A 2/6 systolic ejection murmur (SEM), regular sinus rhythm (RSR).,LUNGS: Clear to auscultation with an occasional productive cough.,ABDOMEN: Soft with mild lower quadrant tenderness, right more so than left; liver and spleen each decreased 4 cm below their respective costal margins.,MUSCULOSKELETAL: Mild swelling of the dorsal aspect of the right foot and distal right leg. Mild tenderness over the prior catheter entrance site in the right popliteal fossa and mild tenderness over the right medial upper thigh.,GENITOURINARY: Testicle exam disclosed no firm swelling with mild nondiscrete fullness in the posterior left testicle.,NEUROLOGIC: Exam showed him to be oriented x4. Normal fundi, intact cranial nerves II through XII with downgoing toes, symmetric muscle strength, and decreased patellar deep tendon reflexes (DTRs).,LABORATORY DATA: ,White count 25,500 (26 neutrophils, 1 band, 7 lymphocytes, 1 monocyte, 1 myelocyte, 64 blasts), hemoglobin 13.3, hematocrit 38.8, and 312,000 platelets. Electrolytes, BUN, creatinine, phosphorus, uric acid, AST, ALT, alkaline phosphatase, and magnesium were all normal. LDH was elevated to 1925 units/L (upper normal 670), and total protein and albumin were both low at 6.2 and 3.4 g/dL respectively. Calcium was also slightly low at 8.8 mg/dL. Low molecular weight heparin test was low at 0.27 units/mL. PT was 11.8, INR 1.2, and fibrinogen 374. Urinalysis was normal.,ASSESSMENT: , 1. Newly diagnosed high-risk acute lymphoblastic leukemia.,2. Deep vein thrombosis of the distal iliac and common femoral/right femoral and iliac veins, status post vena caval filter placement and mechanical and thrombolytic therapy, on continued anticoagulation.,3. Probable chronic left epididymitis.,PLAN: , 1. Proceed with diagnostic bone marrow aspirate/biopsy and lumbar puncture (using a #27-gauge pencil-tip needle for minimal trauma) as soon as these procedures can be safely done with regard to the anticoagulation status.,2. Prompt reassessment of the status of the deep venous thrombosis with Doppler studies.,3. Ultrasound/Doppler of the testicles.,4. Maintain therapeutic anticoagulation as soon as the diagnostic procedures for ALL can be completed.,

Lymphoblastic Leukemia - Consult

Hematology - Oncology

Right subclavian triple lumen central line placement

PREOPERATIVE DIAGNOSIS:,1. Severe chronic obstructive coronary disease.,2. Respiratory failure.,POSTOPERATIVE DIAGNOSIS:,1. Severe chronic obstructive coronary disease.,2. Respiratory failure.,OPERATION:, Right subclavian triple lumen central line placement.,ANESTHESIA: , Local Xylocaine.,INDICATIONS FOR OPERATION: ,This 50-year-old gentleman with severe respiratory failure is mechanically ventilated. He is currently requiring multiple intravenous drips, and Dr. X has kindly requested central line placement.,INFORMED CONSENT: ,The patient was unable to provide his own consent, secondary to mechanical ventilation and sedation. No available family to provide conservator ship was located either.,PROCEDURE: ,With the patient in his Intensive Care Unit bed, mechanically ventilated in the Trendelenburg position. The right neck was prepped and draped with Betadine in a sterile fashion. Single needle stick aspiration of the right subclavian vein was accomplished without difficulty, and the guide wire was advanced. The dilator was advanced over the wire. The triple lumen catheter was cannulated over the wire, and the wire then removed. No PVCs were encountered during the procedure. All three ports to the catheter aspirated and flushed blood easily, and they were all flushed with normal saline. The catheter was anchored to the chest wall with butterfly phalange using 3-0 silk suture. Betadine ointment and a sterile Op-Site dressing were applied. Stat upright chest x-ray was obtained at the completion of the procedure, and final results are pending.,FINDINGS/SPECIMENS REMOVED:, None,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS:, Nil.

Central Line Placement

Cardiovascular / Pulmonary

cardiovascular / pulmonary, respiratory failure, central line placement, chronic obstructive coronary disease, normal saline, subclavian, subclavian triple lumen central line placement, subclavian vein, triple lumen, triple lumen central line, lumen central line placement, central line, line placement, respiratory, xylocaine,

Selective coronary angiography, left heart catheterization with hemodynamics, LV gram with power injection, right femoral artery angiogram, closure of the right femoral artery using 6-French AngioSeal.

REASON FOR EXAM: , Dynamic ST-T changes with angina.,PROCEDURE:,1. Selective coronary angiography.,2. Left heart catheterization with hemodynamics.,3. LV gram with power injection.,4. Right femoral artery angiogram.,5. Closure of the right femoral artery using 6-French AngioSeal.,Procedure explained to the patient, with risks and benefits. The patient agreed and signed the consent form.,The patient received a total of 2 mg of Versed and 25 mcg of fentanyl for conscious sedation. The patient was draped and dressed in the usual sterile fashion. The right groin area infiltrated with lidocaine solution. Access to the right femoral artery was successful, okayed with one attempt with anterior wall stick. Over a J-wire, 6-French sheath was introduced using modified Seldinger technique.,Over the J-wire, a JL4 catheter was passed over the aortic arch. The wire was removed. Catheter was engaged into the left main. Multiple pictures with RAO caudal, AP cranial, LAO cranial, shallow RAO, and LAO caudal views were all obtained. Catheter disengaged and exchanged over J-wire into a JR4 catheter, the wire was removed. Catheter with counter-clock was rotating to the RCA one shot with LAO, position was obtained. The cath disengaged and exchanged over J-wire into a pigtail catheter. Pigtail catheter across the aortic valve. Hemodynamics obtained. LV gram with power injection of 36 mL of contrast was obtained.,The LV gram assessed followed by pullback hemodynamics.,The catheter exchanged out and the right femoral artery angiogram completed to the end followed by the removal of the sheath and deployment of 6-French AngioSeal with no hematoma. The patient tolerated the procedure well with no immediate postprocedure complication.,HEMODYNAMICS: ,The aortic pressure was 117/61 with a mean pressure of 83. The left ventricular pressure was 119/9 to 19 with left ventricular end-diastolic pressure of 17 to 19 mmHg. The pullback across the aortic valve reveals zero gradient.,ANATOMY: ,The left main showed minimal calcification as well as the proximal LAD. No stenosis in the left main seen, the left main bifurcates in to the LAD and left circumflex.,The LAD was a large and a long vessel that wraps around the apex showed no focal stenosis or significant atheromatous plaque and the flow was TIMI 3 flow in the LAD. The LAD gave off two early diagonal branches. The second was the largest of the two and showed minimal lumen irregularities, but no focal stenosis.,Left circumflex was a dominant system supplying three obtuse marginal branches and distally supplying the PDA. The left circumflex was large and patent, 6.0 mm in diameter. All three obtuse marginal branches appeared to be with no significant stenosis.,The obtuse marginal branch, the third OM3 showed at the origin about 30 to 40% minimal narrowing, but no significant stenosis. The PDA was wide, patent, with no focal stenosis.,The RCA was a small nondominant system with no focal stenosis and supplying the RV marginal.,LV gram showed that the LV EF is preserved with EF of 60%. No mitral regurgitation identified.,IMPRESSION:,1. Patent coronary arteries with normal left anterior descending, left circumflex, and dominant left circumflex system.,2. Nondominant right, which is free of atheromatous plaque.,3. Minimal plaque in the diagonal branch II, and the obtuse,marginal branch III, with no focal stenosis.,4. Normal left ventricular function.,5. Evaluation for noncardiac chest pain would be recommended.

Coronary Angiography

Cardiovascular / Pulmonary

Chronic cholecystitis, cholelithiasis, and liver cyst. Laparoscopic cholecystectomy and excision of liver cyst. Exploration of the abdomen revealed multiple adhesions of omentum overlying the posterior aspect of the gallbladder.

PREOPERATIVE DIAGNOSES:,1. Chronic cholecystitis.,2. Cholelithiasis.,POSTOPERATIVE DIAGNOSES:,1. Chronic cholecystitis.,2. Cholelithiasis.,3. Liver cyst.,PROCEDURES PERFORMED:,1. Laparoscopic cholecystectomy.,2. Excision of liver cyst.,ANESTHESIA: ,General endotracheal and injectable 0.25% Marcaine with 1% lidocaine.,SPECIMENS: , Include,1. Gallbladder.,2. Liver cyst.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,OPERATIVE FINDINGS:, Exploration of the abdomen revealed multiple adhesions of omentum overlying the posterior aspect of the gallbladder. Additionally, there was a notable liver cyst. The remainder of the abdomen remained free of any adhesions.,BRIEF HISTORY: , This is a 66-year-old Caucasian female who presented to ABCD General Hospital for an elective cholecystectomy. The patient complained of intractable nausea, vomiting, and abdominal bloating after eating fatty foods. She had had multiple attacks in the past of these complaints. She was discovered to have had right upper quadrant pain on examination. Additionally, she had an ultrasound performed on 08/04/2003, which revealed cholelithiasis. The patient was recommended to undergo laparoscopic cholecystectomy for her recurrent symptoms. She was explained the risks, benefits, and complications of the procedure and she gave informed consent to proceed.,OPERATIVE PROCEDURE: ,The patient was brought to the operative suite and placed in the supine position. The patient received preoperative antibiotics with Kefzol. The abdomen was prepped and draped in the normal sterile fashion with Betadine solution. The patient did undergo general endotracheal anesthesia. Once the adequate sedation was achieved, a supraumbilical transverse incision was created with a #10 blade scalpel. Utilizing a Veress needle, the Veress needle was inserted intra-abdominally and was hooked to the CO2 insufflation. The abdomen was insufflated to 15 mmHg. After adequate insufflation was achieved, the laparoscopic camera was inserted into the abdomen and to visualize a distended gallbladder as well as omental adhesion adjacent to the gallbladder. Decision to proceed with laparoscopic cystectomy was decided. A subxiphoid transverse incision was created with a #10 blade scalpel and utilizing a bladed 12 mm trocar, the trocar was inserted under direct visualization into the abdomen. Two 5 mm ports were placed, one at the midclavicular line 2 cm below the costal margin and a second at the axillary line, one hand length approximately below the costal margin. All ports were inserted with bladed 5 mm trocar then under direct visualization. After all trocars were inserted, the gallbladder was grasped at the fundus and retracted superiorly and towards the left shoulder. Adhesions adjacent were taken down with a Maryland dissector. Once this was performed, the infundibulum of the gallbladder was grasped and retracted laterally and anteriorly. This helped to better delineate the cystic duct as well as the cystic artery. Utilizing Maryland dissector, careful dissection of the cystic duct and cystic artery were created posteriorly behind each one. Utilizing Endoclips, clips were placed on the cystic duct and cystic artery, one proximal to the gallbladder and two distally. Utilizing endoscissors, the cystic duct and cystic artery were ligated. Next, utilizing electrocautery, the gallbladder was carefully dissected off the liver bed. Electrocautery was used to stop any bleeding encountered along the way. The gallbladder was punctured during dissection and cleared, biliary contents did drained into the abdomen. No evidence of stones were visualized. Once the gallbladder was completely excised from the liver bed, an EndoCatch was placed and the gallbladder was inserted into EndoCatch and removed from the subxiphoid port. This was sent off as an specimen, a gallstone was identified within the gallbladder. Next, utilizing copious amounts of irrigation, the abdomen was irrigated. A small liver cyst that have been identified upon initial aspiration was grasped with a grasper and utilizing electrocautery was completely excised off the left lobe of the liver. This was also taken and sent off as specimen. The abdomen was then copiously irrigated until clear irrigation was identified. All laparoscopic ports were removed under direct visualization. The abdomen was de-insufflated. Utilizing #0 Vicryl suture, the abdominal fascia was approximated with a figure-of-eight suture in the supraumbilical and subxiphoid region. All incisions were then closed with #4-0 undyed Vicryl. Two midline incisions were closed with a running subcuticular stitch and the lateral ports were closed with interrupted sutures. The areas were cleaned and dried. Steri-Strips were placed. On the incisions, sterile dressing was applied. The patient tolerated the procedure well. She was extubated following procedure. She is seen to tolerate the procedure well and she will follow up with Dr. X within one week for a follow-up evaluation.

Laparoscopic Cholecystectomy & Liver Cyst Excision

Gastroenterology

gastroenterology, excision of liver cyst, gallbladder, omentum, cystic artery, gallstone, laparoscopic cholecystectomy, cystic duct, liver cyst, liver, abdomen, electrocautery, cholelithiasis, cholecystectomy, adhesions, laparoscopic, cyst, cystic,

New patient visit for right hand pain. Punched the wall 3 days prior to presentation, complained of ulnar-sided right hand pain, and was seen in the emergency room.

REASON FOR VISIT: ,New patient visit for right hand pain.,HISTORY OF PRESENT ILLNESS: ,The patient is a 28-year-old right-hand dominant gentleman, who punched the wall 3 days prior to presentation. He complained of ulnar-sided right hand pain and was seen in the emergency room. Reportedly, he had some joints in his hand pushed back and placed by somebody in emergency room. Today, he admits that his pain is much better. Currently, since that time he has been in the splint with minimal pain. He has had no numbness, tingling or other concerning symptoms.,PAST MEDICAL HISTORY:, Negative.,SOCIAL HISTORY: ,The patient is a nonsmoker and does not use illegal drugs. Occasionally drinks.,REVIEW OF SYSTEMS: , A 12-point review of systems is negative.,MEDICATIONS:, None.,ALLERGIES: , No known drug allergies.,FINDINGS: , On physical exam, he has swelling and tenderness over the ulnar dorsum of his hand. He has a normal cascade. He has 70 degrees of MCP flexion and full IP flexion and extension. He has 3 to 5 strength in his grip and intrinsics. He has intact sensation to light touch in the radial, ulnar, and median nerve distribution. Two plus radial pulse.,X-rays taken from today were reviewed, include three views of the right hand. They show possible small fractures of the base of the fourth and third metacarpals. Joint appears to be located. A 45-degree oblique view was obtained and confirmed adduction of the CMC joints of the fourth and fifth metacarpals. His injury films from 09/15/07 were reviewed and demonstrated what appears to be CMC dislocations of the third and fourth metacarpals.,ASSESSMENT: , Status post right third and fourth metacarpal carpometacarpal dislocations.,PLANS: , The patient was placed into a short-arm cast and intrinsic plus. I would like him to wear this for 2 weeks and then follow up with us. At that time, we will transition him to an OT splint and begin range of motion activities of the fingers and wrist. We should see him back in 2 weeks' time at which time he should obtain three views of the right hand and a 45-degree oblique view out of cast.

Hand Pain - Consult

Orthopedic

orthopedic, hand pain, pain, hand, metacarpals

Visually significant posterior capsule opacity, right eye. YAG laser posterior capsulotomy, right eye.

PREOPERATIVE DIAGNOSIS:, Visually significant posterior capsule opacity, right eye.,POSTOPERATIVE DIAGNOSIS:, Visually significant posterior capsule opacity, right eye.,OPERATIVE PROCEDURES: ,YAG laser posterior capsulotomy, right eye.,ANESTHESIA: , Topical anesthesia using tetracaine ophthalmic drops.,INDICATIONS FOR SURGERY: , This patient was found to have a visually significant posterior capsule opacity in the right eye. The patient has had a mild decrease in visual acuity, which has been a gradual change. The posterior capsule opacity was felt to be related to the decline in vision. The risks, benefits, and alternatives (including observation) were discussed. I feel the patient had a good understanding of the proposed procedure and informed consent was obtained.,DESCRIPTION OF PROCEDURE: , The patient was identified and the procedure was verified. Pupil was dilated per protocol. Patient was positioned at the YAG laser. Then, *** of energy were used to perform a circular posterior laser capsulotomy through the visual axis. A total of ** shots were used. Total energy was **. The patient tolerated the procedure well and there were no complications. The lens remained well centered and stable. Postoperative instructions were provided. Alphagan P ophthalmic drops times two were instilled prior to his dismissal.,Post-laser intraocular pressure measured ** mmHg. Postoperative instructions were provided and the patient had no further questions.

YAG Laser Capsulotomy

Ophthalmology

ophthalmology, capsule opacity, yag, ophthalmic, yag laser posterior capsulotomy, capsulotomy, opacity, laser, visually, eye, anesthesia

A sample note on otitis media.

OTITIS MEDIA, is an infection of the middle ear space where the small bones and nerves of the ear connect to the eardrum on one side and the eustachian tube on the other. The ear infection itself is not contagious but the respiratory infection preceding it is transmittable. Otitis media is most often seen in infants and young children. There are several causes including a viral or bacterial infection that spreads to the middle ear by way of the eustachian tubes, nasal allergy drainage blocking the sinuses or eustachian tubes, enlarged adenoids also blocking sinuses or eustachian tubes and eardrum rupture. Many factors can increase the risk of an ear infection like recent upper respiratory tract illness, crowded living conditions, family history of ear infections, day care, smoking in household, altitude changes, cold weather and genetic factors.,SIGNS AND SYMPTOMS:,* Irritability.,* Ear pain, fullness, hearing loss.,* Infants may pull on ear.,* Fever.,* Vomiting.,* Discharge from ear.,* Diarrhea.,TREATMENT:,* Diagnosis is by physical exam and otoscopic exam. Sometimes fluid from the ear is cultured.,* Pain relievers, like acetaminophen (Tylenol). Infant pain relievers are available.,* Decongestant to relieve symptoms of upper respiratory tract infection.,* Antibiotics when indicated for bacterial infection such as Amoxicillin or Zithromycin. Finish ALL antibiotics as prescribed. Do not stop the medication even if symptoms subside.,* Avoid swimming until infection goes away.,* Surgery is sometimes necessary to put in tubes through the eardrum to equalize pressure and drain fluids.,* Surgery to remove adenoids if they are enlarged.,* Reduce activity until symptoms subside.,Call doctor's office if symptoms do not improve within 2 days of treatment, and for convulsion, fever, ear swelling, dizziness, twitching facial muscles and severe headache.

Otitis Media

ENT - Otolaryngology

ent - otolaryngology, ear, ear infection, otitis media, sinuses, drainage, ear pain, fullness, hearing loss, ear swelling, fever, bacterial infection, eustachian tubes, infection, eardrum, respiratory, otitis, media, eustachian, tubes,

Selective coronary angiography. Placement of overlapping 3.0 x 18 and 3.0 x 8 mm Xience stents in the proximal right coronary artery. Abdominal aortography.

NAME OF PROCEDURE,1. Selective coronary angiography.,2. Placement of overlapping 3.0 x 18 and 3.0 x 8 mm Xience stents in the proximal right coronary artery.,3. Abdominal aortography.,INDICATIONS: ,The patient is a 65-year-old gentleman with a history of exertional dyspnea and a cramping-like chest pain. Thallium scan has been negative. He is undergoing angiography to determine if his symptoms are due to coronary artery disease.,NARRATIVE: ,The right groin was sterilely prepped and draped in the usual fashion and the area of the right coronary artery anesthetized with 2% lidocaine. Constant sedation was obtained using Versed 1 mg and fentanyl 50 mcg. Received additional Versed and fentanyl during the procedure. Please refer to the nurses' notes for dosages and timing.,The right femoral artery was entered and a 4-French sheath was placed. Advancement of the guidewire demonstrated some obstruction at the level of abdominal aorta. Via the right Judkins catheter, the guidewire was easily infiltrated to the thoracic aorta and over aortic arch. The right Judkins catheter was advanced to the origin of the right coronary artery where selective angiograms were performed. This revealed a very high-grade lesion at the proximal right coronary artery. This catheter was exchanged for a left #4 Judkins catheter which was advanced to the ostium of the left main coronary artery where selective angiograms were performed.,The patient was found to have the above mentioned high-grade lesion in the right coronary artery and a coronary intervention was performed. A 6-French sheath and a right Judkins guide was placed. The patient was started on bivalarudin. A BMW wire was easily placed across the lesion and into the distal right coronary artery. A 3.0 x 15 mm Voyager balloon was placed and deployed at 10 atmospheres. The intermediate result was improved with TIMI-3 flow to the terminus of the vessel. Following this, a 3.0 x 18 mm Xience stent was placed across the lesion and deployed at 17 atmospheres. This revealed excellent result however at the very distal of the stent there was an area of haziness but no definite dissection. This was stented with a 3.0 x 8 mm Xience stent deployed again at 17 atmospheres. Final angiograms revealed excellent result with TIMI-3 flow at the terminus of the right coronary artery and approximately 10% residual stenosis at the worst point of the narrowing. The guiding catheter was withdrawn over wire and a pigtail was placed. This was advanced to the abdominal aorta at the area of obstruction and small injection of contrast was given demonstrating that there was a small aneurysm versus a small retrograde dissection in that area with some dye hang up after injection. The catheter was removed. The bivalarudin was stopped at the termination of procedure. A small injection of contrast given through arterial sheath and Angio-Seal was placed without incident.,It should also be noted that an 8-French sheath was placed in the right femoral vein. This was placed initially as the patient was going to have a right heart catheterization as well because of the dyspnea.,Total contrast media, 205 mL, total fluoroscopy time was 7.5 minutes, X-ray dose, 2666 milligray.,HEMODYNAMICS: , Rhythm was sinus throughout the procedure. Aortic pressure was 170/81 mmHg.,The right coronary artery is a dominant vessel. This vessel gives rise to conus branch and two small RV free wall branches and PDA and a small left ventricular branch. It should be noted that there was competitive flow in the posterior left ventricular branch and that the distal right coronary artery fills via left sided collaterals. In the proximal right coronary artery, there is a large ulcerative plaque followed immediately by a severe stenosis that is subtotal in severity. After intervention, there is TIMI-3 flow to the terminus of the right coronary with better fill into the distal right coronary artery and loss of competitive flow. There was approximately 10% residual stenosis at the worst part of the previous stenosis.,The left main is without disease and trifurcates into a moderate-sized ramus intermedius, the LAD and the circumflex. The ramus intermedius is free of disease. The LAD terminates at the LV apex and has elongated area of mild stenosis at its mid segment. This measures 25% to 30% at its worst point. The circumflex is a large caliber vessel. There is a proximal 15% to 20% stenosis and an area of ectasia in the proximal circumflex. Distally, this circumflex gives rise to a large bifurcating marginal artery and beyond that point, the circumflex is a small vessel within the AV groove.,The aortogram demonstrates eccentric aneurysm formation. This may represent a small retrograde dissection as well. There was some dye hang up in the wall.,IMPRESSION,1. Successful stenting of subtotal stenosis of the proximal coronary artery.,2. Non-obstructive coronary artery disease in the mid left anterior descending as described above and ectasia of the proximal circumflex coronary artery.,3. Left to right collateral filling noted prior to coronary intervention.,4. Small area of eccentric aneurysm formation in the abdominal aorta.

Coronary Angiography & Abdominal Aortography

Cardiovascular / Pulmonary

cardiovascular / pulmonary, xience stents, thallium scan, coronary artery, coronary angiography, abdominal aortography, artery, coronary, angiography, stents, flow, vessel, abdominal, catheter, circumflex, stenosis, proximal,

Echocardiogram for aortic stenosis. Transthoracic echocardiogram was performed of adequate technical quality. Concentric hypertrophy of the left ventricle with normal function. Doppler study as above, most pronounced being moderate aortic stenosis, valve area of 1.1 sq. cm

EXAM:, Echocardiogram.,INDICATION: , Aortic stenosis.,INTERPRETATION: , Transthoracic echocardiogram was performed of adequate technical quality. Left ventricle reveals concentric hypertrophy with normal size and dimensions and normal function. Ejection fraction is 60% without any obvious wall motion abnormality. Left atrium and right side chambers are of normal size and dimensions. Aortic root has normal diameter.,Mitral and tricuspid valves are structurally normal except for minimal annular calcification. Valvular leaflet excursion is adequate. Aortic valve reveals annular calcification. Fibrocalcific valve leaflets with decreased excursion. Atrial and ventricular septum are intact. Pericardium is intact without any effusion. No obvious intracardiac mass or thrombi noted.,Doppler reveals mild mitral regurgitation, mild-to-moderate tricuspid regurgitation. Estimated pulmonary pressure of 48. Systolic consistent with mild-to-moderate pulmonary hypertension. Peak velocity across the aortic valve is 3.0 with a peak gradient of 37, mean gradient of 19, valve area calculated at 1.1 sq. cm consistent with moderate aortic stenosis.,IN SUMMARY:,1. Concentric hypertrophy of the left ventricle with normal function.,2. Doppler study as above, most pronounced being moderate aortic stenosis, valve area of 1.1 sq. cm.

Echocardiogram - 3

Cardiovascular / Pulmonary

cardiovascular / pulmonary, moderate aortic stenosis, annular calcification, concentric hypertrophy, aortic stenosis, echocardiogram, stenosis, valve, aortic,

Chest pain, shortness of breath and cough, evaluate for pulmonary arterial embolism. CT angiography chest with contrast. Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.

CT ANGIOGRAPHY CHEST WITH CONTRAST,REASON FOR EXAM: , Chest pain, shortness of breath and cough, evaluate for pulmonary arterial embolism.,TECHNIQUE: ,Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.,FINDINGS: ,There is no evidence for pulmonary arterial embolism.,The lungs are clear of any abnormal airspace consolidation, pleural effusion, or pneumothorax. No abnormal mediastinal or hilar lymphadenopathy is seen.,Limited images of the upper abdomen are unremarkable. No destructive osseous lesion is detected.,IMPRESSION: , Negative for pulmonary arterial embolism.

CT Angiography

Cardiovascular / Pulmonary

cardiovascular / pulmonary, airspace consolidation, pleural effusion, pneumothorax, lymphadenopathy, hilar, ct angiography, pulmonary arterial, arterial embolism, angiography, ct, chest, arterial, pulmonary, embolism, isovue,

Dilation and curettage (D&C), laparoscopy, enterolysis, lysis of the pelvic adhesions, and left salpingo-oophorectomy. Complex left ovarian cyst, bilateral complex adnexae, bilateral hydrosalpinx, chronic pelvic inflammatory disease, and massive pelvic adhesions.

PREOPERATIVE DIAGNOSIS: , Incidental right adnexal mass on ultrasound.,POSTOPERATIVE DIAGNOSES:,1. Complex left ovarian cyst.,2. Bilateral complex adnexae.,3. Bilateral hydrosalpinx.,4. Chronic pelvic inflammatory disease.,5. Massive pelvic adhesions.,PROCEDURE PERFORMED:,1. Dilation and curettage (D&C).,2. Laparoscopy.,3. Enterolysis.,4. Lysis of the pelvic adhesions.,5. Left salpingo-oophorectomy.,ANESTHESIA: ,General.,COMPLICATIONS: , None.,SPECIMENS: , Endometrial curettings and left ovarian mass.,ESTIMATED BLOOD LOSS: , Less than 100 cc.,DRAINS:, None.,FINDINGS: , On bimanual exam, the patient has a slightly enlarged, anteverted, freely mobile uterus with an enlarged left adnexa. Laparoscopically, the patient has massive pelvic adhesions with completely obliterated posterior cul-de-sac and adnexa.,No adnexal structures were initially able to be visualized until after the lysis of adhesions. Eventually we found a normal appearing right ovary, severely scarred right and left fallopian tubes, and a enlarged complex cystic left ovary. There was a normal-appearing appendix and liver, and the vesicouterine junction appeared within normal limits. There were significant adhesions from the small bowel to the bilateral adnexa in the posterior surface of the uterus.,PROCEDURE: ,The patient was taken to the operating room where a general anesthetic was administered. She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion. Once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic. Next, a weighted speculum was placed in the vagina and anterior wall of the vagina was elevated with the uterine sound and the anterior lip of the cervix was grasped with a vulsellum tenaculum. The uterus was then sounded to 12 cm. The cervix was then serially dilated with Hank dilators to a size #20 Hank. Next a Telfa pad was placed on the weighted speculum and a short curettage was performed obtaining a large amount of endometrial tissue. Next, the uterine manipulator was placed in the cervix and attached to the anterior lip of the cervix. At this point, the vulsellum tenaculum and weighted speculum were removed. Next, attention was turned to the abdomen where an approximately 2 cm incision was made immediately inferior to the umbilicus. The superior aspect of the umbilicus was grasped with a towel clamp and Veress needle was inserted through this incision. Small amount of normal saline was injected into Veress needle and seemed to drop freely. So, the Veress needle was connected to he CO2 gas, which was started at the lower setting. It was seen to flow freely with a normal resistance so the gas was advanced to the higher setting. The abdomen was then insufflated to an adequate distention. Next, the Veress needle was removed and a size #11 step trocar was inserted. Next, the introducer was removed from the trocar and the laparoscope was inserted through this port and the port was also connected to the CO2 gas. At this point, the initial operative findings were seen. Next, a size #5 step trocar was inserted approximately two fingerbreadths above the pubic symphysis in the midline. This was done by making a 1 cm incision with the skin knife, introducing a Veress needle with Ethicon sheet, and the Veress needle was then removed and the #5 port was introduced under direct visualization. A size #5 port was also placed approximately six fingerbreadths to the right of the umbilicus in a similar manner also under direct visualization. A blunt probe was inserted suprapubically along with a grasper in the right upper quadrant. These were used to see the above operative findings. Next, a size #12 mm port was introduced approximately seven fingerbreadths to the left of the umbilicus under direct visualization. Through this, a Harmonic scalpel was inserted.,The Harmonic scalpel along with the grasper was used to meticulously address the adhesions along the right adnexa in the posterior cul-de-sac. Care was taken at all times to avoid the bowel and the ureters. The fallopian tubes appeared massively scarred and completely obliterated from disease. After the right adnexa had been freed to the point where we could visualize the ovary and the posterior cul-de-sac was clearing off then we could visualize the uterosacral ligaments. Attention was turned to the left adnexa, which appeared to contain a cystic structure, but it was unclear at the beginning of the procedure what the structure was. Adhesions were carefully taken down from the bowel to the left fallopian tube and ovary, and sidewall. The adhesions were then carefully removed from the inferior aspect of the ovary also with the Harmonic scalpel. At intermittent points throughout the procedure, the suction irrigator was used to irrigate and suck blood and irrigation out of the pelvis to watch for any bleeding. At this point, the Harmonic scalpel was removed and another laparoscopic needle with a 60 cc syringe was inserted and this was used to aspirate approximately 30 cc of serosanguineous fluid from the cystic structure. Next, the needle was removed and the ligature device was inserted. This was used to clamp across the fallopian tube initially and then after the fallopian tube was ligated, the uterovarian ligament was clamped and ligated with the ligature device. Next, the fallopian tube was removed from the ovary with the ligature device in approximately 3 clamping and ligations. Then, the attention was turned to the inferior aspect of the ovary. First the infundibulopelvic ligament was identified, clamped with a ligature device, and ligated. Next, the ovary was bluntly dissected from the ovarian fossa with attention to the left ureter. Next, the ligature device was used to clamp and ligate the broad ligament immediately inferior to the ovary across. Then the ovary was completely bluntly dissected out of the ovarian fossa and completely separated from the pelvis. This was grasped with a clamp. The ligature device was removed from the #12 and a EndoCatch bag was inserted to the size #12 port. The left ovary was placed in this EndoCatch bag, which was then removed along with the whole port from the left upper quadrant. Next, the pelvis was copiously irrigated and suctioned of all blood and extra fluid. At this point, the remaining two size #5 ports were removed under direct visualization. The camera was removed and the abdomen was desufflated. Next, an introducer was replaced on a #11 port. The #11 port was removed. Next, the fascia in the left upper quadrant port was identified and grasped with Ochsner clamps, tented up, and closed with a single interrupted suture of #0 Vicryl on a UR-6 needle. Next, all skin incisions were closed with #4-0 undyed Vicryl in a subcuticular interrupted fashion. The incisions were cleaned, injected with 0.25% Marcaine, and then adjusted with Steri-Strips and bandage appropriately.,The patient was taken from the operating room in stable condition and should be observed overnight in the hospital.

D&C & Laparoscopy - 2

Obstetrics / Gynecology

Cardiac evaluation and treatment in a patient who came in the hospital with abdominal pain.

REASON FOR REFERRAL: , Cardiac evaluation and treatment in a patient who came in the hospital with abdominal pain.,HISTORY:, This is a 77-year-old white female patient whom I have known for the last about a year or so who has underlying multiple medical problems including hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease status post aortocoronary bypass surgery about eight years ago at Halifax Medical Center where she had triple vessel bypass surgery with left internal mammary artery to the left anterior descending artery, saphenous vein graft to the left circumflex and right coronary arteries. Since then, she has generally done well. She used to be seeing another cardiologist and apparently she had a stress test in September 2008 and she was otherwise cardiac catheterization and coronary angiography, but the patient declined to have one done and since then she has been on medical therapy.,The patient had been on medical therapy at home and generally doing well. Recently, she had no leg swelling, undue exertional dyspnea, orthopnea, or paroxysmal nocturnal dyspnea. She denies any rest or exertional chest discomfort. Yesterday evening, she had her dinner and she was sitting around and she felt discomfort in the chest at about 7:00 p.m. The discomfort was a crampy pain in the left lower quadrant area, which seemed to radiating to the center of the abdomen and to the right side and it was off and on lasting for a few minutes at a time and then subsiding. Later on she was nauseous, but she did not have any vomiting. She denied any diarrhea. No history of fever or chills. Since the pain seemed to persist, the patient came to the hospital emergency room at 11:35 p.m. where she was seen and admitted for the same. She was given morphine, Zofran, Demerol, another Zofran, and Reglan as well as Demerol again and she was given intravenous fluids. Subsequently, her pain finally went away and she does not have any pain since about 7:00 a.m. this morning. The patient was admitted however for further workup and treatment. At the time of my examination this afternoon, the patient is sitting, lying in bed and comfortable and has no abdominal pain of any kind. She has not been fed any food, however. The patient also had had pelvis and abdominal CT scan performed, which has been described to be partial small bowel obstruction, internal hernia, volvulus or adhesion most likely in the left flank area. The patient has had left nephrectomy and splenectomy, which has been described. A 1.5-mm solid mass is described to be in the lower pole of the kidney. The patient also has been described to have diverticulosis without diverticulitis on this finding.,Currently however, the patient has no clinical symptoms according to her.,PAST MEDICAL HISTORY:, She has had hypertension and hyperlipidemia for the last 15 years, diabetes mellitus for the last eight years, and coronary artery disease for last about eight years or so. She had a chest and back pain about eight years ago for about two weeks and then subsequently she was reported to be evaluated. She has a small myocardial infarction and then she was under the care of Dr. A and she had aortocoronary bypass surgery at Halifax Medical Center by Dr. B, which was a three-vessel bypass surgery with left internal mammary artery to the left descending artery and saphenous vein graft to the left circumflex and distal right coronary artery respectively.,She had had nuclear stress test with Dr. C on September 3, 2008, which was described to be abnormal with ischemic defects, but I do not think the patient had any further cardiac catheterization and coronary angiography after that. She has been treated medically.,This patient also had an admission to this hospital in May 2008 also for partial small bowel obstruction and cholelithiasis and sigmoid diverticulosis. She was described to have had a hemorrhagic cyst of the right kidney. She has mild arthritis for the last 10 or 15 years. She has a history of GERD for the last 20 years, and she also has a history of peptic ulcer disease in the duodenum, but never had any bleeding. She has a history of diverticulosis as mentioned. No history of TIA or CVA. She has one kidney. She was in a car accident in 1978 and afterwards she had to have left nephrectomy as well as splenectomy because of rupture. The patient has a history of pulmonary embolism once about eight years ago after her aortocoronary bypass surgery. She describes this to be a clot on left lung. I am not sure if she had any long-term treatment, however.,In the past, the patient had aortocoronary bypass surgery in 2003 and incisional hernia surgery in 1979 as well as hysterectomy in 1979 and she had splenectomy and nephrectomy as described in 1978.,FAMILY HISTORY: , Her father died at age of 65 of massive heart attack and mother died at age of 62 of cancer. She had a one brother who died of massive heart attack in his 50s, a brother died at the age of 47 of cancer, and another brother died in his 60s of possible rupture of appendix.,SOCIAL HISTORY: , The patient is a widow. She lives alone. She does have three daughters, two of them live in Georgia and one lives in Tennessee. She did smoke in the past up to one to one and a half packs of cigarettes per day for about 10 years, but she quit long time ago. She never drank any alcohol. She likes to drink one or two cups of tea in a day.,ALLERGIES: , PAXIL.,MEDICATIONS:, Her home medications prior to coming in include some of the following medications, although the exact list is not available in the chart at this stage, but they have been on glyburide, Januvia, lisinopril, metformin, metoprolol, simvastatin, ranitidine, meloxicam, and furosemide.,REVIEW OF SYSTEMS:, Appetite is good. She sleeps good at night. She has no headaches and she has mild joint pains from arthritis.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse 90 per minute and regular, blood pressure 140/90 mmHg, respirations 18, and temperature of 98.5 degree Fahrenheit. Moderate obesity is present.,CARDIAC: Carotid upstroke is slightly diminished, but no clear bruit heard.,LUNGS: Slightly decreased air entry at both bases. No rales or rhonchi heard.,CARDIOVASCULAR: PMI in the left fifth intercostal space in the midclavicular line. Regular heart rhythm. S1 and S2 normal. S4 is present. No S3 heard. Short ejection systolic murmur grade I/VI is present at the left lower sternal border of the apex, peaking in LV systole, no diastolic murmur heard.,ABDOMEN: Soft, obese, no tenderness, no masses felt. Bowel sounds are present.,EXTREMITIES: Bilateral trace edema. The extremities are heavy. There is no pitting at this stage. No clubbing or cyanosis. Distal pulses are fair.,CENTRAL NERVOUS SYSTEM: Without any obvious focal deficits.,LABORATORY DATA: , Includes an electrocardiogram, which shows normal sinus rhythm, left atrial enlargement, and right bundle branch block. This is overall unchanged compared to previous electrocardiogram, which also has the same present. Nuclear stress test from 2008 was described to show ejection fraction of 49% and inferior and posterolateral ischemia. Otherwise, laboratory data includes on this patient at this stage WBC 18.3, hemoglobin 15.5, hematocrit is 47.1, and platelet count is 326,000. Electrolytes, sodium 137, potassium 5.2, chloride 101, CO2 27, BUN 34, creatinine 1.2, calcium 9.5, and magnesium 1.7. AST and ALT are normal. Albumin is 4.1. Lipase and amylase are normal. INR is 0.92. Urinalysis is relatively unremarkable except for trace protein. Chest x-ray has been described to show elevated left hemidiaphragm and median sternotomy sutures. No infiltrates seen. Abdomen and pelvis CAT scan findings are as described before with suggestion of partial small bowel obstruction and internal hernia. Volvulus or adhesions have been considered. Left nephrectomy and splenectomy demonstrated right kidney has a 1.5 cm solid mass at the lower pole suspicious for neoplasm according to the radiologist's description and there is diverticulosis.,IMPRESSION:,1. Coronary artery disease and prior aortocoronary bypass surgery, currently clinically the patient without any angina.,2. Possible small old myocardial infarction.,3. Hypertension with hypertensive cardiovascular disease.,4. Non-insulin-dependent diabetes mellitus.,5. Moderate obesity.,6. Hyperlipidemia.,7. Chronic non-pitting leg edema.,8. Arthritis.,9. GERD and positive history of peptic ulcer disease.,CONCLUSION:,1. Past left nephrectomy and splenectomy after an accident and injury and rupture of the spleen.,2. Abnormal nuclear stress test in September 2008, but no further cardiac studies performed, such as cardiac catheterization.,3. Lower left quadrant pain, which could be due to diverticulosis.,4. Diverticulosis and partial bowel obstruction.,RECOMMENDATION:,1. At this stage, the patient's cardiac medication should be continued if the patient is allowed p.o. intake.

Cardiac Consultation - 5

Cardiovascular / Pulmonary

The patient is a 55-year-old gentleman who presents for further evaluation of right leg weakness.

HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old gentleman who presents for further evaluation of right leg weakness. He has difficulty recollecting the exact details and chronology of his problem. To the best of his recollection, he thinks that about six months ago he developed weakness of his right leg. He describes that he is reaching to get something from a cabinet and he noticed that he was unable to stand on his right toe. Since that time, he has had difficulty pushing off when he walks. He has mild tingling and numbness in his toes, but this has been a chronic problem and nothing new since he has developed the weakness. He has chronic mild back pain, but this has been persistent for many years and has not changed. He has experienced cramps in both calves for the past year. This dissipated about two months ago. He does not think that his left leg is weak. He does not have any bowel or bladder incontinence. There is no radicular pain. He does not think that the problem is progressive, meaning that the weakness that he perceives in his right leg is no different than when it was six months ago.,He first sought medical attention for this problem in October. He then saw you a couple of months later. He has undergone an EMG and nerve conduction studies. Unfortunately, he cannot undergo an MRI of his spine because he has an ear implant. He has had a CT scan that shows degenerative changes, but nothing obviously abnormal.,In addition, the patient has hyperCKemia. He tells me that he has had an elevated CK prior to starting taking stat medications, although this is not entirely clear to me. He thinks that he is not taking Lipitor for about 15 months and thought that his CK was in the 500 or 600s prior to starting it. Once it was started, it increased to about 800 and then came down to about 500 when it was stopped. He then had a recent bump again up to the 1000 and since Lipitor has been stopped, his CK apparently has returned to about the 500 or 600s. I do no have any laboratory data to support these statements by the patient, but he seems to be up to speed on this. More recently, he has been started taking Zetia. He does not have any proximal weakness. He denies any myalgias., ,PAST MEDICAL HISTORY:, He has coronary artery disease and has received five stents. He has hypertension and hypercholesterolemia. He states that he was diagnosed with diabetes based on the results of an abnormal oral glucose tolerance test. He believes that his glucose shot up to over 300 with this testing. He does not take any medications for this and his blood glucoses are generally normal when he checks it. He has had plastic surgery on his face from an orbital injury. He also had an ear graft when he developed an ear infection during his honeymoon., ,CURRENT MEDICATIONS:, He takes amlodipine, Diovan, Zetia, hydrochlorothiazide, Lovaza (fish oil), Niaspan, aspirin, and Chantix. , ,ALLERGIES:, He has no known drug allergies., ,SOCIAL HISTORY:, He lives with his wife. He works at Shepherd Pratt doing network engineering. He smokes a pack of cigarettes a day and is working on quitting. He drinks four alcoholic beverages per night. Prior to that, he drank significantly more. He denies illicit drug use. He was athletic growing up., ,FAMILY HISTORY:, His mother died of complications from heart disease. His father died of heart disease in his 40s. He has two living brothers. One of them he does not speak too much with and does not know about his medical history. The other is apparently healthy. He has one healthy child. His maternal uncles apparently had polio. When I asked him to tell me further details about this, he states that one of them had to wear crutches due to severe leg deformans and then the other had leg deformities in only one leg. He is fairly certain that they had polio. He is unaware of any other family members with neurological conditions.,REVIEW OF SYSTEMS: , He has occasional tinnitus. He has difficulty sleeping. Otherwise, a complete review of systems was obtained and was negative except for as mentioned above. This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:, ,Vital Signs:

Neuro Consult - Leg Weakness

Neurology

Lumbar puncture. A 20-gauge spinal needle was then inserted into the L3-L4 space. Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained.

PROCEDURE PERFORMED:, Lumbar puncture.,The procedure, benefits, risks including possible risks of infection were explained to the patient and his father, who is signing the consent form. Alternatives were explained. They agreed to proceed with the lumbar puncture. Permit was signed and is on the chart. The indication was to rule out toxoplasmosis or any other CNS infection. ,DESCRIPTION: , The area was prepped and draped in a sterile fashion. Lidocaine 1% of 5 mL was applied to the L3-L4 spinal space after the area had been prepped with Betadine three times. A 20-gauge spinal needle was then inserted into the L3-L4 space. Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained. The spinal needle was then withdrawn and the area cleaned and dried and a Band-Aid applied to the clean, dry area.,COMPLICATIONS:, None. The patient was resting comfortably and tolerated the procedure well.,ESTIMATED BLOOD LOSS: , None.,DISPOSITION: , The patient was resting comfortably with nonlabored breathing and the incision was clean, dry, and intact. Labs and cultures were sent for the usual in addition to some extra tests that had been ordered.,The opening pressure was 292, the closing pressure was 190.

Lumbar Puncture - 2

Neurosurgery

neurosurgery, spinal needle, lumbar puncture, lumbar, gauge, csf

2-D Echocardiogram

2-D ECHOCARDIOGRAM,Multiple views of the heart and great vessels reveal normal intracardiac and great vessel relationships. Cardiac function is normal. There is no significant chamber enlargement or hypertrophy. There is no pericardial effusion or vegetations seen. Doppler interrogation, including color flow imaging, reveals systemic venous return to the right atrium with normal tricuspid inflow. Pulmonary outflow is normal at the valve. Pulmonary venous return is to the left atrium. The interatrial septum is intact. Mitral inflow and ascending aorta flow are normal. The aortic valve is trileaflet. The coronary arteries appear to be normal in their origins. The aortic arch is left-sided and patent with normal descending aorta pulsatility.

2-D Echocardiogram - 3

Cardiovascular / Pulmonary

cardiovascular / pulmonary, 2-d echocardiogram, cardiac function, doppler, echocardiogram, multiple views, aortic valve, coronary arteries, descending aorta, great vessels, heart, hypertrophy, interatrial septum, intracardiac, pericardial effusion, tricuspid, vegetation, venous, pulmonaryNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

MRI T-L spine - L2 conus medullaris lesion and syndrome secondary to Schistosomiasis.

CC: ,Paraplegia.,HX:, This 32 y/o RHF had been performing missionary work in Jos, Nigeria for several years and delivered her 4th child by vaginal delivery on 4/10/97. The delivery was induced with Pitocin, but was otherwise uncomplicated. For the first 4 days post-partum she noted clear liquid diarrhea without blood and minor abdominal discomfort. This spontaneous resolved without medical treatment. The second week post-partum she had 4-5 days of sinusitis, purulent nasal discharge and facial pain. She was otherwise well until 5/4/97 when stationed in a more rural area of Nigeria, she noted a dull ache in both knees (lateral to the patellae) and proximal tibia, bilaterally. The pain was not relieved by massage and seemed more bothersome when seated or supine. She had no sensory loss at the time.,On 5/6/97, she awakened to pain radiating down her knees to her anterior tibia. Over the next few hours the pain radiated circumferentially around both calves, and involved the soles of her feet and posterior BLE to her buttocks. Rising from bed became a laborious task and she required assistance to walk to the bathroom. Ibuprofen provided minimal analgesia. By evening the sole of one foot was numb.,She awoke the next morning, 5/9/97, with "pins & needles" sensation in BLE up to her buttocks. She was given Darvocet for analgesia and took an airplane back to the larger city she was based in. During the one hour flight her BLE weakness progressed to a non-weight bearing state (i.e. she could not stand). Local evaluation revealed 3/3 proximal and 4/4 distal BLE weakness. She had a sensory level to her waist on PP and LT testing. She also had mild lumbar back pain. Local laboratory evaluation: WBC 12.7, ESR 10. She was presumed to have Guillain-Barre syndrome and was placed on Solu-Cortef 1000mg qd and Sandimmune IV IgG 12.0 g.,On 5/10/97, she was airlifted to Geneva, Switzerland. Upon arrival there she had total anesthesia from the feet up to the inguinal region, bilaterally. There was flaccid areflexic paralysis of BLE and she was unable to void or defecate. Straight catheterization of the bladder revealed a residual volume of 1000cc. On 5/12/ CSF analysis revealed: Protein 1.5g/l, Glucose 2.2mmol/l, WBC 92 (O PMNS, 100% Lymphocytes), RBC 70, Clear CSF, bacterial-fungal-AFB-cultures were negative. Broad spectrum antibiotics and Solu-Medrol 1g IV qd were started. MRI T-L-spine, 5/12/97 revealed an intradural T12-L1 lesion that enhanced minimally with gadolinium and was associated with spinal cord edema in the affected area. MRI Brain, 5/12/97, was unremarkable and showed no evidence of demyelinating disease. HIV, HTLV-1, HSV, Lyme, EBV, Malaria and CMV serological titers were negative. On 5/15/97 the Schistosomiasis Mekongi IFAT serological titer returned positive at 1:320 (normal<1:80). 5/12/97 CSF Schistosomiasis Mekongi IFAT and ELISA were negative. She was then given a one day course of Praziquantel 3.6g total in 3 doses; and started on Prednisone 60 mg po qd; the broad spectrum antibiotics and Solu-Medrol were discontinued.,On 5/22/97, a rectal biopsy was performed to evaluate parasite eradication. The result came back positive for ova and granulomata after she had left for UIHC. The organism was not speciated. 5/22/97 CSF schistosomiasis ELISA and IFAT titers were positive at 1.09 and 1:160, respectively. These titers were not known when she initially arrived at UIHC.,Following administration of Praziquantel, she regained some sensation in BLE but the paraplegia, and urinary retention remained.,MEDS:, On 5/24/97 UIHC arrival: Prednisone 60mg qd, Zantac 50 IV qd, Propulsid 20mg tid, Enoxaparin 20mg qd.,PMH:, 1)G4P4.,FHX:, unremarkable.,SHX: ,Missionary. Married. 4 children ( ages 7,5,3,6 weeks).,EXAM:, BP110/70, HR72, RR16, 35.6C,MS: A&O to person, place and time. Speech fluent and without dysarthria. Lucid thought process.,CN: unremarkable.,Motor: 5/5 BUE strength. Lower extremities: 1/1 quads and hamstrings, 0/0 distally.,Sensory: Decreased PP/LT/VIB from feet to inguinal regions, bilaterally. T12 sensory level to temperature (ice glove).,Coord: normal FNF.,Station/Gait: not done.,Reflexes: 2/2 BUE. 0/0 BLE. No plantar responses, bilaterally.,Rectal: decreased to no rectal tone. Guaiac negative.,Other: No Lhermitte's sign. No paraspinal hypertonicity noted. No vertebral tenderness.,Gen exam: Unremarkable.,COURSE:, MRI T-L-spine, 5/24/97, revealed a 6 x 8 x 25 soft tissue mass at the L1 level posterior to the tip of the conus medullaris and extending into the canal below that level. This appeared to be intradural. There was mild enhancement. There was more enhancement along the distal cord surface and cauda equina. The distal cord had sign of diffuse edema. She underwent exploratory and decompressive laminectomy on 5/27/97, and was retreated with a one day course of Praziquantel 40mg/kg/day. Praziquantel is reportedly only 80% effective at parasite eradication.,She continued to reside on the Neurology/Neurosurgical service on 5/31/97 and remained paraplegic.

MRI T-L Spine - Schistosomiasis

Radiology

Right common carotid endarterectomy, internal carotid endarterectomy, external carotid endarterectomy, and Hemashield patch angioplasty of the right common, internal and external carotid arteries.

PREOPERATIVE DIAGNOSIS:, Right common, internal and external carotid artery stenosis.,POSTOPERATIVE DIAGNOSIS:, Right common, internal and external carotid artery stenosis.,OPERATIONS,1. Right common carotid endarterectomy.,2. Right internal carotid endarterectomy.,3. Right external carotid endarterectomy.,4. Hemashield patch angioplasty of the right common, internal and external carotid arteries.,ANESTHESIA:, General endotracheal anesthesia.,URINE OUTPUT: , Not recorded,OPERATION IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered. Next the right neck was prepped and draped in the standard surgical fashion. A #10-blade scalpel was used to make an incision at the anterior tip of the sternocleidomastoid muscle. Dissection was carried down to the level of the carotid artery using Bovie electrocautery and sharp dissection with Metzenbaum scissors. The common, internal and external carotid arteries were identified. The facial vein was ligated with #3-0 silk. The hypoglossal nerve was identified and preserved as it coursed across the carotid artery. After dissecting out an adequate length of common, internal and external carotid artery, heparin was given. Next, an umbilical tape was passed around the common carotid artery. A #0 silk suture was passed around the internal and external carotid arteries. The hypoglossal nerve was identified and preserved. An appropriate sized Argyle shunt was chosen. A Hemashield patch was cut to the appropriate size. Next, vascular clamps were placed on the external carotid artery. DeBakey pickups were used to control the internal carotid artery and common carotid artery. A #11-blade scalpel was used to make an incision on the common carotid artery. The arteriotomy was lengthened onto the internal carotid artery. Next, the Argyle shunt was placed. It was secured in place. Next, an endarterectomy was performed; and this was done on the common, internal carotid and external carotid arteries. An inversion technique was used on the external carotid artery. The artery was irrigated and free debris was removed. Next, we sewed the Hemashield patch onto the artery using #6-0 Prolene in a running fashion. Prior to completion of our anastomosis, we removed our shunt. We completed the anastomosis. Next, we removed our clamp from the external carotid artery, followed by the common carotid artery, and lastly by the internal carotid artery. There was no evidence of bleeding. Full-dose protamine was given. The incision was closed with #0 Vicryl, followed by #2-0 Vicryl, followed by #4-0 PDS in a running subcuticular fashion. A sterile dressing was applied.

Carotid Endarterectomy - 2

Cardiovascular / Pulmonary

cardiovascular / pulmonary, angioplasty, common carotid artery, external carotid artery, hemashield patch, common carotid, carotid endarterectomy, external, artery, carotid, hemashield, endarterectomy

This is a 48-year-old black male with stage IV chronic kidney disease likely secondary to HIV nephropathy, although there is no history of renal biopsy, who has been noncompliant with the Renal Clinic and presents today for followup at the recommendation of his Infection Disease doctors.

HISTORY OF PRESENT ILLNESS: , This is a 48-year-old black male with stage IV chronic kidney disease, likely secondary to HIV nephropathy who presents to clinic for followup having missed prior clinic appointments. He was last seen in this clinic on 05/29/2007 by Dr. X. This is the first time that I have met the patient. The patient's history of renal insufficiency dates back to 06/2006 when he was hospitalized for an HIV-associated complication. He is unclear of the exact reason for his hospitalization at that time, but he was diagnosed with renal insufficiency and was followed in our Renal Clinic for approximately one year. He had a baseline creatinine during that time of between 3.2 to 3.3. When he was initially diagnosed with renal insufficiency, he had been noncompliant with his HAART regimen. Since that time, he has been very compliant with treatment for his HIV and is seeing Dr. Y in our Infectious Disease Clinic. He is currently on three-drug antiretroviral therapy. His last CD4 count in 03/2008 was 350. He has had no HIV complications since he was last seen in our clinic. The patient is also followed by Dr. Z at the outpatient VA Clinic, here in ABCD, although he has not seen her in approximately one year. The patient has an AV fistula that was placed in late 2006. The latest blood work that I have is from 06/11/2008 and shows a serum creatinine of 3.8, which represents a GFR of 22 and a potassium of 5.9. These laboratories were drawn by his infectious disease doctor and the results prompted their recommendation for him to return to our clinic for further evaluation. The only complaint that the patient has at this time is some difficulty sleeping. He was given Ambien by his primary care doctor, but this has not helped significantly with his difficulty sleeping. He says that he has trouble getting to sleep. The Ambien will allow him to sleep for about two hours, and then he is awake again. He is tired during the day, but is not taking any daytime naps. He has no history of excessive snoring or apneic periods. He has no history of falling asleep at work or while driving. He has never had a formal sleep study. He does continue to work in sales at a local butcher shop.,REVIEW OF SYSTEMS: ,He denies any change in his appetite. He has actually gained some weight in recent months. He denies any nausea, vomiting, or abdominal discomfort. He denies any pruritus. He denies any lower extremity edema. All other systems are reviewed and negative.,PAST MEDICAL HISTORY:,1. Stage IV chronic kidney disease with most recent GFR of 22.,2. HIV diagnosed in 09/2006 with the most recent CD4 count of 350 in 03/2008.,3. Hyperlipidemia.,4. Hypertension.,5. Secondary hyperparathyroidism.,6. Status post right upper extremity AV fistula in the fall of 2006.,7. History of a right brachial plexus palsy.,8. Recent lower back pain, status post lumbar steroid injection.,ALLERGIES:, HE SAYS THAT VITAMIN D HAS CAUSED HEADACHES.,MEDICATIONS:,1. Kaletra daily.,2. Epivir one daily.,3. Ziagen two daily.,4. Lasix 20 mg b.i.d.,5. Valsartan 20 mg b.i.d.,6. Ambien 10 mg q.h.s.,SOCIAL HISTORY: , He lives here in ABCD. He is employed at the sales counter of a local butcher shop. He continues to smoke one pack of cigarettes daily, as he has for the past 28 years. He denies any alcohol or illicit substances.,FAMILY HISTORY:, His mother is deceased. He said that she had some type of paralysis before she died. His father is deceased at age 64 of a head and neck cancer. He has a 56-year-old brother with type-two diabetes and blindness secondary to diabetic retinopathy. He has a 41-year-old brother who has hypertension. He has a sister who has thyroid disease.,PHYSICAL EXAMINATION:,VITAL SIGNS: Weight is 191 pounds. His temperature is 97.1. Pulse is 94. Blood pressure by automatic cuff 173/97, by manual cuff 180/90.,HEENT: His oropharynx is clear without thrush or ulceration.,NECK: Supple without lymphadenopathy or thyromegaly.,HEART: Regular with normal S1 and S2. There are no murmurs, rubs, or gallops. He has no JVD.,LUNGS: Clear to auscultation bilaterally without wheezes, rhonchi, or crackles.,ABDOMEN: Soft, nontender, nondistended, without abdominal bruit or organomegaly.,MUSCULOSKELETAL: He has difficulty with abduction of his right shoulder.,ACCESS: He has a right forearm AV fistula with an audible bruit and a palpable thrill. There is no sign of stenosis. The vascular access looks like it is ready to use.,EXTREMITIES: No peripheral edema.,SKIN: No bruises, petechiae, or rash.,LABS: ,Sodium was 140, potassium 5.9, chloride 114, bicarbonate 18. BUN is 49, creatinine 4.3. GFR is 19. Albumin 3.2. Protein 7. AST 17, ALT 16, alkaline phosphatase 106. Total bilirubin 0.4. Calcium 9.1., phosphorus 4.7, PTH of 448. The corrected calcium was 9.7. WBC is 8.9, hemoglobin 13.4, platelet 226. Total cholesterol 234, triglycerides 140, LDL 159, HDL 47. His ferritin is 258, iron is 55, and percent sat is 24.,IMPRESSION: ,This is a 48-year-old black male with stage IV chronic kidney disease likely secondary to HIV nephropathy, although there is no history of renal biopsy, who has been noncompliant with the Renal Clinic and presents today for followup at the recommendation of his Infection Disease doctors.,RECOMMENDATIONS:,1. Renal. His serum creatinine is progressively worsening. His creatinine was 3.2 the last time we saw him in 05/2007 and today is 4.3. This represents a GFR of 19. This is stage IV chronic kidney disease. He does have vascular access and this appears to be ready to use. He is having some difficulty sleeping and it is possible that this represents some early signs of uremia. Otherwise, he has no signs or symptoms of uremia at this time. I am going to touch base with the dialysis educator and try to get The patient in to the dialysis teaching classes. He has already received some literature for the dialysis teaching, but has not yet enrolled in the classes. I have encouraged him to continue to exercise his right forearm. I am also going to contact the transplant coordinator and see if he can be evaluated for possible transplant. Given his progression of his chronic kidney disease, I will anticipate that he will need to start dialysis soon.,2. Hypertension. I have added labetolol 100 mg b.i.d. to his antihypertensive regimen. He shows no signs at this point of volume overload, although if he does demonstrate this in the future, his Lasix could be increased. Goal blood pressure would be less than 130/80.,3. Hyperkalemia. I am going to instruct him in a low-potassium diet and decrease his valsartan to 20 mg daily. I will have him return in one week to recheck his potassium. If his potassium continues to remain elevated, he may require initiation of dialysis for this.,4. Bone metabolism. His PTH is elevated and I am going to add PhosLo 800 mg t.i.d. with meals. His corrected calcium is 9.7, and I would like to avoid calcium-containing phosphate bonders in this situation.,5. Acid base. His bicarbonate is 18 and I will initiate the sodium bicarbonate 650 mg three tablets t.i.d.,6. Anemia. His hemoglobin is at goal for this stage of chronic kidney disease. His iron stores are adequate.

Chronic Kidney Disease - Consult

Nephrology

MRI Brain to evaluate sudden onset blindness - Basilar/bilateral thalamic strokes.

CC:, Sudden onset blindness.,HX:, This 58 y/o RHF was in her usual healthy state, until 4:00PM, 1/8/93, when she suddenly became blind. Tongue numbness and slurred speech occurred simultaneously with the loss of vision. The vision transiently improved to "severe blurring" enroute to a local ER, but worsened again once there. While being evaluated she became unresponsive, even to deep noxious stimuli. She was transferred to UIHC for further evaluation. Upon arrival at UIHC her signs and symptoms were present but markedly improved.,PMH:, 1) Hysterectomy many years previous. 2) Herniorrhaphy in past. 3) DJD, relieved with NSAIDs.,FHX/SHX:, Married x 27yrs. Husband denied Tobacco/ETOH/illicit drug use for her.,Unremarkable FHx.,MEDS:, none.,EXAM:, Vitals: 36.9C. HR 93. BP 151/93. RR 22. 98% O2Sat.,MS: somnolent, but arousable to verbal stimulation. minimal speech. followed simple commands on occasion.,CN: Blinked to threat from all directions. EOM appeared full, Pupils 2/2 decreasing to 1/1. +/+Corneas. Winced to PP in all areas of Face. +/+Gag. Tongue midline. Oculocephalic reflex intact.,Motor: UE 4/5 proximally. Full strength in all other areas. Normal tone and muscle bulk.,Sensory: Withdrew to PP in all extremities.,Gait: ND.,Reflexes: 2+/2+ throughout UE, 3/3 patella, 2/2 ankles, Plantar responses were flexor bilaterally.,Gen exam: unremarkable.,COURSE: ,MRI Brain revealed bilateral thalamic strokes. Transthoracic echocardiogram (TTE) showed an intraatrial septal aneurysm with right to left shunt. Transesophageal echocardiogram (TEE) revealed the same. No intracardiac thrombus was found. Lower extremity dopplers were unremarkable. Carotid duplex revealed 0-15% bilateral ICA stenosis. Neuroophthalmologic evaluation revealed evidence of a supranuclear vertical gaze palsy OU (diminished up and down gaze). Neuropsychologic assessment 1/12-15/93 revealed severe impairment of anterograde verbal and visual memory, including acquisition and delayed recall and recognition. Speech was effortful and hypophonic with very defective verbal associative fluency. Reading comprehension was somewhat preserved, though she complained that despite the ability to see type clearly, she could not make sense of words. There was impairment of 2-D constructional praxis. A follow-up Neuropsychology evaluation in 7/93 revealed little improvement. Laboratory studies, TSH, FT4, CRP, ESR, GS, PT/PTT were unremarkable. Total serum cholesterol 195, Triglycerides 57, HDL 43, LDL 141. She was placed on ASA and discharged1/19/93.,She was last seen on 5/2/95 and was speaking fluently and lucidly. She continued to have mild decreased vertical eye movements. Coordination and strength testing were fairly unremarkable. She continues to take ASA 325 mg qd.

MRI Brain - Bilateral Thalamic Strokes

Neurology

neurology, blindness, mri, transthoracic echocardiogram, transesophageal echocardiogram, tsh, ft4, crp, esr, gs, pt/ptt, bilateral thalamic strokes, sudden onset blindness, mri brain, thalamic strokes, brain, thalamic, strokes,

Insertion of subclavian dual-port Port-A-Cath and surgeon-interpreted fluoroscopy.

PROCEDURES PERFORMED,1. Insertion of subclavian dual-port Port-A-Cath.,2. Surgeon-interpreted fluoroscopy.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered. Next, the chest was prepped and draped in a standard surgical fashion. A #18-gauge spinal needle was used to aspirate blood from the subclavian vein. After aspiration of venous blood, Seldinger technique was used to thread a J wire. The distal tip of the J wire was confirmed to be in adequate position with surgeon-interpreted fluoroscopy. Next a #15-blade scalpel was used to make an incision in the skin. Dissection was carried down to the level of the pectoralis muscle. A pocket was created. A dual-port Port-A-Cath was lowered into the pocket and secured with #2-0 Prolene. Both ports were flushed. The distal tip was pulled through to the wire exit site with a Kelly clamp. It was cut to the appropriate length. Next a dilator and sheath were threaded over the J wire. The J wire and dilator were removed, and the distal tip of the dual-port Port-A-Cath was threaded over the sheath, which was simultaneously withdrawn. Both ports of the dual-port Port-A-Cath were flushed and aspirated without difficulty. The distal tip was confirmed to be in adequate position with surgeon-interpreted fluoroscopy. The wire access site was closed with a 4-0 Monocryl. The port pocket was closed in 2 layers with 2-0 Vicryl followed by 4-0 Monocryl in a running subcuticular fashion. Sterile dressing was applied. The patient tolerated the procedure well and was transferred to the PACU in good condition

Port-A-Cath Insertion - 6

Cardiovascular / Pulmonary

cardiovascular / pulmonary, surgeon-interpreted fluoroscopy, j wire, dual-port port-a-cath, port a cath, subclavian, fluoroscopy, cathNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

MRI Spine - T12-L5 epidural lipoma and thoracic spinal cord infarction vs. transverse myelitis.

CC:, Progressive lower extremity weakness.,HX: ,This 54 y/o RHF presented on 7/3/93 with a 2 month history of lower extremity weakness. She was admitted to a local hospital on 5/3/93 for a 3 day h/o of progressive BLE weakness associated with incontinence and BLE numbness. There was little symptom of upper extremity weakness at that time, according to the patient. Her evaluation was notable for a bilateral L1 sensory level and 4/4 strength in BLE. A T-L-S Spine MRI revealed a T4-6 lipomatosis with anterior displacement of the cord without cord compression. CSF analysis yielded: opening pressure of 14cm H20, protein 88, glucose 78, 3 lymphocytes and 160 RBC, no oligoclonal bands or elevated IgG index, and negative cytology. Bone marrow biopsy was negative. B12, Folate, and Ferritin levels were normal. CRP 5.2 (elevated). ANA was positive at 1:5,120 in speckled pattern. Her hospital course was complicated by deep venous thrombosis, which recurred after heparin was stopped to do the bone marrow biopsy. She was subsequently placed on Coumadin. EMG/NCV testing revealed " lumbosacral polyradiculopathy with axonal degeneration and nerve conduction block." She was diagnosed with atypical Guillain-Barre vs. polyradiculopathy and received a single course of Decadron; and no plasmapheresis or IV IgG. She was discharged home o 6/8/93.,She subsequently did not improve and after awaking from a nap on her couch the day of presentation, 7/3/93, she found she was paralyzed from the waist down. There was associated mild upper lumbar back pain without radiation. She had had no bowel movement or urination since that time. She had no recent trauma, fever, chills, changes in vision, dysphagia or upper extremity deficit.,MEDS:, Coumadin 7.5mg qd, Zoloft 50mg qd, Lithium 300mg bid.,PMH:, 1) Bi-polar Affective Disorder, dx 1979 2) C-section.,FHX:, Unremarkable.,SHX:, Denied Tobacco/ETOH/illicit drug use.,EXAM: ,BP118/64, HR103, RR18, Afebrile.,MS: ,A&O to person, place, time. Speech fluent without dysarthria. Lucid thought processes.,CN: ,Unremarkable.,MOTOR:, 5/5 strength in BUE. Plegic in BLE. Flaccid muscle tone.,SENSORY:, L1 sensory level (bilaterally) to PP and TEMP, without sacral sparing. Proprioception was lost in both feet.,CORD: ,Normal in BUE.,Reflexes were 2+/2+ in BUE. They were not elicited in BLE. Plantar responses were equivocal, bilaterally.,RECTAL: ,Poor rectal tone. stool guaiac negative. She had no perirectal sensation.,COURSE:, CRP 8.8 and ESR 76. FVC 2.17L. WBC 1.5 (150 bands, 555 neutrophils, 440 lymphocytes and 330 monocytes), Hct 33%, Hgb 11.0, Plt 220K, MCV 88, GS normal except for slightly low total protein (8.0). LFT were normal. Creatinine 1.0. PT and PTT were normal. ABCG 7.46/25/79/96% O2Sat. UA notable for 1+ proteinuria. EKG normal.,MRI L-spine, 7/3/93, revealed an area of abnormally increased T2 signal extending from T12 through L5. This area causes anterior displacement of the spinal cord and nerve roots. The cauda equina are pushed up against the posterior L1 vertebral body. There bilaterally pulmonary effusions. There is also abnormally increased T2 signal in the center of the spinal cord extending from the mid thoracic level through the conus. In addition, the Fila Terminale appear thickened. There is increased signal in the T3 vertebral body suggestion a hemangioma. The findings were felt consistent with a large epidural lipoma displacing the spinal cord anteriorly. there also appeared spinal cord swelling and increased signal within the spinal cord which suggests an intramedullary process.,CSF analysis revealed: protein 1,342, glucose 43, RBC 4,900, WBC 9. C3 and C$ complement levels were 94 and 18 respectively (normal) Anticardiolipin antibodies were negative. Serum Beta-2 microglobulin was elevated at 2.4 and 3.7 in the CSF and Serum, respectively. It was felt the patient had either a transverse myelitis associated with SLE vs. partial cord infarction related to lupus vasculopathy or hypercoagulable state. She was place on IV Decadron. Rheumatology felt that a diagnosis of SLE was likely. Pulmonary effusion analysis was consistent with an exudate. She was treated with plasma exchange and place on Cytoxan.,On 7/22/93 she developed fever with associated proptosis and sudden loss of vision, OD. MRI Brain, 7/22/93, revealed a 5mm thick area of intermediate signal adjacent to the posterior aspect of the right globe, possibly representing hematoma. Ophthalmology felt she had a central retinal vein occlusion; and it was surgically decompressed.,She was placed on prednisone on 8/11/93 and Cytoxan was started on 8/16/93. She developed a headache with meningismus on 8/20/93. CSF analysis revealed: protein 1,002, glucose2, WBC 8,925 (majority were neutrophils). Sinus CT scan negative. She was placed on IV Antibiotics for presumed bacterial meningitis. Cultures were subsequently negative. She spontaneously recovered. 8/25/93, cisternal tap CSF analysis revealed: protein 126, glucose 35, WBC 144 (neutrophils), RBC 95, Cultures negative, cytology negative. MRI Brain scan revealed diffuse leptomeningeal enhancement in both brain and spinal canal.,DSDNA negative. She developed leukopenia in 9/93, and she was switched from Cytoxan to Imuran. Her LFT's rose and the Imuran was stopped and she was placed back on prednisone.,She went on to have numerous deep venous thrombosis while on Coumadin. This required numerous hospital admissions for heparinization. Anticardiolipin antibodies and Protein C and S testing was negative.

MRI Spine - Epidural Lipoma

Radiology

The patient is a 22-year-old woman with a possible ruptured ectopic pregnancy.

TITLE OF OPERATION:, Diagnostic laparoscopy.,INDICATION FOR SURGERY: , The patient is a 22-year-old woman with a possible ruptured ectopic pregnancy.,PREOP DIAGNOSIS: , Possible ruptured ectopic pregnancy.,POSTOP DIAGNOSIS: , No evidence of ectopic pregnancy or ruptured ectopic pregnancy.,ANESTHESIA: , General endotracheal.,SPECIMEN: , Peritoneal fluid.,EBL: , Minimal.,FLUIDS:, 900 cubic centimeters crystalloids.,URINE OUTPUT: , 400 cubic centimeters.,FINDINGS: , Adhesed left ovary with dilated left fallopian tube, tortuous right fallopian tube with small 1 cm ovarian cyst noted on right ovary, perihepatic lesions consistent with history of PID, approximately 1-200 cubic centimeters of more serous than sanguineous fluid. No evidence of ectopic pregnancy.,COMPLICATIONS: , None.,PROCEDURE:, After obtaining informed consent, the patient was taken to the operating room where general endotracheal anesthesia was administered. She was examined under anesthesia. An 8-10 cm anteverted uterus was noted. The patient was placed in the dorsal-lithotomy position and prepped and draped in the usual sterile fashion, a sponge on a sponge stick was used in the place of a HUMI in order to not instrument the uterus in the event that this was a viable intrauterine pregnancy and this may be a desired intrauterine pregnancy. Attention was then turned to the patient's abdomen where a 5-mm incision was made in the inferior umbilicus. The abdominal wall was tented and VersaStep needle was inserted into the peritoneal cavity. Access into the intraperitoneal space was confirmed by a decrease in water level when the needle was filled with water. No peritoneum was obtained without difficulty using 4 liters of CO2 gas. The 5-mm trocar and sleeve were then advanced in to the intraabdominal cavity and access was confirmed with the laparoscope.,The above-noted findings were visualized. A 5-mm skin incision was made approximately one-third of the way from the ASI to the umbilicus at McBurney's point. Under direct visualization, the trocar and sleeve were advanced without difficulty. A third incision was made in the left lower quadrant with advancement of the trocar into the abdomen in a similar fashion using the VersaStep. The peritoneal fluid was aspirated and sent for culture and wash and cytology. The abdomen and pelvis were surveyed with the above-noted findings. No active bleeding was noted. No evidence of ectopic pregnancy was noted. The instruments were removed from the abdomen under good visualization with good hemostasis noted. The sponge on a sponge stick was removed from the vagina. The patient tolerated the procedure well and was taken to the recovery room in stable condition.,The attending, Dr. X, was present and scrubbed for the entire procedure.

Diagnostic Laparoscopy

Obstetrics / Gynecology

obstetrics / gynecology, peritoneal fluid, sanguineous fluid, ruptured ectopic pregnancy, diagnostic laparoscopy, intrauterine pregnancy, ectopic pregnancy, trocar, ruptured, ectopic, tortuous, pregnancy,

History of right leg pain. Leg pain is no longer present.

HISTORY OF PRESENT ILLNESS: , The patient is a 44-year-old man who was seen for complaints of low back and right thigh pain. He attributes this to an incident in which he was injured in 1994. I do not have any paperwork authenticating his claim that there is an open claim. Most recently he was working at Taco Bell, when he had a recurrence of back pain, and he was seen in our clinic on 04/12/05. He rated pain of approximately 8/10 in severity., ,He took a Medrol Dosepak and states that his pain level has decreased to approximately 4-5/10. He still localizes it to a band between L4 and the sacrum. He initially had some right leg pain but states that this is minimal and intermittent at the present time. His back history is significant for two laminectomies and a discectomy performed from 1990 to 1994. The area of concern was L4-L5., ,The patient's MRI dated 10/18/04 showed multi-level degenerative changes, with facet involvement at L2-L3, L3-L4 and L5-S1. There was no neural impingement. He also had an MR myelogram, which showed severe stenosis at L3-L4, however it was qualified in that it may have been artifact, rather than a genuine finding., ,REVIEW OF SYSTEMS:, Focal lower paralumbar pain, affecting both right and left sides, as well as intermittent right leg pain which appears to have improved significantly with the Medrol Dosepak. He denies any recent illness. He has no constitutional complaints such as fevers, chills or sweats. HEENT: The patient denies any cephalgia, ocular, nasopharyngeal symptoms. He has no dysphagia. Cardiovascular: He denies any palpitations, chest pain, syncope or near-syncope. Pulmonary: He denies any dyspnea or respiratory difficulties. GI: The patient has no abdominal pain, nausea or vomiting. GU: The patient denies any urinary frequency or dysuria. There is no gross hematuria. Dermatologic: The patient notes no new onset of rash or other dermatological abnormalities. Musculoskeletal: Denies any recent falls or near-falls. He denies any abnormalities of endocrine, immunologic, hematologic, organ systems. , ,MEDICATIONS: , Atenolol, Zestril, Vicodin., ,ALLERGIES:, None., ,SOCIOECONOMIC STATUS:, Lifting limitations of 5 pounds and limited stooping, bending and twisting., ,PHYSICAL EXAMINATION: , Vital signs: Blood pressure 158/86, respiration 14, pulse 60, temperature 100.2. He is sitting upright, alert and oriented and in no acute distress. Skin is warm and dry. Gross neurologic examination is normal. ENT examination reveals normal oropharynx, nasopharynx, and tympanic membranes. Neck: Full range of motion with no adenopathy or thyromegaly. Cardiovascular: Regular rate and rhythm. Lungs: Clear. , ,On examination of the lumbar spine, he is minimally tender to palpation. There is no overt muscular spasm. His range of motion is estimated at 40 degrees of flexion and 15 degrees of extension. Straight leg raises do not elicit any leg complaints on today's visit. Lower extremity reflexes are symmetric., ,DIAGNOSIS: , Low back pain with a history of right leg pain. The leg pain is no longer present. His pain level has improved., ,PLAN: ,1. The patient will take another Medrol Dosepak.,2. He can continue with physical therapy.,3. He also continues with the same lifting restrictions.,4. Follow up is within one week.

Leg Pain - Progress Note

Orthopedic

Aplastic anemia. After several bone marrow biopsies, she was diagnosed with aplastic anemia. She started cyclosporine and prednisone.

CHIEF COMPLAINT: , Aplastic anemia.,HISTORY OF PRESENT ILLNESS: , This is a very pleasant 72-year-old woman, who I have been following for her pancytopenia. After several bone marrow biopsies, she was diagnosed with aplastic anemia. She started cyclosporine and prednisone on 03/30/10. She was admitted to the hospital from 07/11/10 to 07/14/10 with acute kidney injury. Her cyclosporine level was 555. It was thought that her acute kidney injury was due to cyclosporine toxicity and therefore that was held.,Overall, she tells me that now she feels quite well since leaving the hospital. She was transfused 2 units of packed red blood cells while in the hospital. Repeat CBC from 07/26/10 showed white blood cell count of 3.4 with a hemoglobin of 10.7 and platelet count of 49,000.,CURRENT MEDICATIONS:, Folic acid, Aciphex, MiraLax, trazodone, prednisone for 5 days every 4 weeks, Bactrim double strength 1 tablet b.i.d. on Mondays, Wednesdays and Fridays.,ALLERGIES: ,No known drug allergies.,REVIEW OF SYSTEMS: , As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1. Hypertension.,2. GERD.,3. Osteoarthritis.,4. Status post tonsillectomy.,5. Status post hysterectomy.,6. Status post bilateral cataract surgery.,7. Esophageal stricture status post dilatation approximately four times.,SOCIAL HISTORY: ,She has no tobacco use. She has rare alcohol use. She has three children and is a widow. Her husband died after they were married only eight years. She is retired.,FAMILY HISTORY: , Her sister had breast cancer.,PHYSICAL EXAM:,VIT:

Aplastic Anemia Followup

Hematology - Oncology

Diagnostic fiberoptic bronchoscopy with biopsies and bronchoalveolar lavage. Bilateral upper lobe cavitary lung masses. Airway changes including narrowing of upper lobe segmental bronchi, apical and posterior on the right, and anterior on the left. There are also changes of inflammation throughout.

PREOPERATIVE DIAGNOSIS:, Bilateral upper lobe cavitary lung masses.,POSTOPERATIVE DIAGNOSES:,1. Bilateral upper lobe cavitary lung masses.,2. Final pending pathology.,3. Airway changes including narrowing of upper lobe segmental bronchi, apical and posterior on the right, and anterior on the left. There are also changes of inflammation throughout.,PROCEDURE PERFORMED: , Diagnostic fiberoptic bronchoscopy with biopsies and bronchoalveolar lavage.,ANESTHESIA: , Conscious sedation was with Demerol 150 mg and Versed 4 mg IV.,OPERATIVE REPORT: , The patient is residing in the endoscopy suite. After appropriate anesthesia and sedation, the bronchoscope was advanced transorally due to the patient's recent history of epistaxis. Topical lidocaine was utilized for anesthesia. Epiglottis and vocal cords demonstrated some mild asymmetry of the true cords with right true and false vocal cord appearing slightly more prominent. This may be normal anatomic variant. The scope was advanced into the trachea. The main carina was sharp in appearance. Right upper, middle, and lower segmental bronchi as well as left upper lobe and lower lobe segmental bronchi were serially visualized. Immediately noted were some abnormalities including circumferential narrowing and probable edema involving the posterior and apical segmental bronchi on the right and to a lesser degree the anterior segmental bronchus on the left. No specific intrinsic masses were noted. Under direct visualization, the scope was utilized to lavage the posterior segmental bronchus in the right upper lobe. Also cytologic brushings and protected bacteriologic brushing specimens were obtained. Three biopsies were attempted within the cavitary lesion in the posterior segment of the right upper lobe. During lavage, some caseous appearing debris appeared intermittently. The specimens were collected and sent to the lab. Procedure was terminated with hemostasis having been verified. The patient tolerated the procedure well.,Throughout the procedure, the patient's vital signs and oximetry were monitored and remained within satisfactory limits.,The patient will be returned to her room with orders as per usual.

Fiberoptic Bronchoscopy

Cardiovascular / Pulmonary

cardiovascular / pulmonary, inflammation, lung masses, lobe cavitary, bronchoalveolar, biopsies, segmental bronchi, fiberoptic, bronchoscopy, lavage, cavitary, segmental, lobe,

Coronary artery disease, prior bypass surgery. The patient has history of elevated PSA and BPH. He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic. From cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness.

REASON FOR CONSULTATION:, Coronary artery disease (CAD), prior bypass surgery.,HISTORY OF PRESENT ILLNESS: , The patient is a 70-year-old gentleman who was admitted for management of fever. The patient has history of elevated PSA and BPH. He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic. From cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness. No symptoms of chest pain or shortness of breath.,His history from cardiac standpoint as mentioned below.,CORONARY RISK FACTORS: , History of hypertension, history of diabetes mellitus, nonsmoker. Cholesterol elevated. History of established coronary artery disease in the family and family history positive.,FAMILY HISTORY: , Positive for coronary artery disease.,SURGICAL HISTORY: , Coronary artery bypass surgery and a prior angioplasty and prostate biopsies.,MEDICATIONS:,1. Metformin.,2. Prilosec.,3. Folic acid.,4. Flomax.,5. Metoprolol.,6. Crestor.,7. Claritin.,ALLERGIES:, DEMEROL, SULFA.,PERSONAL HISTORY: , He is married, nonsmoker, does not consume alcohol, and no history of recreational drug use.,PAST MEDICAL HISTORY:, Significant for multiple knee surgeries, back surgery, and coronary artery bypass surgery with angioplasty, hypertension, hyperlipidemia, elevated PSA level, BPH with questionable cancer. Symptoms of shortness of breath, fatigue, and tiredness.,REVIEW OF SYSTEMS:,CONSTITUTIONAL: No history of fever, rigors, or chills except for recent fever and rigors.,HEENT: No history of cataract or glaucoma.,CARDIOVASCULAR: As above.,RESPIRATORY: Shortness of breath. No pneumonia or valley fever.,GASTROINTESTINAL: Nausea and vomiting. No hematemesis or melena.,UROLOGICAL: Frequency, urgency.,MUSCULOSKELETAL: No muscle weakness.,SKIN: None significant.,NEUROLOGICAL: No TIA or CVA. No seizure disorder.,PSYCHOLOGICAL: No anxiety or depression.,ENDOCRINE: As above.,HEMATOLOGICAL: None significant.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse of 75, blood pressure 130/68, afebrile, and respiratory rate 16 per minute.,HEENT: Atraumatic, normocephalic.,NECK: Veins flat. No significant carotid bruits.,LUNGS: Air entry bilaterally fair.,HEART: PMI displaced. S1 and S2 regular.,ABDOMEN: Soft, nontender. Bowel sounds present.,EXTREMITIES: No edema. Pulses are palpable. No clubbing or cyanosis.,CNS: Benign.,EKG:

Consult - Coronary Artery Disease

Cardiovascular / Pulmonary

Refractory anemia that is transfusion dependent. At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion.

DIAGNOSIS:, Refractory anemia that is transfusion dependent.,CHIEF COMPLAINT: , I needed a blood transfusion.,HISTORY: , The patient is a 78-year-old gentleman with no substantial past medical history except for diabetes. He denies any comorbid complications of the diabetes including kidney disease, heart disease, stroke, vision loss, or neuropathy. At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion. He reports that he has no signs or symptom of bleeding and had a blood transfusion approximately two months ago and actually several weeks before that blood transfusion, he had a transfusion for anemia. He has been placed on B12, oral iron, and Procrit. At this time, we are asked to evaluate him for further causes and treatment for his anemia. He denies any constitutional complaints except for fatigue, malaise, and some dyspnea. He has no adenopathy that he reports. No fevers, night sweats, bone pain, rash, arthralgias, or myalgias.,PAST MEDICAL HISTORY: ,Diabetes.,PAST SURGICAL HISTORY:, Hernia repair.,ALLERGIES: , He has no allergies.,MEDICATIONS: , Listed in the chart and include Coumadin, Lasix, metformin, folic acid, diltiazem, B12, Prevacid, and Feosol.,SOCIAL HISTORY: , He is a tobacco user. He does not drink. He lives alone, but has family and social support to look on him.,FAMILY HISTORY:, Negative for blood or cancer disorders according to the patient.,PHYSICAL EXAMINATION:,GENERAL: He is an elderly gentleman in no acute distress. He is sitting up in bed eating his breakfast. He is alert and oriented and answering questions appropriately.,VITAL SIGNS: Blood pressure of 110/60, pulse of 99, respiratory rate of 14, and temperature of 97.4. He is 69 inches tall and weighs 174 pounds.,HEENT: Sclerae show mild arcus senilis in the right. Left is clear. Pupils are equally round and reactive to light. Extraocular movements are intact. Oropharynx is clear.,NECK: Supple. Trachea is midline. No jugular venous pressure distention is noted. No adenopathy in the cervical, supraclavicular, or axillary areas.,CHEST: Clear.,HEART: Regular rate and rhythm.,ABDOMEN: Soft and nontender. There may be some fullness in the left upper quadrant, although I do not appreciate a true spleen with inspiration.,EXTREMITIES: No clubbing, but there is some edema, but no cyanosis.,NEUROLOGIC: Noncontributory.,DERMATOLOGIC: Noncontributory.,CARDIOVASCULAR: Noncontributory.,IMPRESSION: , At this time is refractory anemia, which is transfusion dependent. He is on B12, iron, folic acid, and Procrit. There are no sign or symptom of blood loss and a recent esophagogastroduodenoscopy, which was negative. His creatinine was 1. My impression at this time is that he probably has an underlying myelodysplastic syndrome or bone marrow failure. His creatinine on this hospitalization was up slightly to 1.6 and this may contribute to his anemia.,RECOMMENDATIONS: ,At this time, my recommendation for the patient is that he undergoes further serologic evaluation with reticulocyte count, serum protein, and electrophoresis, LDH, B12, folate, erythropoietin level, and he should undergo a bone marrow aspiration and biopsy. I have discussed the procedure in detail which the patient. I have discussed the risks, benefits, and successes of that treatment and usefulness of the bone marrow and predicting his cause of refractory anemia and further therapeutic interventions, which might be beneficial to him. He is willing to proceed with the studies I have described to him. We will order an ultrasound of his abdomen because of the possible fullness of the spleen, and I will probably see him in follow up after this hospitalization.,As always, we greatly appreciate being able to participate in the care of your patient. We appreciate the consultation of the patient.

Anemia - Consult

Hematology - Oncology

Total abdominal hysterectomy (TAH), left salpingo-oophorectomy, lysis of interloop bowel adhesions. Chronic pelvic pain, endometriosis, prior right salpingo-oophorectomy, history of intrauterine device perforation and exploratory surgery.

PREOPERATIVE DIAGNOSES:,1. Chronic pelvic pain.,2. Endometriosis.,3. Prior right salpingo-oophorectomy.,4. History of intrauterine device perforation and exploratory surgery.,POSTOPERATIVE DIAGNOSES:,1. Endometriosis.,2. Interloop bowel adhesions.,PROCEDURE PERFORMED:,1. Total abdominal hysterectomy (TAH).,2. Left salpingo-oophorectomy.,3. Lysis of interloop bowel adhesions.,ANESTHESIA:, General.,ESTIMATED BLOOD LOSS: ,400 cc.,FLUIDS: , 2300 cc of lactated Ringers, as well as lactated Ringers for intraoperative irrigation.,URINE: , 500 cc of clear urine output.,INTRAOPERATIVE FINDINGS: , The vulva and perineum are without lesions. On bimanual exam, the uterus was enlarged, movable, and anteverted. The intraabdominal findings revealed normal liver margin, kidneys, and stomach upon palpation. The uterus was found to be normal in size with evidence of endometriosis on the uterus. The right ovary and fallopian tube were absent. The left fallopian tube and ovary appeared normal with evidence of a small functional cyst. There was evidence of left adnexal adhesion to the pelvic side wall which was filmy, unable to be bluntly dissected. There were multiple interloop bowel adhesions that were filmy in nature noted.,The appendix was absent. There did appear to be old suture in a portion of the bowel most likely from a prior procedure.,INDICATIONS: , This patient is a 45-year-old African-American gravida7, para3-0-0-3, who is here for definitive treatment of chronic pelvic pain with a history of endometriosis. She did have a laparoscopic ablation of endometriosis on a laparoscopy and also has a history of right salpingo-oophorectomy. She has tried Lupron and did stop secondary to the side effects.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the Operating Suite and placed under general anesthesia. She was then prepped and draped in the sterile fashion and placed in the dorsal supine position. An indwelling Foley catheter was placed. With the skin knife, an incision was made removing the old cicatrix. A Bovie was used to carry the tissue through to the underlying layer of the fascia which was incised in the midline and extended with the Bovie. The rectus muscle was then sharply and bluntly dissected off the superior aspect of the rectus fascia in the superior as well as the inferior aspect using the Bovie. The rectus muscle was then separated in the midline using a hemostat and the peritoneum was entered bluntly. The peritoneal incision was then extended superiorly and inferiorly with Metzenbaum scissors with careful visualization of the bladder. At this point, the intraabdominal cavity was manually explored and the above findings were noted. A Lahey clamp was then placed on the fundus of the uterus and the uterus was brought to the surgical field. The bowel was then packed with moist laparotomy sponges. Prior to this, the filmy adhesions leftover were taken down. At this point, the left round ligament was identified, grasped with two hemostats, transected, and suture ligated with #0 Vicryl. At this point, the broad ligament was dissected down and the lost portion of the bladder flap was created. The posterior aspect of the peritoneum was also dissected. At this point, the infundibulopelvic ligament was isolated and three tie of #0 Vicryl was used to isolate the pedicle. Two hemostats were then placed across the pedicle and this was transected with the scalpel. This was then suture ligated in Heaney fashion. The right round ligament was then identified and in the similar fashion, two hemostats were placed across the round ligament and using the Mayo scissors the round ligament was transected and dissected down the broad ligament to create the bladder flap anteriorly as well as dissect the posterior peritoneum and isolate the round ligament. This was then ligated with three tie of #0 Vicryl. Also incorporated in this was the remnant from the previous right salpingo-oophorectomy. At this point, the bladder flap was further created with sharp dissection as well as the moist Ray-Tech to push the bladder down off the anterior portion of the cervix.,The left uterine artery was then skeletonized and a straight Heaney was placed. In a similar fashion, the contralateral uterine artery was skeletonized and straight Heaney clamp was placed. These ligaments bilaterally were transected and suture ligated in a left Heaney stitch. At this point, curved Masterson was used to incorporate the cardinal ligament complex, thus was transected and suture ligated. Straight Masterson was then used to incorporate the uterosacrals bilaterally and this was also transected and suture ligated. Prior to ligating the uterine arteries, the uterosacral arteries were tagged bilaterally with #0 Vicryl. At this point, the roticulator was placed across the vaginal cuff and snug underneath the entire cervix. The roticulator was then clamped and removed and the staple line was in place. This was found to be hemostatic. A suture was then placed through each cuff angle bilaterally and cardinal ligament complex was found to be fixed to each apex bilaterally. At this point, McCall culdoplasty was performed with an #0 Vicryl incorporating each uterosacral as well as the posterior peritoneum. There did appear to be good support on palpation. Prior to this, the specimen was handed off and sent to pathology. At this point, there did appear to be small amount of oozing at the right peritoneum. Hemostasis was obtained using a #0 Vicryl in two single stitches. Good hemostasis was then obtained on the cuff as well as the pedicles. Copious irrigation was performed at this point with lactate Ringers. The round ligaments were then incorporated into the cuff bilaterally. Again, copious amount of irrigation was performed and good hemostasis was obtained. At this point, the peritoneum was reapproximated in a single interrupted stitch on the left and right lateral aspects to cover each pedicle bilaterally. At this point, the bowel packing as well as moist Ray-Tech was removed and while re-approximating the bowel it was noted that there were multiple interloop bowel adhesions which were taken down using the Metzenbaum scissors with good visualization of the underlying bowel. Good hemostasis was obtained of these sites as well. The sigmoid colon was then returned to its anatomic position and the omentum as well. The rectus muscle was then reapproximated with two interrupted sutures of #2-0 Vicryl. The fascia was then reapproximated with #0 Vicryl in a running fashion from lateral to medial meeting in the midline. The Scarpa's fascia was then closed with #3-0 plain in a running suture. The skin was then re-approximated with #4-0 undyed Vicryl in a subcuticular closure. This was dressed with an Op-Site. The patient tolerated the procedure well. The sponge, lap, and needle were correct x2. After the procedure, the patient was extubated and brought out of general anesthesia. She will go to the floor where she will be followed postoperatively in the hospital.

TAH & Salpingo-oophorectomy & Lysis of Adhesions

Obstetrics / Gynecology

obstetrics / gynecology, chronic pelvic pain, endometriosis, intrauterine device, exploratory, abdominal hysterectomy, tah, total abdominal hysterectomy, lysis of interloop bowel adhesions, salpingo oophorectomy, bowel, ligament, adhesions, interloop, hemostasis, uterus, salpingo, oophorectomy,

Cardiac catheterization and coronary intervention report.

EXAM: , Cardiac catheterization and coronary intervention report.,PROCEDURES:,1. Left heart catheterization, coronary angiography, left ventriculography.,2. PTCA/Endeavor stent, proximal LAD.,INDICATIONS: , Acute anterior ST-elevation MI.,ACCESS: , Right femoral artery 6-French.,MEDICATIONS:,1. IV Valium.,2. IV Benadryl.,3. Subcutaneous lidocaine.,4. IV heparin.,5. IV ReoPro.,6. Intracoronary nitroglycerin.,ESTIMATED BLOOD LOSS: , 10 mL.,CONTRAST: ,185 mL.,COMPLICATIONS: , None.,PROCEDURE: , The patient was brought to the cardiac catheterization laboratory with acute ST-elevation MI and EKG. She was prepped and draped in the usual sterile fashion. The right femoral region was infiltrated with subcutaneous lidocaine, adequate anesthesia was obtained. The right femoral artery was entered with _______ modified Seldinger technique and a J wire was passed. The needle was exchanged for 6 French sheath. The wire was removed. The sheath was washed with sterile saline. Following this, the left coronary was attempted to be cannulated with an XP catheter, however, the catheter folded on itself and could not reach the left main, this was removed. A second 6-French JL4 guiding catheter was then used to cannulate the left main and initial guiding shots demonstrated occlusion of the proximal LAD. The patient had an ACT check, received additional IV heparin and IV ReoPro. The lesion was crossed with 0.014 BMW wire and redilated with a 2.5 x 20-mm balloon at nominal pressures. The balloon was deflated and angiography demonstrated establishment of flow. Following this, the lesion was stented with a 2.5 x 18-mm Endeavor stent at 10 atmospheres. The balloon was deflated, reinflated at 12 atmospheres, deflated and removed. Final angiography demonstrated excellent clinical result. Additional angiography was performed with a wire out. Following this, the wire and the catheter was removed. Following this, the right coronary was selectively cannulated with diagnostic catheter and angiographic views were obtained in multiple views. This catheter was removed. The pigtail catheter was placed in the left ventricle and left ventriculography was performed with pullback pressures across the aortic valve. At the end of procedure, wires and catheter were removed. Right femoral angiography was performed and a right femoral Angio-Seal kit was deployed at the right femoral arteriotomy site. There was no hematoma. Peripheral pulses _______ procedure. The patient tolerated the procedure well. Symptoms of chest pain resolved at the end of the procedure with no complications.,RESULTS:,1. Coronary angiography.,A. Left main free of obstruction.,B. LAD, subtotal proximal stenosis.,C. Circumflex large vessel with three large obtuse marginal branches. No high-grade obstruction, evidence of minimal plaquing.,D. Right coronary 70% mid vessel stenosis and 50% mid to distal stenosis before giving rise to a right dominant posterior lateral and posterior descending artery.,2. Left ventriculogram. Left ventricular ejection fraction estimated at 45% to 50%. There was an akinetic apical wall.,3. Hemodynamics. Aortic pressure 145/109, left ventricular pressure 147/13, left ventricular end-diastolic pressure 34 mmHg.,IMPRESSION:,1. Acute ST-elevation myocardial infarction, culprit lesion, left anterior descending occlusion.,2. Two-vessel coronary disease.,3. Mild-to-moderate impaired LV systolic function.,4. Successful stent left anterior descending, 100% occlusion, 0% residual stenosis.,PLAN: ,Overnight observation in ICU. Start aspirin, Plavix, beta-blocker and ACE inhibitor. Check serial cardiac enzymes. Further recommendations to follow. Check fasting lipid panel, in addition add a statin. Further recommendations to follow.

Cardiac Catheterization - 10

Cardiovascular / Pulmonary

Modified Barium swallow study evaluation to objectively evaluate 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 chocking with meals.

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 chocking with meals. The patient's complete medical history is unknown to me at this time. The patient was cooperative and compliant throughout this evaluation.,STUDY:, Modified barium swallow study was performed in the Radiology Suite in cooperation with Dr. X. The patient was seated upright at a 90-degree angle in a video imaging chair. To evaluate her swallowing function and safety, she was administered graduated amounts of food and liquid mixed with barium in the form of thin liquids (teaspoon x3. cup sip x4); thickened liquid (cup sip x3); puree consistency (teaspoon x3); and solid consistency (1/4 cracker x1). The patient was given 2 additional cup sips of thin liquid following the puree and solid food presentation.,ORAL STAGE: ,The patient had no difficulty with bolus control and transport. No spillage out lips. The patient appears to have pocketing __________ particularly with puree and solid food between her right faucial pillars. The patient did state that she had her tonsil taken out as a child and appears to be a diverticulum located in this state. Further evaluation by an ENT is highly recommended based on the residual and pooling that occurred during this evaluation. We were not able to clear out the residual with alternating cup sips and thin liquid.,PHARYNGEAL STAGE: ,No aspiration or penetration occurred during this evaluation. The patient's hyolaryngeal elevation and anterior movements are within the functional limits. Epiglottic inversion is within functional limits. She had no residual or pooling in the pharynx after the swallow.,CERVICAL ESOPHAGEAL STAGE: ,The patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus.,DIAGNOSTIC IMPRESSION: ,The patient had no aspiration or penetration occurred during this evaluation. She does appear to have a diverticulum in the area between her right faucial pillars. Additional evaluation is needed by an ENT physician.,PLAN: ,Based on this evaluation, the following is recommended:,1. The patient's diet should consist regular consistency food with thin liquids. She needs to take small bites and small sips to help decrease her risk of aspiration and penetration as well as reflux.,2. The patient should be referred to an otolaryngologist for further evaluation of her oral cavity particularly the area between her faucial pillars.,The above recommendations and results of the evaluation were discussed with the patient as well as her daughter and both responded appropriately.,Thank you for the opportunity to be required the patient's medical care. She is not in need of skilled speech therapy and is discharged from my services.

Barium Swallow Study Evaluation

Gastroenterology

gastroenterology, globus sensation, oral stage, pharyngeal stage, cervical esophageal stage, consistency, otolaryngologist, barium swallow study evaluation, faucial pillars, swallow study, solid foods, evaluation, liquid, barium, oral, swallow, foods,

Closure of gastrostomy placed due to feeding difficulties.

PREOPERATIVE DIAGNOSIS: , Gastrostomy (gastrocutaneous fistula).,POSTOPERATIVE DIAGNOSIS: , Gastrostomy (gastrocutaneous fistula).,OPERATION PERFORMED: , Surgical closure of gastrostomy.,ANESTHESIA: , General.,INDICATIONS: , This 1-year-old child had a gastrostomy placed due to feeding difficulties. Since then, he has reached a point where he is now eating completely by mouth and no longer needed the gastrostomy. The tube was, therefore, removed, but the tract has not shown signs of spontaneous closure. He, therefore, comes to the operating room today for surgical closure of his gastrostomy.,OPERATIVE PROCEDURE: , After the induction of general anesthetic, the abdomen was prepped and draped in the usual manner. An elliptical incision was made around the gastrostomy site and carried down through skin and subcutaneous tissue with sharp dissection. The tract and the stomach were freed. Stay sutures were then placed on either side of the tract. The tract was amputated. The intervening stomach was then closed with interrupted #4-0 Lembert, Nurolon sutures. The fascia was then closed over the stomach using #3-0 Vicryl sutures. The skin was closed with #5-0 subcuticular Monocryl. A dressing was applied, and the child was awakened and taken to the recovery room in satisfactory condition.

Surgical Closure of Gastrostomy

Gastroenterology

gastroenterology, gastrocutaneous fistula, nurolon, closure of gastrostomy, feeding difficulties, surgical closure, gastrostomy

Encephalopathy related to normal-pressure hydrocephalus.

ADMITTING DIAGNOSIS: , Encephalopathy related to normal-pressure hydrocephalus.,CHIEF COMPLAINT:, Diminished function secondary to above.,HISTORY: ,This pleasant gentleman was recently admitted to ABCD Medical Center and followed by the neurosurgical staff, including Dr. X, where normal-pressure hydrocephalus was diagnosed. He had a shunt placed and was stabilized medically. He has gotten a return of function to the legs and was started on some early therapy. Significant functional limitations have been identified and ongoing by the rehab admission team. Significant functional limitations have been ongoing. He will need to be near-independent at home for periods of time, and he is brought in now for rehabilitation to further address functional issues, maximize skills and safety and allow a safe disposition home.,PAST MEDICAL HISTORY: , Positive for prostate cancer, intermittent urinary incontinence and left hip replacement.,ALLERGIES: , No known drug allergies.,CURRENT MEDICATIONS,1. Tylenol as needed. ,2. Peri-Colace b.i.d.,SOCIAL HISTORY:, He is a nonsmoker and nondrinker. Prior boxer. He lives in a home where he would need to be independent during the day. Family relatives intermittently available. Goal is to return home to an independent fashion to that home setting.,FUNCTIONAL HISTORY: , Prior to admission was independent with activities of daily living and ambulatory skills. Presently, he has resumed therapies and noted to have supervision levels for most activities of daily living. Memory at minimal assist. Walking at supervision., REVIEW OF SYSTEMS: ,Negative for headaches, nausea, vomiting, fevers, chills, shortness of breath or chest pain currently. He has had some dyscoordination recently and headaches on a daily basis, most days, although the Tylenol does seem to control that pain.,PHYSICAL EXAMINATION,VITAL SIGNS: The patient is afebrile with vital signs stable.,HEENT: Oropharynx clear, extraocular muscles are intact.,CARDIOVASCULAR: Regular rate and rhythm, without murmurs, rubs or gallops.,LUNGS: Clear to auscultation bilaterally.,ABDOMEN: Nontender, nondistended, positive bowel sounds.,EXTREMITIES: Without clubbing, cyanosis, or edema. The calves are soft and nontender bilaterally.,NEUROLOGIC: No focal, motor or sensory losses through the lower extremities. He moves upper and lower extremities well. Bulk and tone normal in the upper and lower extremities. Cognitively showing intact with appropriate receptive and expressive skills.,IMPRESSION ,

Encephalopathy - Rehab Consult

Neurology

The patient is a 58-year-old female, referred to therapy due to left knee osteoarthritis. The patient states that approximately 2 years ago, she fell to the ground and thereafter had blood clots in the knee area. The patient was transferred from the hospital to a nursing home and lived there for 1 year. The patient states that her primary concern is her left knee pain and they desire to walk short distances again in her home.

DIAGNOSIS: , Left knee osteoarthritis.,HISTORY: , The patient is a 58-year-old female, referred to therapy due to left knee osteoarthritis. The patient states that approximately 2 years ago, she fell to the ground and thereafter had blood clots in the knee area. The patient was transferred from the hospital to a nursing home and lived there for 1 year. Prior to this incident, the patient was ambulating independently with a pickup walker throughout her home. Since that time, the patient has only been performing transverse and has been unable to ambulate. The patient states that her primary concern is her left knee pain and they desire to walk short distances again in her home.,PAST MEDICAL HISTORY: , High blood pressure, obesity, right patellar fracture with pin in 1990, and history of blood clots.,MEDICATIONS: ,Naproxen, Plavix, and stool softener.,MEDICAL DIAGNOSTICS: , The patient states that she had an x-ray of the knee in 2007 and was diagnosed with osteoarthritis.,SUBJECTIVE:, The patient reports that when seated and at rest, her knee pain is 0/10. The patient states that with active motion of the left knee, the pain in the anterior portion increases to 5/10.,PATIENT'S GOAL: , To transfer better and walk 5 feet from her bed to the couch.,INSPECTION: , The right knee has a large 8-inch long and very wide tight scar with adhesions to the underlying connective tissue due to her patellar fracture and surgery following an MVA in 1990, bilateral knees are very large due to obesity. There are no scars, bruising or increased temperature noted in the left knee.,RANGE OF MOTION: , Active and passive range of motion of the right knee is 0 to 90 degrees and the left knee, 0 to 85 degrees. Pain is elicited during active range of motion of the left knee.,PALPATION: , Palpation to the left knee elicits pain around the patellar tendon and to each side of this area.,FUNCTIONAL MOBILITY: ,The patient reports that she transfers with standby to contact-guard assist in the home from her bed to her wheelchair and return. The patient is able to stand modified independent from wheelchair level and tolerates at least 15 seconds of standing prior to needing to sit down due to the left knee pain.,ASSESSMENT: ,The patient is a 58-year-old female with left knee osteoarthritis. Examination indicates deficits in pain, muscle endurance, and functional mobility. The patient would benefit from skilled physical therapy to address these impairments.,TREATMENT PLAN: ,The patient will be seen two times per week for an initial 4 weeks with re-assessment at that time for an additional 4 weeks if needed.,INTERVENTIONS INCLUDE:,1. Modalities including electrical stimulation, ultrasound, heat, and ice.,2. Therapeutic exercise.,3. Functional mobility training.,4. Gait training.,LONG-TERM GOALS TO BE ACHIEVED IN 4 WEEKS:,1. The patient is to have increased endurance in bilateral lower extremities as demonstrated by being able to perform 20 repetitions of all lower extremity exercises in seated and supine positions with minimum 2-pound weight.,2. The patient is to perform standby assist transfer using a pickup walker.,3. The patient is to demonstrate 4 steps of ambulation using forward and backward using a pickup walker or front-wheeled walker.,4. The patient is to report maximum 3/10 pain with weightbearing of 2 minutes in the left knee.,LONG-TERM GOALS TO BE ACHIEVED IN 8 WEEKS:,1. The patient is to be independent with the home exercise program.,2. The patient is to tolerate 20 reps of standing exercises with pain maximum of 3/10.,3. The patient is to ambulate 20 feet with the most appropriate assistive device.,PROGNOSIS TO THE ABOVE-STATED GOALS:, Fair to good.,The above treatment plan has been discussed with the patient. She is in agreement.

Physical Therapy - Osteoarthritis

Orthopedic

Open reduction and internal fixation, high grade Frykman VIII distal radius fracture.

PREOPERATIVE DIAGNOSIS: , Severely comminuted fracture of the distal radius, left.,POSTOPERATIVE DIAGNOSIS: , Severely comminuted fracture of the distal radius, left.,OPERATIVE PROCEDURE: ,Open reduction and internal fixation, high grade Frykman VIII distal radius fracture.,ANESTHESIA: , General endotracheal.,PREOPERATIVE INDICATIONS: , This is a 52-year-old patient of mine who I have repaired both shoulder rotator cuffs, the most recent one in the calendar year 2007. While he was climbing a ladder recently in the immediate postop stage, he fell suffering the aforementioned heavily comminuted Frykman fracture. This fracture had a fragment that extended in the distal radial ulnar joint, a die-punch fragment in the center of the radius. The ulnar styloid and the radial styloid were off and there were severe dorsal comminutions. He presented to my office the morning of April 3, 2007, having had a left reduction done elsewhere a day ago. The reduction, although adequate, had allowed for the fragments to settle and I discussed with him the severity of the injury on a scale of 1-8, this was essentially an 8. The best results have been either with external fixation or internal fixation, most recently volar plating of a locking variety has been popular, and I felt that this would be appropriate in his case.,Risks and benefits otherwise described were bleeding, infection, need to do operative revise or removal of hardware. He is taking a job out of state in the next couple of months. Hence I felt that even with close followup, this is a particularly difficult fracture as far as the morbidity of the injury proceeds.,OPERATIVE NOTE: , After adequate general endotracheal anesthesia was obtained, one gram of Ancef was given intravenously. The left upper extremity was prepped and draped in supine position with the left hand in the arm table, magnification was used throughout. The time out procedure was done to the satisfaction of all present that this was indeed the appropriate extremity on the appropriate patient. A small C-arm was brought in to help guide the incision which was a volar curvilinear incision that included as part of this due to the fracture blisters eminent compartment syndrome and numbness in fingers. A carpal tunnel release was done with the transverse carpal ligament being protected with a Freer elevator. The usual amount of dissection of the pronator quadratus was necessary to view the distal radial fragment. The pronator quadratus actually grasped several of the fragments itself which had to be dissected free from them, specifically the distal radial ulnar joint and die-punch fragment. At this point, a locking Synthes distal radius plate from the modular handset was selected that had five articular screws as well as five locking shaft screws. The ulnar styloid was not affixed in any portion of this repair. The plate was viewed under the image intensification device, i.e., x-ray and the screws were placed in this order. The most proximal shaft screw was placed to allow the remainder of the plate to form a buttress to then rearrange the fragments around the locking screws and a locking plate having been selected from the volar approach, a locking 12-mm screw through 16-mm screws were placed in the following order. Most proximal on the radial shaft of the plate, then the radial styloid, i.e., the most distal and lateral screw, the next most proximal shaft screw followed by the distal radial ulnar joint screw. Three screws were locking across the die-punch fragment. The remaining two screws were placed into the radial shaft. All of these were locking screws of 2 mm in diameter and as the construct was created, the relative motion of the intra-articular fragment in dorsal comminution all diminished greatly, although the exposure as well as the amount of reduction force used was substantial. The tourniquet time was 1.5 hours. At this point, the tourniquet was let down. The entire construct was irrigated with copious amounts of bacitracin and normal saline. Closure was affected with 0 Vicryl underneath the skin surface followed by 3-0 Prolene in interrupted sutures in the volar wound. Several image intensification x-rays were taken at the conclusion of the case to check screw length. Screw lengths were changed out during the case as needed based on the x-ray findings. The wound was injected with Marcaine, lidocaine, Depo-Medrol, and Kantrex. A very heavily padded fluffy cotton Jones-type dressing was applied with a volar splint. Estimated blood loss was 10 mL. There were no specimens. Tourniquet time was 1.5 hours.

ORIF - 2

Orthopedic

orthopedic, distal radius, c-arm, depo-medrol, frykman, jones-type dressing, kantrex, marcaine, open reduction and internal fixation, die-punch, intra-articular, lidocaine, pronator quadratus, radial styloid, ulnar styloid, distal radial ulnar joint, radial ulnar joint, distal, screws, orif, fracture, radial

Anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray. Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy and moderate stenosis C5-6.

FINAL DIAGNOSES:,1. Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy.,2. Moderate stenosis C5-6.,OPERATION: , On 06/25/07, anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray.,This is a 60-year-old white male who was in the office on 05/01/07 because of neck pain with left radiculopathy and "tension headaches." In the last year or so, he has had more and more difficulty and more recently has developed tingling and numbness into the fingers of the left hand greater than right. He has some neck pain at times and has seen Dr. X for an epidural steroid injection, which was very helpful. More recently he saw Dr. Y and went through some physical therapy without much relief.,Cervical MRI scan was obtained and revealed a large right-sided disc herniation at C4-5 with significant midline herniations at C5-6 and a large left HNP at C6-7. In view of the multiple levels of pathology, I was not confident that anything short of surgical intervention would give him significant relief. The procedure and its risk were fully discussed and he decided to proceed with the operation.,HOSPITAL COURSE: , Following admission, the procedure was carried out without difficulty. Blood loss was about 125 cc. Postop x-ray showed good alignment and positioning of the cages, plate, and screws. After surgery, he was able to slowly increase his activity level with assistance from physical therapy. He had some muscle spasm and soreness between the shoulder blades and into the back part of his neck. He also had some nausea with the PCA. He had a low-grade fever to 100.2 and was started on incentive spirometry. Over the next 12 hours, his fever resolved and he was able to start getting up and around much more easily.,By 06/27/07, he was ready to go home. He has been counseled regarding wound care and has received a neck sheet for instruction. He will be seen in two weeks for wound check and for a followup evaluation/x-rays in about six weeks. He has prescriptions for Lortab 7.5 mg and Robaxin 750 mg. He is to call if there are any problems.

Anterior Cervical Discectomy & Fusion - Discharge Summary

Orthopedic

orthopedic, slimlock, herniated nucleuses pulposus, anterior cervical discectomy, bengal cages, anterior, herniated, cervical, radiculopathy, discectomy,

Suction dilation and curettage for incomplete abortion. On bimanual exam, the patient has approximately 15-week anteverted, mobile uterus with the cervix that is dilated to approximately 2 cm with multiple blood colts in the vagina. There was a large amount of tissue obtained on the procedure.

PREOPERATIVE DIAGNOSIS: ,Incomplete abortion.,POSTOPERATIVE DIAGNOSIS: ,Incomplete abortion.,PROCEDURE PERFORMED:, Suction dilation and curettage.,ANESTHESIA: ,General and nonendotracheal by Dr. X.,ESTIMATED BLOOD LOSS: , Less than 200 cc.,SPECIMENS: , Endometrial curettings.,DRAINS: , None.,FINDINGS: ,On bimanual exam, the patient has approximately 15-week anteverted, mobile uterus with the cervix that is dilated to approximately 2 cm with multiple blood colts in the vagina. There was a large amount of tissue obtained on the procedure.,PROCEDURE: ,The patient was taken to the operating room where a general anesthetic was administered. She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion. Once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic. Next, a weighted speculum was placed in the vagina. The anterior lip of cervix was grasped with the vulsellum tenaculum and due to the patient already being dilated approximately 2 cm, no cervical dilation was needed. A size 12 straight suction curette was used and connected to the suction and was placed in the cervix and a suction curettage was performed. Two passes were made with the suction curettage. Next, a sharp curettage was performed obtaining a small amount of tissue and this was followed by third suction curettage and then a final sharp curettage was performed, which revealed a good uterine cry on all sides of the uterus. After the procedure, the vulsellum tenaculum was removed. The cervix was seemed to be hemostatic. The weighted speculum was removed. The patient was given 0.25 mg of Methergine IM approximately half-way through the procedure. After the procedure, a second bimanual exam was performed and the patient's uterus had significantly decreased in size. It is now approximately eight to ten-week size. The patient was taken from the operating room in stable condition after she was cleaned. She will be discharged on today. She was given Methergine, Motrin, and doxycycline for her postoperative care. She will follow-up in one week in the office.

Suction, Dilation, & Curettage - 1

Obstetrics / Gynecology

obstetrics / gynecology, uterus, anteverted, dorsal lithotomy position, weighted speculum, mobile uterus, vulsellum tenaculum, bimanual exam, vagina, tenaculum, dilation, bimanual, cervix, suction, curettage,

Patient with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia.

REASON FOR CONSULTATION:, Atrial fibrillation.,HISTORY OF PRESENT ILLNESS:, The patient is a 78-year-old, Hispanic woman with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia. Apparently, the patient is a resident of Lake Harris Port Square long-term facility after her stroke. She was found to have confusion while in her facility. She then came to the emergency room and found to have a right sided acute stroke. 12-lead EKG performed on August 10, 2009, found to have atrial fibrillation. Telemetry also revealed atrial fibrillation with rapid ventricular response. Currently, the telemetry is normal sinus rhythm. Because of the finding of atrial fibrillation, cardiology was consulted.,The patient is a poor historian. She did not recall why she is in the hospital, she said she had a stroke. She reported no chest discomfort, no shortness of breath, no palpitations.,The following information was obtained from the patient's chart:,PAST MEDICAL HISTORY:,1. Coronary artery disease status post bypass grafting surgery. Unable to obtain the place, location, anatomy, and the year it was performed.,2. Carotid artery stenosis status post right carotid artery stenting. Again, the time was unknown.,3. Diabetes.,4. Hypertension.,5. Hyperlipidemia.,6. History of stroke with left side hemiplegia.,ALLERGIES: , No known drug allergies.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:, The patient is a resident of Lake Harris Port Square. She has no history of alcohol use.,CURRENT MEDICATIONS: , Please see attached list including hydralazine, Celebrex, Colace, metformin, aspirin, potassium, Lasix, Levaquin, Norvasc, insulin, Plavix, lisinopril, and Zocor.,REVIEW OF SYSTEMS: , Unable to obtain.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 133/44, pulse 98, O2 saturation is 98% on room air. Temperature 99, respiratory rate 16.,GENERAL: The patient is sitting in the chair at bedside. Appears comfortable. Left facial droop. Left side hemiplegia.,HEAD AND NECK: No JVP seen. Right side carotid bruit heard.,CHEST: Clear to auscultation bilaterally.,CARDIOVASCULAR: PMI not displaced, regular rhythm. Normal S1 and S2. Positive S4. There is a 2/6 systolic murmur best heard at the left lower sternal border.,ABDOMEN: Soft.,EXTREMITIES: Not edematous.,DATA:, A 12-lead EKG performed on August 9, 2009, revealed atrial fibrillation with a ventricular rate of 96 beats per minute, nonspecific ST wave abnormality.,Review of telemetry done the last few days, currently the patient is in normal sinus rhythm at the rate of 60 beats per minute. Atrial fibrillation was noted on admission noted August 8 and August 10; however, there was normal sinus rhythm on August 10.,LABORATORY DATA: , WBC 7.2, hemoglobin 11.7. The patient's hemoglobin was 8.2 a few days ago before blood transfusion. Chemistry-7 within normal limits. Lipid profile: Triglycerides 64, total cholesterol 106, HDL 26, LDL 17. Liver function tests are within normal limits. INR was 1.1.,A 2D echo was performed on August 11, 2009, and revealed left ventricle normal in size with EF of 50%. Mild apical hypokinesis. Mild dilated left atrium. Mild aortic regurgitation, mitral regurgitation, and tricuspid regurgitation. No intracardiac masses or thrombus were noted. The aortic root was normal in size.,ASSESSMENT AND RECOMMENDATIONS:,1. Paroxysmal atrial fibrillation. It is unknown if this is a new onset versus a paroxysmal atrial fibrillation. Given the patient has a recurrent stroke, anticoagulation with Coumadin to prevent further stroke is indicated. However, given the patient's current neurologic status, the safety of falling is unclear. We need to further discuss with the patient's primary care physician, probably rehab physician. If the patient's risk of falling is low, then Coumadin is indicated. However, if the patient's risk for falling is high, then a course using aspirin and Plavix will be recommended. Transesophageal echocardiogram probably will delineate possible intracardiac thrombus better, however will not change our current management. Therefore, I will not recommend transesophageal echocardiogram at this point. Currently, the patient's heart rate is well controlled, antiarrhythmic agent is not recommended at this point.,2. Carotid artery stenosis. The patient underwent a carotid Doppler ultrasound on this admission and found to have a high-grade increased velocity of the right internal carotid artery. It is difficult to assess the severity of the stenosis given the history of possible right carotid stenting. If clinically indicated, CT angio of the carotid will be indicated to assess for stent patency. However, given the patient's current acute stroke, revascularization is not indicated at this time.,3. Coronary artery disease. Clinically stable. No further test is indicated at this time.

Consult - Atrial Fibrillation

Cardiovascular / Pulmonary

Left heart catheterization, left ventriculography, selective coronary angiography, and right femoral artery approach.

PROCEDURE: , Cardiac catheterization by:,a. Left heart catheterization.,b. Left ventriculography.,c. Selective coronary angiography.,d. Right femoral artery approach.,COMPLICATIONS:, None.,MEDICATIONS,1. IV Versed.,2. IV fentanyl.,3. Intravenous fluid administration.,4. Heparin 3000 units IV.,INDICATIONS: , This 70-year-old Asian-American presents with chest pain syndrome, abnormal EKG suggesting an acute ST elevation, anterior myocardial infarction, being taken urgently to cardiac catheterization laboratory with possible coronary intervention.,NARRATIVE: , After detailed informed consent had been obtained. Usual benefits, alternatives, and risks of the procedure had been discussed with the patient, she was agreeable to proceed. The patient was prepped, draped, and anesthetized in the usual manner. Using modified Seldinger technique a 6 French introducer sheath inserted into the right femoral artery. Next, 6 French 3D right coronary catheter was inserted and right coronary angiogram was obtained in various projections. Next, a 6 French JL4.0 left coronary catheter was inserted and left coronary angiogram was obtained in various projections. Next, 4 French pigtail catheter was inserted into left ventricle under fluoroscopic guidance. Left ventricular angiogram was performed. Pre and post angiogram LVEDP, LV, and aortic pressures were obtained. At the end of the procedure catheters were removed and the introducer sheath was secured. The patient was admitted to the TCU in stable condition.,FINDINGS,HEMODYNAMICS,LEFT HEART PRESSURES:, LVEDP of 5, left ventricular systolic pressure of 81, central aortic pressure systolic 70, diastolic 20.,LEFT VENTRICULOGRAPHY: , Left ventricular chamber size is normal. The distal half of the anterior wall of the entire apex and the distal half of the inferior wall are completely akinetic with hypercontractility of the basilar segments of the anterior and inferior wall. Calculated ejection fraction of 51%, which probably overestimates the overall effective ejection fraction. No LV thrombus or mitral regurgitation present.,CORONARY ARTERIOGRAPHY,1. ,RIGHT CORONARY ARTERY: , The RCA gives rise to a posterior descending artery and a small posterolateral branch. Angiographically the right coronary artery is normal.,2. ,LEFT MAIN ARTERY:, The left main vessel is angiographically normal, bifurcates into left anterior descending artery and circumflex system.,3. ,LEFT ANTERIOR DESCENDING ARTERY: , The LAD gives rise to a normal complement of septal branches, diagonal branches, and extends around the apex. Angiographically the mid left anterior descending artery and distal left anterior descending artery demonstrates systolic compression of the vessel lumen, consistent with myocardial bridging. The degree of myocardial bridging appears moderate in the mid vessel and mild in the distal segment. Otherwise, there is no evidence of atherosclerotic obstruction.,4. ,CIRCUMFLEX ARTERY: , The circumflex gives rise to two large extremely tortuous marginal vessels that extend towards the apex. Angiographically, the circumflex artery is normal.,CONCLUSION: , This is a 70-year-old female with above clinical and cardiovascular history, who has angiographic evidence of a large anterior apical and inferior apical wall motion abnormality with angiographically patent coronary arteries with two segments of myocardial bridging involving the mid and distal left anterior descending artery. These angiographic findings are consistent with Takasubo syndrome, aka apical ballooning syndrome. The patient will be treated medically.

Heart Catheterization, Ventriculography, & Angiography - 12

Cardiovascular / Pulmonary

A 26-mm Dacron graft replacement of type 4 thoracoabdominal aneurysm from T10 to the bifurcation of the aorta, re-implanting the celiac, superior mesenteric artery and right renal as an island and the left renal as a 8-mm interposition Dacron graft, utilizing left heart bypass and cerebrospinal fluid drainage.

POSTOPERATIVE DIAGNOSIS: , Type 4 thoracoabdominal aneurysm.,OPERATION/PROCEDURE: , A 26-mm Dacron graft replacement of type 4 thoracoabdominal aneurysm from T10 to the bifurcation of the aorta, re-implanting the celiac, superior mesenteric artery and right renal as an island and the left renal as a 8-mm interposition Dacron graft, utilizing left heart bypass and cerebrospinal fluid drainage.,DESCRIPTION OF PROCEDURE IN DETAIL: , Patient was brought to the operating room and put in supine position, and general endotracheal anesthesia was induced through a double-lumen endotracheal tube. Patient was placed in the thoracoabdominal position with the left chest up and the hips back to a 30-degree angle. The left groin, abdominal and chest were prepped and draped in a sterile fashion. A thoracoabdominal incision was made. The 8th interspace was entered. The costal margin was divided. The retroperitoneal space was entered and bluntly dissected free to the psoas, bringing all the peritoneal contents to the midline, exposing the aorta. The inferior pulmonary ligament was then taken down so the aorta could be dissected free at the T10 level just above the diaphragm. It was dissected free circumferentially. The aortic bifurcation was dissected free, dissecting free both iliac arteries. The left inferior pulmonary vein was then dissected free, and a pursestring of 4-0 Prolene was placed on this. The patient was heparinized. Through a stab wound in the center of this, a right-angle venous cannula was then placed at the left atrium and secured to a Rumel tourniquet. This was hooked to a venous inflow of left heart bypass machine. A pursestring of 4-0 Prolene was placed on the aneurysm and through a stab wound in the center of this, an arterial cannula was placed and hooked to outflow. Bypass was instituted. The aneurysm was cross clamped just above T10 and also, cross clamped just below the diaphragm. The area was divided at this point. A 26-mm graft was then sutured in place with running 3-0 Prolene suture. The graft was brought into the diaphragm. Clamps were then placed on the iliacs, and the pump was shut off. The aorta was opened longitudinally, going posterior between the left and right renal arteries, and it was completely transected at its bifurcation. The SMA, celiac and right renal artery were then dissected free as a complete island, and the left renal was dissected free as a complete Carrell patch. The island was laid in the graft for the visceral liner, and it was sutured in place with running 4-0 Prolene suture with pledgetted 4-0 Prolene sutures around the circumference. The clamp was then moved below the visceral vessels, and the clamp on the chest was removed, re-establishing flow to the visceral vessels. The graft was cut to fit the bifurcation and sutured in place with running 3-0 Prolene suture. All clamps were removed, and flow was re-established. An 8-mm graft was sutured end-to-end to the Carrell patch and to the left renal. A partial-occlusion clamp was placed. An area of graft was removed. The end of the graft was cut to fit this and sutured in place with running Prolene suture. The partial-occlusion clamp was removed. Protamine was given. Good hemostasis was noted. The arterial cannula, of course, had been removed when that part of the aneurysm was removed. The venous cannula was removed and oversewn with a 4-0 Prolene suture. Good hemostasis was noted. A 36 French posterior and a 32 French anterior chest tube were placed. The ribs were closed with figure-of-eight #2 Vicryl. The fascial layer was closed with running #1 Prolene, subcu with running 2-0 Dexon and the skin with running 4-0 Dexon subcuticular stitch. Patient tolerated the procedure well.

Thoracoabdominal Aneurysm

Cardiovascular / Pulmonary

cardiovascular / pulmonary, dacron graft, thoracoabdominal, cerebrospinal, thoracoabdominal aneurysm, running prolene, prolene suture, dissected free, graft, interposition, aneurysm, dacron, cannula, bifurcation, aorta, endotracheal, proleneNOTE

A complex closure and debridement of wound. The patient is a 26-year-old female with a long history of shunt and hydrocephalus presenting with a draining wound in the right upper quadrant, just below the costal margin that was lanced by General Surgery and resolved; however, it continued to drain.

TITLE OF OPERATION:, A complex closure and debridement of wound.,INDICATION FOR SURGERY:, The patient is a 26-year-old female with a long history of shunt and hydrocephalus presenting with a draining wound in the right upper quadrant, just below the costal margin that was lanced by General Surgery and resolved; however, it continued to drain. There is no evidence of fevers. CRP was normal. Shunt CT were all normal. The thought was he has insidious fistula versus tract where recommendation was for excision of this tract.,PREOP DIAGNOSIS: , Possible cerebrospinal fluid versus wound fistula.,POSTOP DIAGNOSIS: , Possible cerebrospinal fluid versus wound fistula.,PROCEDURE DETAIL: , The patient was brought to the operating room and willing to be inducted with a laryngeal mask airway, positioned supine and the right side was prepped and draped in the usual sterile fashion. Next, working on the fistula, this was elliptically excised. Once this was excised, this was followed down to the fistulous tract, which was completely removed. There was no CSF drainage. The catheter was visualized, although not adequately properly. Once this was excised, it was irrigated and then closed in multiple layers using 3-0 Vicryl for the deep layers and 4-0 Caprosyn and Indermil with a dry sterile dressing applied. The patient was reversed, extubated and transferred to the recovery room in stable condition. Multiple cultures were sent as well as the tracts sent to Pathology. All sponge and needle counts were correct.

Wound Closure & Debridement - Hydrocephalus

Neurosurgery

neurosurgery, debridement of wound, shunt, costal margin, cerebrospinal fluid, cerebrospinal, closure, debridement, hydrocephalus, surgery, draining, fistula, wound,

Patient with complaints of significant coughing and wheezing.

PAST MEDICAL HISTORY:, Unremarkable, except for diabetes and atherosclerotic vascular disease.,ALLERGIES:, PENICILLIN.,CURRENT MEDICATIONS:, Include Glucovance, Seroquel, Flomax, and Nexium.,PAST SURGICAL HISTORY: , Appendectomy and exploratory laparotomy.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: ,The patient is a non-smoker. No alcohol abuse. The patient is married with no children.,REVIEW OF SYSTEMS:, Significant for an old CVA.,PHYSICAL EXAMINATION:, The patient is an elderly male alert and cooperative. Blood pressure 96/60 mmHg. Respirations were 20. Pulse 94. Afebrile. O2 was 94% on room air. HEENT: Normocephalic and atraumatic. Pupils are reactive. Oral mucosa is grossly normal. Neck is supple. Lungs: Decreased breath sounds. Disturbed breath sounds with poor exchange. Heart: Regular rhythm. Abdomen: Soft and nontender. No organomegaly or masses. Extremities: No cyanosis, clubbing, or edema.,LABORATORY DATA: , Oropharyngeal evaluation done on 11/02/2006 revealed mild oropharyngeal dysphagia with no evidence of laryngeal penetration or aspiration with food or liquid. Slight reduction in tongue retraction resulting in mild residual remaining in the palatal sinuses, which clear with liquid swallow and double-saliva swallow.,ASSESSMENT:,1. Cough probably multifactorial combination of gastroesophageal reflux and recurrent aspiration.,2. Old CVA with left hemiparesis.,3. Oropharyngeal dysphagia.,4. Diabetes.,PLAN:, At the present time, the patient is recommended to continue on a regular diet, continue speech pathology evaluation as well as perform double-swallow during meals with bolus sensation. He may use Italian lemon ice during meals to help clear sinuses as well. The patient will follow up with you. If you need any further assistance, do not hesitate to call me.

Pulmonary Consultation - 2

Cardiovascular / Pulmonary

cardiovascular / pulmonary, pulmonary evaluation, cough, wheezing, congestion, coughing and wheezing, breath sounds, oropharyngeal dysphagia, pulmonary, breath, sounds, dysphagia, aspiration, sinuses, oropharyngeal, coughing, swallowing,

History and Physical for right ankle sprain

CHIEF COMPLAINT:, Right ankle sprain.,HISTORY OF PRESENT ILLNESS: , This is a 56-year-old female who fell on November 26, 2007 at 11:30 a.m. while at work. She did not recall the specifics of her injury but she thinks that her right foot inverted and subsequently noticed pain in the right ankle. She describes no other injury at this time.,PAST MEDICAL HISTORY: , Hypertension and anxiety.,PAST SURGICAL HISTORY: , None.,MEDICATIONS: , She takes Lexapro and a blood pressure pill, but does not know anything more about the names and the doses.,ALLERGIES:, No known drug allergies.,SOCIAL HISTORY: , The patient lives here locally. She does not report any significant alcohol or illicit drug use. She works full time.,FAMILY HISTORY:, Noncontributory.,REVIEW OF SYSTEMS:,Pulm: No cough, No wheezing, No shortness of breath,CV: No chest pain or palpitations,GI: No abdominal pain. No nausea, vomiting, or diarrhea.,PHYSICAL EXAM:,GENERAL APPEARANCE: No acute distress,VITAL SIGNS: Temperature 97.8, blood pressure 122/74, heart rate 76, respirations 24, weight 250 lbs, O2 sat 95% on R.A.,NECK: Supple. No lymphadenopathy. No thyromegaly.,CHEST: Clear to auscultation bilaterally.,HEART: Regular rate and rhythm. No murmurs.,ABDOMEN: Non-distended, nontender, normal active bowel sounds.,EXTREMITIES: No Clubbing, No Cyanosis, No edema.,MUSCULOSKELETAL: The spine is straight and there is no significant muscle spasm or tenderness there. Both knees appear to be non-traumatic with no deformity or significant tenderness. The right ankle has some swelling just below the right lateral malleolus and the dorsum of the foot is tender. There is decreased range of motion and some mild ecchymosis noted around the ankle.,DIAGNOSTIC DATA: , X-ray of the right ankle reveals no acute fracture by my observation. Radiologic interpretation is pending., ,IMPRESSION:, Right ankle sprain.,PLAN:,1. Motrin 800 mg t.i.d.,2. Tylenol 1 gm q.i.d. as needed.,3. Walking cast is prescribed.,4. I told the patient to call back if any problems. The next morning she called back complaining of worsening pain and I called in some Vicodin ES 1-2 p.o. q. 8 hours p.r.n. pain #60 with no refills.

Ankle Sprain - H&P

Orthopedic

Insertion of right subclavian central venous catheter. Need for intravenous access, status post fall, and status post incision and drainage of left lower extremity.

PREOPERATIVE DIAGNOSES:,1. Need for intravenous access.,2. Status post fall.,3. Status post incision and drainage of left lower extremity.,POSTOPERATIVE DIAGNOSES:,1. Need for intravenous access.,2. Status post fall.,3. Status post incision and drainage of left lower extremity.,PROCEDURE PERFORMED: , Insertion of right subclavian central venous catheter.,SECOND ANESTHESIA: , Approximately 10 cc of 1% lidocaine.,ESTIMATED BLOOD LOSS: , Minimal.,INDICATIONS FOR PROCEDURE: ,The patient is a 74-year-old white female who presents to ABCD General Hospital after falling down flight of eleven stairs and sustained numerous injuries. The patient went to OR today for an I&D of left lower extremity degloving injury. Orthopedics was planning on taking the patient back for serial debridements and need for reliable IV access is requested.,PROCEDURE: , Informed consent was obtained by the patient and her daughter. All risks and benefits of the procedure were explained and all questions were answered. The patient was prepped and draped in the normal sterile fashion. After landmarks were identified, approximately 5 cc of 1% lidocaine were injected into the skin and subcuticular tissues and the right neck posterior head of the sternocleidomastoid. Locator needle was used to correctly cannulate the right internal jugular vein. Multiple attempts were made and the right internal jugular vein was unable to be cannulized.,Therefore, we prepared for a right subclavian approach. The angle of the clavicle was found and a #22 gauge needle was used to anesthetize approximately 5 cc of 1% lidocaine in skin and subcuticular tissues along with the periosteum of the clavicle. A Cook catheter needle was then placed and ________ the clavicle in the orientation aimed toward the sternal notch. The right subclavian vein was then accessed. A guidewire was placed with a Cook needle and then the needle was subsequently removed and a #11 blade scalpel was used to nick the skin. A dilator sheath was placed over the guidewire and subsequently removed. The triple lumen catheter was then placed over the guidewire and advanced to 14 cm. All ports aspirated and flushed. Good blood return was noted and all ports were flushed well. The triple lumen catheter was then secured at 14 cm using #0 silk suture. A sterile dressing was then applied. A stat portable chest x-ray was ordered to check line placement. The patient tolerated the procedure well and there were no complications.

Subclavian Central Venous Catheter Insertion

Cardiovascular / Pulmonary

cardiovascular / pulmonary, intravenous access, incision and drainage, subclavian central venous catheter, central venous catheter, lower extremity, venous, intravenous, lidocaine, subclavian, needle, catheter, insertion

Synovitis - anterior cruciate ligament tear of the left knee. The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The patient fell in a grocery store. He reports slipping on a grape that was on the floor.

DIAGNOSIS:, Synovitis/anterior cruciate ligament tear of the left knee.,HISTORY: , The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The patient states that on 10/02/08, the patient fell in a grocery store. He reports slipping on a grape that was on the floor. The patient states he went to the emergency room and then followed up with his primary care physician. The patient was then ultimately referred to Physical Therapy. After receiving a knee brace, history and information was received through a translator as the patient is Spanish speaking only.,PAST MEDICAL HISTORY: , Past medical history is unremarkable.,MEDICAL IMAGING: , Medical imaging is significant for x-rays and MRIs. The report was available at the time of the evaluation. The patient reports abnormal posterior horn of medial meniscus consistent with knee degenerative change and possibly tears.,MEDICATIONS:,1. Tramadol.,2. Diclofenac.,3. Advil.,4. Tylenol.,SUBJECTIVE: , The patient rates his pain at 6/10 on the Pain Analog Scale, primarily with ambulation. The patient does deny pain at night. The patient does present with his knee brace on the exterior of his __________ leg and appears to be on backboard.,FUNCTIONAL ACTIVITIES AND HOBBIES: ,Functional activities and hobbies that are currently limited include any work as the patient is currently unemployed and is looking for a job; however, his primary skills are of a laborer and a street broker for new homes.,OBJECTIVE: ,Upon observation, the patient is ambulating with a significant antalgic gait pattern. However, he is not using any assistive device. The knee brace was corrected and the patient and his wife demonstrated understanding and knowledge of how to place the knee brace on correctly.,ACTIVE RANGE OF MOTION: , Active range of motion of the left knee is 0 to 105 degrees with pain during range of motion. Right knee active range of motion is 0 to 126 degrees.,STRENGTH: ,Strength is 3/5 for left knee, 4+/5 for right knee. The patient denies any pain upon light and deep palpation at the knee joints. There is no evidence of temperature change, increased swelling or any discoloration at the left knee joint. The patient does not appear to have instability at this time with formal tests at the left knee joint.,SPECIAL TESTS: ,The patient performed a six-minute walk test. He was able to complete 600 feet; however, had to stop this test at approximately five minutes, secondary to significant increase in pain.,ASSESSMENT:, The patient would benefit from skilled physical therapy intervention in order to address the following problem list:,1. Increased pain.,2. Decreased range of motion.,3. Decreased strength.,4. Decreased ability to perform functional activities and work tasks.,5. Decreased ambulation tolerance.,SHORT-TERM GOALS TO BE COMPLETED IN THREE WEEKS:,1. Patient will demonstrate independence with the home exercise program.,2. Patient will report maximum pain of 2/10 on a Pain Analog Scale within a 24-hour period.,3. The patient will demonstrate left knee active range of motion, 0 to 120 degrees, without significant increase in pain during motion.,4. The patient will demonstrate 4/5 strength for the left knee.,5. The patient will complete 800 feet in a six-minute walk test without significant increase in pain.,LONG-TERM GOALS TO BE COMPLETED IN SIX WEEKS:,1. The patient will demonstrate bilateral knee active range of motion, 0 to 130 degrees.,2. The patient will demonstrate 5/5 lower extremity strength bilaterally without significant increase in pain.,3. Patient will complete 1000 feet in a six-minute walk test without increase in pain and tolerate full completion of the six minutes.,4. The patient will improve confidence with ability to perform work activity, when the situation improves and resolves.,PROGNOSIS: ,Prognosis is good for above-stated goals, with compliance to a home exercise program and treatment.,SESSION PLAN: , The patient to be seen two to three times a week for six weeks for the following:,1. Therapeutic exercise with home exercise program.

Physical Therapy - Synovitis

Orthopedic

The patient is 14 months old, comes in with a chief complaint of difficulty breathing.

HISTORY:, The patient is 14 months old, comes in with a chief complaint of difficulty breathing. Difficulty breathing began last night. He was taken to Emergency Department where he got some Xopenex, given a prescription for amoxicillin and discharged home. They were home for about an hour when he began to get worse and they drove here to Children's Hospital. He has a history of reactive airway disease. He has been seen here twice in the last month on 10/04/2007 and 10/20/2007, both times with some wheezing. He was diagnosed with pneumonia back on 06/12/2007 here in the Emergency Department but was not admitted at that time. He has been on albuterol off and on over that period. He has had fever overnight. No vomiting, no diarrhea. Increased work of breathing with retractions and audible wheezes noted and thus brought to the Emergency Department. Normal urine output. No rashes have been seen.,PAST MEDICAL HISTORY: , As noted above. No hospitalizations, surgeries, allergies.,MEDICATIONS: , Xopenex.,IMMUNIZATIONS:, Up-to-date.,BIRTH HISTORY:, The child was full term, no complications, home with mom. No surgeries.,FAMILY HISTORY: , Negative.,SOCIAL HISTORY: , No smokers or pets in the home. No ill contacts, no travel, no change in living condition.,REVIEW OF SYSTEMS: , Ten are asked, all are negative, except as noted above.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temp 37.1, pulse 158, respiratory rate 48, 84% on room air indicating hypoxia.,GENERAL: The child is awake, alert, in moderate respiratory distress.,HEENT: Pupils equal, round, reactive to light. Extraocular movements are intact. The TMs are clear. The nares show some dry secretions. Audible congestion and wheezing is noted. Mucous membranes are dry. Throat is clear. No oral lesions noted.,NECK: Supple without lymphadenopathy or masses. Trachea is midline.,LUNGS: Show inspiratory and expiratory wheezes in all fields. Audible wheezes are noted. There are intercostal and subcostal retractions and suprasternal muscle use is noted.,HEART: Shows tachycardia. Regular rhythm. Normal S1, S2. No murmur.,ABDOMEN: Soft, nontender. Positive bowel sounds. No guarding. No rebound. No hepatosplenomegaly.,EXTREMITIES: Capillary refill is brisk. Good distal pulses.,NEUROLOGIC: Cranial nerves II through XII intact. Moves all 4 extremities equally and normally.,HOSPITAL COURSE: , The child has an IV placed. I felt the child was dehydrated on examination. We gave 20 mL/kg bolus of normal saline over one hour. The child was given Solu-Medrol 2 mg/kg IV. He was initially started on unit dose albuterol and Atrovent but high-dose albuterol for continuous nebulization was ordered.,A portable chest x-ray was done showing significant peribronchial thickening bilaterally. Normal heart size. No evidence of pneumothorax. No evidence of focal pneumonia. After 3 unit dose of albuterol/Atrovent breathing treatments, there was much better air exchange bilaterally but still with inspiratory/expiratory wheezes and high-dose continuous albuterol was started at that time. The child was monitored closely while on high-dose albuterol and slowly showed improvement resulting in only expiratory wheezes after one hour. The child's pulse ox on breathing treatments with 100% oxygen was 100%. Respiratory rate remained about 40 to 44 breaths per minute indicating tachypnea. The child's color improved with oxygen therapy, and the capillary refill was always less than 2 seconds.,The child has failed outpatient therapy at this time. After 90 minutes of continuous albuterol treatment, the child still has expiratory wheezes throughout. After I removed the oxygen, the pulse ox was down at 91% indicating hypoxia. The child has a normal level of alertness; however, has not had any vomiting here. I spoke with Dr. X, on call for hospitalist service. She has come down and evaluated the patient. We both feel that since this child had two ER visits this last month, one previous ER visit within the last 5 hours, we should admit the child for continued albuterol treatments, IV steroids, and asthma teaching for the family. The child is admitted in a stable condition.,DIFFERENTIAL DIAGNOSES: ,Ruled out pneumothorax, pneumonia, bronchiolitis, croup.,TIME SPENT: ,Critical care time outside billable procedures was 45 minutes with this patient.,IMPRESSION: ,Status asthmaticus, hypoxia.,PLAN: ,Admitted to Pediatrics.

Difficulty Breathing - ER Visit

Pediatrics - Neonatal

Chronic lymphocytic leukemia (CLL), autoimmune hemolytic anemia, and oral ulcer. The patient was diagnosed with chronic lymphocytic leukemia and was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis.

CHIEF COMPLAINT:,1. Chronic lymphocytic leukemia (CLL).,2. Autoimmune hemolytic anemia.,3. Oral ulcer.,HISTORY OF PRESENT ILLNESS: , The patient is a 72-year-old gentleman who was diagnosed with chronic lymphocytic leukemia in May 2008. He was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis. He has been on chronic steroids to control his hemolysis and is currently on prednisone 5 mg every other day. He comes in to clinic today for follow-up and complete blood count. At his last office visit we discontinued this prophylactic antivirals and antibacterial.,CURRENT MEDICATIONS:, Prilosec 20 mg b.i.d., levothyroxine 50 mcg q.d., Lopressor 75 mg q.d., vitamin C 500 mg q.d., multivitamin q.d., simvastatin 20 mg q.d., and prednisone 5 mg q.o.d.,ALLERGIES: ,Vicodin.,REVIEW OF SYSTEMS: ,The patient reports ulcer on his tongue and his lip. He has been off of Valtrex for five days. He is having some difficulty with his night vision with his left eye. He has a known cataract. He denies any fevers, chills, or night sweats. He continues to have headaches. The rest of his review of systems is negative.,PHYSICAL EXAM:,VITALS:

Anemia & Leukemia Followup

Hematology - Oncology

hematology - oncology, oral ulcer, leukemia, anemia, hemolysis, blood count, chronic lymphocytic leukemia, autoimmune hemolytic anemia, hemolytic, cll, lymphocytic, autoimmune,

Patient with wrist pain and swelling, status post injury.

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.,There is a partial tear of the volar component of the scapholunate ligament in the region of the posttraumatic lunate cyst with retraction and thickening towards the scaphoid (series #6 image #5, series #8 images #22-36). There is tearing of the membranous portion of the ligament. The dorsal component is intact.,The lunatotriquetral ligament is thickened and lax, but intact (series #8 image #32).,There is no tearing of the radial or ulnar attachment of the triangular fibrocartilage (series #6 image #7). There is a mildly positive ulnar variance. Normal ulnar collateral ligament.,The patient was positioned in dorsiflexion. Carpal alignment is normal and there are no tears of the dorsal or ventral intercarpal ligaments (series #14 image #9).,There is a longitudinal split tear of the ECU tendon which is enlarged both at the level of and distal to the ulnar styloid with severe synovitis (series #4 images #8-16, series #3 images #9-16).,There is thickening of the extensor tendon sheaths within the fourth dorsal compartment with intrinsically normal tendons (series #4 image #12).,There is extensor carpi radialis longus and brevis synovitis in the second dorsal compartment (series #4 image #13).,Normal flexor tendons within the carpal tunnel. There is mild thickening of the tendon sheaths and the median nerve demonstrates increased signal without compression or enlargement (series #3 image #7, series #4 image #7).,There are no pathological cysts or soft tissue masses.,IMPRESSION:,Partial tear of the volar and membranous components of the scapholunate ligament with an associated posttraumatic cyst in the lunate. There is thickening and laxity of the lunatotriquetral ligament.,Longitudinal split tear of the ECU tendon with tendinosis and severe synovitis.,Synovitis of the second dorsal compartment and tendon sheath thickening in the fourth dorsal compartment.,Tendon sheath thickening within the carpal tunnel with increased signal within the median nerve.

MRI Wrist - 1

Orthopedic

orthopedic, fourth dorsal compartment, tendon sheath thickening, tendon sheaths, dorsal compartment, volar, carpals, tear, ulnar, synovitis, sheaths, ligament, thickening, dorsal, tendon, injury,

MRI Brain - Pilocytic Astrocytoma in thalamus and caudate.

CC:, Headache.,HX: ,The patient is an 8y/o RHM with a 2 year history of early morning headaches (3:00-6:00AM) intermittently relieved by vomiting only. He had been evaluated 2 years ago and an EEG was "normal" then, but no brain imaging was performed. His headaches progressively worsened, especially in the past two months prior to this presentation. For 2 weeks prior to his 1/25/93 evaluation at UIHC, he would awake screaming. His parent spoke with a local physician who thought this might be due to irritability secondary to pinworms and,Vermox was prescribed and arrangements were made for a neurologic evaluation. On the evening of 1/24/93 the patient awoke screaming and began to vomit. This was followed by a 10 min period of tonic-clonic type movements and postictal lethargy. He was taken to a local ER and a brain CT revealed an intracranial mass. He was given Decadron and Phenytoin and transferred to UIHC for further evaluation.,MEDS:, noted above.,PMH: ,1)Born at 37.5 weeks gestation by uncomplicated vaginal delivery to a G1P0 mother. Pregnancy complicated by vaginal bleeding at 7 months. Met developmental milestones without difficulty. 2) Frequent otitis media, now resolved. 3) Immunizations were "up to date.",FHX:, non-contributory.,SHX:, lives with biologic father and mother. No siblings. In 3rd grade (mainstream) and maintaining good marks in schools.,EXAM:, BP121/57mmHg HR103 RR16 36.9C,MS: Sleepy, but cooperative.,CN: EOM full and smooth. Advanced papilledema, OU. VFFTC. Pupils 4/4 decreasing to 2/2. Right lower facial weakness. Tongue midline upon protrusion. Corneal reflexes intact bilaterally.,Motor: 5/5 strength. Slightly increased muscle on right side.,Sensory. No deficit to PP/VIB noted.,Coord: normal FNF, HKS and RAM, bilaterally.,Station: Mild truncal ataxia. Tends to fall backward.,Reflexes: BUE 2+/2+, Patellar 3/3, Ankles 3+/3+ with 6 beats of nonsustained clonus bilaterally.,Gen exam: unremarkable.,COURSE:, The patient was continued on Dilantin 200mg qd and Decadron 5mg IV q6hrs. Brain MRI, 1/26/93, revealed a large mass lesion in the region of the left caudate nucleus and thalamus which was hyperintense on T2 weighted images. There were areas of cystic formation at its periphery. The mass appeared to enhance on post gadolinium images. there was associated white matter edema and compression of the left lateral ventricle, and midline shift to the right. There was no sign of uncal herniation. He underwent bilateral VP shunting on 1/26/93; and then, subtotal resection (left frontal craniotomy with excision of the left caudate and thalamus with creation of an opening in the septum pellucidum) on 1/28/93. He then received 5040cGy of radiation therapy in 28 fractions completed on 3/25/93. A 3/20/95 neuropsychological evaluation revealed low average intellect on the WISC-III. There were also signs of memory, attention, reading and spelling deficits; and mild right-sided motor incoordination and mood variability. He remained in mainstream classes at school, but his physical and cognitive performance began to deteriorate in 4/95. Neurosurgical evaluation in 4/95 noted increased right hemiplegia and right homonymous hemianopia. MRI revealed tumor progression and he was subsequently placed on Carboplatin/VP-16 (CG 9933 protocol chemotherapy, regimen A). He was last seen on 4/96 and was having difficulty in the 6th grade; he was also undergoing physical therapy for his right hemiplegia.

MRI Brain - Pilocytic Astrocytoma

Neurology

neurology, mri brain, pilocytic astrocytoma, caudate, thalamus, headache, astrocytoma, hemiplegia, pilocytic, mri,

MRI Brain & T-spine - Demyelinating disease.

CC: ,Sensory loss.,HX: ,25y/o RHF began experiencing pruritus in the RUE, above the elbow and in the right scapular region, on 10/23/92. In addition she had paresthesias in the proximal BLE and toes of the right foot. Her symptoms resolved the following day. On 10/25/92, she awoke in the morning and her legs felt "asleep" with decreased sensation. The sensory loss gradually progressed rostrally to the mid chest. She felt unsteady on her feet and had difficulty ambulating. In addition she also began to experience pain in the right scapular region. She denied any heat or cold intolerance, fatigue, weight loss.,MEDS:, None.,PMH:, Unremarkable.,FHX: ,GF with CAD, otherwise unremarkable.,SHX:, Married, unemployed. 2 children. Patient was born and raised in Iowa. Denied any h/o Tobacco/ETOH/illicit drug use.,EXAM:, BP121/66 HR77 RR14 36.5C,MS: A&O to person, place and time. Speech normal with logical lucid thought process.,CN: mild optic disk pallor OS. No RAPD. EOM full and smooth. No INO. The rest of the CN exam was unremarkable.,MOTOR: Full strength throughout all extremities except for 5/4+ hip extensors. Normal muscle tone and bulk.,Sensory: Decreased PP/LT below T4-5 on the left side down to the feet. Decreased PP/LT/VIB in BLE (left worse than right). Allodynic in RUE.,Coord: Intact FNF, HKS and RAM, bilaterally.,Station: No pronator drift. Romberg's test not documented.,Gait: Unsteady wide-based. Able to TT and HW. Poor TW.,Reflexes: 3/3 BUE. Hoffman's signs were present bilaterally. 4/4 patellae. 3+/3+ Achilles with 3-4 beat nonsustained clonus. Plantar responses were extensor on the right and flexor on the left.,Gen. Exam: Unremarkable.,COURSE:, CBC, GS, PT, PTT, ESR, FT4, TSH, ANA, Vit B12, Folate, VDRL and Urinalysis were normal. MRI T-spine, 10/27/92, was unremarkable. MRI Brain, 10/28/92, revealed multiple areas of abnormally increased signal on T2 weighted images in the white matter regions of the right corpus callosum, periventricular region, brachium pontis and right pons. The appearance of the lesions was felt to be strongly suggestive of multiple sclerosis. 10/28/92, Lumbar puncture revealed the following CSF results: RBC 1, WBC 9 (8 lymphocytes, 1 histiocyte), Glucose 55mg/dl, Protein 46mg/dl (normal 15-45), CSF IgG 7.5mg/dl (normal 0.0-6.2), CSF IgG index 1.3 (normal 0.0-0.7), agarose gel electrophoresis revealed oligoclonal bands in the gamma region which were not seen on the serum sample. Beta-2 microglobulin was unremarkable. An abnormal left tibial somatosensory evoked potential was noted consistent with central conduction slowing. Visual and Brainstem Auditory evoked potentials were normal. HTLV-1 titers were negative. CSF cultures and cytology were negative. She was not treated with medications as her symptoms were primarily sensory and non-debilitating, and she was discharged home.,She returned on 11/7/92 as her symptoms of RUE dysesthesia, lower extremity paresthesia and weakness, all worsened. On 11/6/92, she developed slow slurred speech and had marked difficulty expressing her thoughts. She also began having difficulty emptying her bladder. Her 11/7/92 exam was notable for normal vital signs, lying motionless with eyes open and nodding and rhythmically blinking every few minutes. She was oriented to place and time of day, but not to season, day of the week and she did not know who she was. She had a leftward gaze preference and right lower facial weakness. Her RLE was spastic with sustained ankle clonus. There was dysesthetic sensory perception in the RUE. Jaw jerk and glabellar sign were present.,MRI brain, 11/7/92, revealed multiple enhancing lesions in the peritrigonal region and white matter of the centrum semiovale. The right peritrigonal region is more prominent than on prior study. The left centrum semiovale lesion has less enhancement than previously. Multiple other white matter lesions are demonstrated on the right side, in the posterior limb of the internal capsule, the anterior periventricular white matter, optic radiations and cerebellum. The peritrigonal lesions on both sides have increased in size since the 10/92 MRI. The findings were felt more consistent with demyelinating disease and less likely glioma. Post-viral encephalitis, Rapidly progressive demyelinating disease and tumor were in the differential diagnosis. Lumbar Puncture, 11/8/92, revealed: RBC 2, WBC 12 (12 lymphocytes), Glucose 57, Protein 51 (elevated), cytology and cultures were negative. HIV 1 titer was negative. Urine drug screen, negative. A stereotactic brain biopsy of the right parieto-occipital region was consistent with demyelinating disease. She was treated with Decadron 6mg IV qhours and Cytoxan 0.75gm/m2 (1.25gm). On 12/3/92, she has a focal motor seizure with rhythmic jerking of the LUE, loss of consciousness and rightward eye deviation. EEG revealed diffuse slowing with frequent right-sided sharp discharges. She was placed on Dilantin. She became depressed.

MRI Brain & T-spine - Demyelinating disease.

Orthopedic

orthopedic, sensory loss, lumbar puncture, peritrigonal region, centrum semiovale, mri brain, white matter, demyelinating disease, csf, demyelinating, mri, brain,

Functional endoscopic sinus surgery, bilateral maxillary antrostomy, bilateral total ethmoidectomy, bilateral nasal polypectomy, and right middle turbinate reduction.

PROCEDURES PERFORMED:,1. Functional endoscopic sinus surgery.,2. Bilateral maxillary antrostomy.,3. Bilateral total ethmoidectomy.,4. Bilateral nasal polypectomy.,5. Right middle turbinate reduction.,ANESTHESIA:, General endotracheal tube.,BLOOD LOSS:, Approximately 50 cc.,INDICATION: , This is a 48-year-old female with a history of chronic sinusitis as well as nasal polyposis that have been refractory to outpatient medical management. She has underwent sinus surgery in the past approximately 12 years ago with the CT evaluation revealed evidence of chronic mucosal thickening within the maxillary and ethmoid sinuses as well as the presence of polyposis within the nasal cavities bilaterally.,PROCEDURE: ,After all risks, benefits, and alternatives have been discussed with the patient in detail, informed consent was obtained. The patient was brought to the operative suite where she was placed in supine position and general anesthesia was delivered by the Department of Anesthesia. The patient was rotated 90 degrees away where cotton pledgets saturated with 4 cc of 10% cocaine solution were inserted into the nasal cavity. The nasal septum, as well as the turbinates were then localized with a mixture of 1% lidocaine with 1:100,000 epinephrine solution. The patient was then prepped and draped in the usual fashion.,Attention was directed first to the left nasal cavity. A zero-degree sinus endoscope was inserted into the nasal cavity down to the level of the nasopharynx. The initial examination revealed a gross polypoid disease emanating from the sphenoid sinuses as well as off the supreme turbinate. There was also polypoid disease present within the left middle meatus. Nasopharynx was visualized with a patent eustachian tube. At this point, the XPS micro debrider was used to take down all the polyps emanating from the inferior surface of the left middle turbinate as well as from the supreme turbinate. The ostium to the sphenoid sinus was visualized and was not entered. At this point, the left middle turbinate was localized and then medialized with the use of a freer elevator. A ball-tip probe was then used to localize the openings for the natural maxillary ostium. Side-biting forceps were used to take down the uncinate process and was further taken down with the use of the microdebrider. The opening of the maxillary sinus was visualized. The posterior fontanelle was taken down with the use of straight line forceps. It should be mentioned that tissue was very thick and polypoid with chronic inflammatory changes evident. The maxillary sinus ostia was then suctioned with Olive-tip suction and maxillary wash was performed. The remainder of the anterior ethmoid was then cleaned again removing excess polypoid tissue. The basal lamella was visualized and the posterior ethmoid air cells were then entered with use of the microdebrider as the surgical assistant palpated the patient's eyes for any vibration. All polypoid tissue was collected in the microdebrider and sent as a surgical specimen. Once all polypoid tissue has been removed, the cocaine pledgets were reinserted into the ethmoid air cells for hemostatic purposes. Attention was then directed to the right nasal cavity. Again, a sinus endoscope was inserted. Inspection revealed a grossly hypertrophied turbinate. It was felt that this enlarged and polypoid turbinate was contributing the patient's symptoms. Therefore, the turbinate was localized and a hemostat was used to crush the mid portion of the turbinate, which was then resected with use of side-biting scissors as well the Takahashi forceps. Sinus endoscope was then inserted all the way down through the nasopharynx. Again, the eustachian tube was visualized without any obstructing lesions or masses. Upon retraction, there was again polypoid tissue noted within the ethmoid sinuses. The ball-tip probe was again used to locate the right maxillary ostium. The side-biting forceps was used further take down the uncinate process. The maxillary ostium was then widened with use of a XPS microdebrider. A maxillary sinus wash was then performed. Now, the attention was directed to the ethmoid air cells. It should be mentioned again that the tissue of the anterior ethmoid was very thickened and polypoid. This was again taken down with the use of XPS microdebrider while the surgical assistant carefully palpated the patient's eye.,Once all polypoid tissue have been removed, some bleeding that was encountered was controlled with the use of suction cautery in a very conservative manner. Once all bleeding has been controlled, all surgical instruments were removed and Merocel packing was placed in the bilateral nasal cavities with the intent to remove in the recovery room. At this point, the procedure was felt to be complete. The patient was awakened and taken to the recovery room without incident.

Ethmoidectomy & Nasal Polypectomy

ENT - Otolaryngology

ent - otolaryngology, endoscopic sinus surgery, maxillary antrostomy, ethmoidectomy, nasal polypectomy, turbinate reduction, sinus surgery, sinus endoscope, maxillary sinus, nasal cavity, polypoid tissue, sinus, maxillary, turbinate, polypoid, nasal, total, ostium, microdebrider,

The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma of the right adrenal gland with favorable Shimada histology and history of stage 2 left adrenal neuroblastoma, status post gross total resection.

REASON FOR VISIT:, The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma here for ongoing management of his disease and the visit is supervised by Dr. X.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-month-old with neuroblastoma, which initially presented on the left when he was 6 weeks old and was completely resected. It was felt to be stage 2. It was not N-Myc amplified and had favorable Shimada histology. In followup, he was found to have a second primary in his right adrenal gland, which was biopsied and also consistent with neuroblastoma with favorable Shimada histology. He is now being treated with chemotherapy per protocol P9641 and not on study. He last received chemotherapy on 05/21/07, with carboplatin, cyclophosphamide, and doxorubicin. He received G-CSF daily after his chemotherapy due to neutropenia that delayed his second cycle. In the interval since he was last seen, his mother reports that he had a couple of days of nasal congestion, but it is now improving. He is not acted ill or had any fevers. He has had somewhat diminished appetite, but it seems to be improving now. He is peeing and pooping normally and has not had any diarrhea. He did not have any appreciated nausea or vomiting. He has been restarted on fluconazole due to having redeveloped thrush recently.,REVIEW OF SYSTEMS: , The following systems reviewed and negative per pathology except as noted above. Eyes, ears, throat, cardiovascular, GI, genitourinary, musculoskeletal skin, and neurologic., PAST MEDICAL HISTORY:, Reviewed as above and otherwise unchanged.,FAMILY HISTORY:, Reviewed and unchanged.,SOCIAL HISTORY: , The patient's parents continued to undergo a separation and divorce. The patient spends time with his father and his family during the first part of the week and with his mother during the second part of the week.,MEDICATIONS: ,1. Bactrim 32 mg by mouth twice a day on Friday, Saturday, and Sunday.,2. G-CSF 50 mcg subcutaneously given daily in his thighs alternating with each dose.,3. Fluconazole 37.5 mg daily.,4. Zofran 1.5 mg every 6 hours as needed for nausea.,ALLERGIES: , No known drug allergies.,FINDINGS: , A detailed physical exam revealed a very active and intractable, well-nourished 11-month-old male with weight 10.5 kilos and height 76.8 cm. Vital Signs: Temperature is 35.3 degrees Celsius, pulse is 121 beats per minute, respiratory rate 32 breaths per minute, blood pressure 135/74 mmHg. Eyes: Conjunctivae are clear, nonicteric. Pupils are equally round and reactive to light. Extraocular muscle movements appear intact with no strabismus. Ears: TMs are clear bilaterally. Oral Mucosa: No thrush is appreciated. No mucosal ulcerations or erythema. Chest: Port-a-Cath is nonerythematous and nontender to VP access port. Respiratory: Good aeration, clear to auscultation bilaterally. Cardiovascular: Regular rate, normal S1 and S2, no murmurs appreciated. Abdomen is soft, nontender, and no organomegaly, unable to appreciate a right-sided abdominal mass or any other masses. Skin: No rashes. Neurologic: The patient walks without assistance, frequently falls on his bottom.,LABORATORY STUDIES: , CBC and comprehensive metabolic panel were obtained and they are significant for AST 51, white blood cell count 11,440, hemoglobin 10.9, and platelets 202,000 with ANC 2974. Medical tests none. Radiologic studies are none.,ASSESSMENT: , This patient's disease is life threatening, currently causing moderately severe side effects.,PROBLEMS DIAGNOSES: ,1. Neuroblastoma of the right adrenal gland with favorable Shimada histology.,2. History of stage 2 left adrenal neuroblastoma, status post gross total resection.,3. Immunosuppression.,4. Mucosal candidiasis.,5. Resolving neutropenia.,PROCEDURES AND IMMUNIZATIONS:, None.,PLANS: ,1. Neuroblastoma. The patient will return to the Pediatric Oncology Clinic on 06/13/07 to 06/15/07 for his third cycle of chemotherapy. I will plan for restaging with CT of the abdomen prior to the cycle.,2. Immunosuppression. The patient will continue on his Bactrim twice a day on Thursday, Friday, and Saturday. Additionally, we will tentatively plan to have him continue fluconazole since this is his second episode of thrush.,3. Mucosal candidiasis. We will continue fluconazole for thrush. I am pleased that the clinical evidence of disease appears to have resolved. For resolving neutropenia, I advised Gregory's mother about it is okay to discontinue the G-CSF at this time. We will plan for him to resume G-CSF after his next chemotherapy and prescription has been sent to the patient's pharmacy.,PEDIATRIC ONCOLOGY ATTENDING: , I have reviewed the history of the patient. This is an 11-month-old with neuroblastoma who received chemotherapy with carboplatin, cyclophosphamide, and doxorubicin on 05/21/07 for cycle 2 of POG-9641 due to his prior history of neutropenia, he has been on G-CSF. His ANC is nicely recovered. He will have a restaging CT prior to his next cycle of chemotherapy and then return for cycle 3 chemotherapy on 06/13/07 to 06/15/07. He continues on fluconazole for recent history of thrush. Plans are otherwise documented above.

Neuroblastoma - Consult

Neurology

Possible inflammatory bowel disease. Polyp of the sigmoid colon.. Total colonoscopy with photography and polypectomy.

PREOPERATIVE DIAGNOSIS: , Possible inflammatory bowel disease.,POSTOPERATIVE DIAGNOSIS: , Polyp of the sigmoid colon.,PROCEDURE PERFORMED: ,Total colonoscopy with photography and polypectomy.,GROSS FINDINGS: , The patient had a history of ischiorectal abscess. He has been evaluated now for inflammatory bowel disease. Upon endoscopy, the colon prep was good. We were able to reach the cecum without difficulty. There are no diverticluli, inflammatory bowel disease, strictures, or obstructing lesions. There was a pedunculated polyp approximately 4.5 cm in size located in the sigmoid colon at approximately 35 cm. This large polyp was removed using the snare technique.,OPERATIVE PROCEDURE: ,The patient was taken to the endoscopy suite, prepped and draped in left lateral decubitus position. IV sedation was given by Anesthesia Department. The Olympus videoscope was inserted into anus. Using air insufflation, the colonoscope was advanced through the anus to the rectum, sigmoid colon, descending colon, transverse colon, ascending colon and cecum, the above gross findings were noted. The colonoscope was slowly withdrawn and carefully examined the lumen of the bowel. When the polyp again was visualized, the snare was passed around the polyp. It required at least two to three passes of the snare to remove the polyp in its totality. There was a large stalk on the polyp. ________ the polyp had been removed down to the junction of the polyp in the stalk, which appeared to be cauterized and no residual adenomatous tissue was present. No bleeding was identified. The colonoscope was then removed and patient was sent to recovery room in stable condition.

Colonoscopy - 18

Gastroenterology

gastroenterology, polypectomy, inflammatory bowel disease, sigmoid colon, rectum, descending colon, transverse colon, ascending colon, cecum, total colonoscopy, bowel disease, inflammatory, polyp, colonoscopy, colonoscope, bowel,

Rigid bronchoscopy, removal of foreign body, excision of granulation tissue tumor, bronchial dilation , Argon plasma coagulation, placement of a tracheal and bilateral bronchial stents.

PREOPERATIVE DIAGNOSIS:, Airway stenosis with self-expanding metallic stent complication.,POSTOPERATIVE DIAGNOSIS:, Airway stenosis with self-expanding metallic stent complication.,PROCEDURES:,1. Rigid bronchoscopy with removal of foreign body, prolonged procedure taking two hours to remove the stent piecemeal in a very difficult and trying situation.,2. Excision of granulation tissue tumor.,3. Bronchial dilation with a balloon bronchoplasty, right main bronchus.,4. Argon plasma coagulation to control bleeding in the trachea.,5. Placement of a tracheal and bilateral bronchial stents with a silicon wire stent.,ENDOSCOPIC FINDINGS:,1. Normal true vocal cords.,2. Proximal trachea with high-grade occlusion blocking approximately 90% of the trachea due to granulation tissue tumor and break down of metallic stent.,3. Multiple stent fractures in the mid portion of the trachea with granulation tissue.,4. High-grade obstruction of the right main bronchus by stent and granulation tissue.,5. Left main bronchus was covered by the distal portion of the stent and was only being ventilated through the struts of the stent.,6. All in all a high-grade terrible airway obstruction with involvement of the carina, left and right main stem bronchus, mid, distal, and proximal trachea.,TECHNIQUE IN DETAIL: , After informed consent was obtained from the patient, he was brought into the operating field. A rapid sequence induction was done. He was intubated with a rigid scope. Jet ventilation technique was carried out using a rigid and flexible scope. A thorough airway inspection was carried out with findings as described above.,Dr. D was present in the operating room and we conferred on operative strategy and agreed that the best of strategy would be to first dilate the right main bronchus, cauterize it to control bleeding and then piecemeal removed the stent from distal to proximal. This is the technique that was carried out in a painstaking fashion removing bits of the stent piecemeal with finally getting all of the visible stent out of the airway. It should be noted that Dr. Donovan and I felt that two of the metallic stents were probably in place but we cannot be sure because of the terrible anatomy and the fact that the stent pieces were coming out twisted metal in fragments. Nevertheless, all the visible stent was removed, and the airway was much better after with the dilation of balloon and the rigid scope. We took measurements and decided to place stents in the trachea, left and right main bronchus using a Dumon Y-stent. It was measured 18 mm in tracheal diameter and 14 mm in bronchial diameter. The right main stem stent was 2.25 cm in length, the left main stem stent was 3 cm in length and the tracheal portion was 9 cm in length. After it was placed, excellent placement was achieved with the proximal end of the stent 3 cm below the true vocal cords. The patient tolerated the procedure well and was brought to the recovery room extubated.

Bronchoscopy - 5

Cardiovascular / Pulmonary

cardiovascular / pulmonary, airway, argon plasma coagulation, bronchial dilation, balloon bronchoplasty, bronchoscopy, bronchus, foreign body, granulation, metallic stent, stenosis, vocal cords, granulation tissue tumor, plasma coagulation, granulation tissue, tracheal, argon, stents, bronchial, metallic,

Newly diagnosed mantle cell lymphoma, admitted now to start chemotherapy. She will start treatment with hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone.

CHIEF COMPLAINT:, Newly diagnosed mantle cell lymphoma.,HISTORY OF PRESENT ILLNESS: , The patient is a 47-year-old woman who presented with abdominal pain in September 2006. On chest x-ray, she had a possible infiltrate and it was thought she might have pneumonia and she was treated with antibiotics and prednisone. Symptoms improved temporarily, but did not completely resolve. By the end of September, her pain had worsened and she was seen in the emergency room at ABC. Chest x-ray was compatible with pleurisy and she was treated with Percocet. Few days later, she was seen and given a prescription for Ultram because Percocet was causing nausea. Eventually, she was seen by Dr. X and noted to have splenomegaly. Repeat ultrasound was done and showed the spleen enlarged at 19 cm. In retrospect, this was not changed in comparison to an ultrasound that was done in September. She underwent positron emission tomography (PET) scanning, which showed diffuse hypermetabolic lymph nodes measuring 1 to 2 cm in diameter, as well as a hypermetabolic spleen that was enlarged.,The patient underwent lymph node biopsy on the right neck on 10/27/2006. Pathology is consistent with mantle cell lymphoma.,On 10/31/2006, she had a bone marrow biopsy. This does show involvement of bone marrow with lymphoma.,She was noted to have circulating lymphoma cells on peripheral smear as well.,Although CBC was normal, MCV was low and the ferritin was assessed and was low at 8, consistent with iron deficiency.,ALLERGIES:, NONE.,MEDICATIONS: ,1. Estradiol/Prometrium. ,2. Ultram p.r.n. ,3. Baby aspirin. ,4. Lunesta for sleep. ,5. She has been started on iron supplements.,PAST MEDICAL HISTORY: ,1. Tubal ligation in 1986.,2. Possible cyst removed from the left neck in 1991.,3. Tonsillectomy.,4. Migraines, which are rare.,SOCIAL HISTORY: , She does not smoke cigarettes and drinks alcohol only occasionally. She is married and has two children, ages 24 and 20. She works as a project administrator.,FAMILY HISTORY: ,Father is deceased. He had emphysema and colon cancer at age 68. Mother has arrhythmia and hypertension. Her sister has hypertension and her brother is healthy.,PHYSICAL EXAMINATION: ,GENERAL: She is in no acute distress.,VITAL SIGNS: Her weight is 168 pounds, and she is afebrile with a normal blood pressure and pulse.,HEENT: The oropharynx is benign.,SKIN: The skin is warm and dry and shows no jaundice.,NECK: There is shotty adenopathy in the neck.,CARDIAC: Regular rate without murmur.,LUNGS: Clear to auscultation bilaterally.,ABDOMEN: Soft and nontender and shows the spleen palpable about 10 cm below the right costal margin.,EXTREMITIES: No peripheral edema is noted.,LABORATORY DATA: , CBC and chemistry panel are pending. CBC was normal last week. PT/INR was normal as well.,IMPRESSION:, Newly diagnosed mantle cell lymphoma, admitted now to start chemotherapy. She will start treatment with hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone. Toxicities have already been discussed with her including myelosuppression, mucositis, diarrhea, nausea, alopecia, the low risk for cardiac toxicity, bladder toxicity, neuropathy, constipation, etc. Written materials were provided to her last week.,PLAN: , Plan will be to add Rituxan a little later in her course because she has circulating lymphoma cells. She will be started on allopurinol today as well as hydration further to avoid the possibility of tumor lysis syndrome.,Plan will be to have her evaluated for bone marrow transplant in first remission. I will have Dr. Y see her while she is in the hospital.,The patient is anxious, and will be given Ativan as needed. We will discontinue aspirin for now, but continue estradiol/Prometrium.,Iron deficiency will be treated with oral iron supplements and we will follow her counts. She may well have gastrointestinal (GI) involvement, which is not uncommon with mantle cell lymphoma. After she undergoes remission, we will consider colonoscopy for biopsies prior to proceeding to transplant.

Mantle Cell Lymphoma - Consult

Hematology - Oncology

Endoscopic subperiosteal midface lift using the endotine midface suspension device. Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad.

PREOPERATIVE DIAGNOSES:,1. Request for cosmetic surgery.,2. Facial asymmetry following motor vehicle accident.,POSTOPERATIVE DIAGNOSES:,1. Request for cosmetic surgery.,2. Facial asymmetry following motor vehicle accident.,PROCEDURES:,1. Endoscopic subperiosteal midface lift using the endotine midface suspension device.,2. Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR OPERATION: , The patient is a 28-year-old country and western performer who was involved in a motor vehicle accident over a year ago. Since that time, she is felt to have facial asymmetry, which is apparent in publicity photographs for her record promotions. She had requested a procedure to bring about further facial asymmetry. She was seen preoperatively by psychiatrist specializing in body dysmorphic disorder as well as analysis of the patient's requesting cosmetic surgery and was felt to be a psychiatrically good candidate. She did have facial asymmetry with the bit of more fullness in higher cheekbone on the right as compared to the left. Preoperative workup including CT scan failed to show any skeletal trauma. The patient was counseled with regard to the risks, benefits, alternatives, and complications of the postsurgical procedure including but not limited to bleeding, infection, unacceptable cosmetic appearance, numbness of the face, change in sensation of the face, facial nerve paralysis, need for further surgery, need for revision, hair loss, etc., and informed consent was obtained.,PROCEDURE:, The patient was taken to the operating room, placed in supine position after having been marked in the upright position while awake. General endotracheal anesthesia was induced with a #6 endotracheal tube. All appropriate measures were taken to preserve the vocal cords in a professional singer. Local anesthesia consisting of 5/6th 1% lidocaine with 1:100,000 units of epinephrine in 1/6th 0.25% Marcaine was mixed and then injected in a regional field block fashion in the subperiosteal plane via the gingivobuccal sulcus injection on either side as well as into the temporal fossa at the level of the true temporal fascia. The upper eyelids were injected with 1 cc of 1% Xylocaine with 1:100,000 units of epinephrine. Adequate time for vasoconstriction and anesthesia was allowed to be obtained. The patient was prepped and draped in the usual sterile fashion. A 4-0 silk suture was placed in the right lower lid. For traction, it was brought anteriorly. The conjunctiva was incised with the needle tip Bovie with Jaeger lid plate protecting the cornea and globe. A Q-Tip was then used to separate the orbicularis oculi muscle from the fat pad beneath and carried down to the bone. The middle and medial fat pads were identified and a small amount of fat was removed from each to take care of the pseudofat herniation, which was present. The inferior oblique muscle was identified, preserved, and protected throughout the procedure. The transconjunctival incision was then closed with buried knots of 6-0 fast absorbing gut. Contralateral side was treated in similar fashion with like results and throughout the procedure. Lacri-Lube was in the eyes in order to maintain hydration. Attention was next turned to the midface, where a temporal incision was made parallel to the nasojugal folds. Dissection was carried out with the hemostat down to the true temporal fascia and the endoscopic temporal dissection dissector was used to elevate the true temporal fascia. A 30-degree endoscope was used to visualize the fat pads, so that we knew we are in the proper plane. Subperiosteal dissection was carried out over the zygomatic arch and Whitnall's tubercle and the temporal dissection was completed.,Next, bilateral gingivobuccal sulcus incisions were made and a Joseph elevator was used to elevate the periosteum of the midface and anterior face of the maxilla from the tendon of the masseter muscle up to Whitnall's tubercle. The two dissection planes within joint in the subperiosteal fashion and dissection proceeded laterally out to the zygomatic neurovascular bundle. It was bipolar electrocauteried and the tunnel was further dissected free and opened. The endotine 4.5 soft tissue suspension device was then inserted through the temporal incision, brought down into the subperiosteal midface plane of dissection. The guard was removed and the suspension spikes were engaged into the soft tissues. The spikes were elevated superiorly such that a symmetrical midface elevation was carried out bilaterally. The endotine device was then secured to the true temporal fascia with three sutures of 3-0 PDS suture. Contralateral side was treated in similar fashion with like results in order to achieve facial symmetry and symmetry was obtained. The gingivobuccal sulcus incisions were closed with interrupted 4-0 chromic and the scalp incision was closed with staples. The sterile dressing was applied. The patient was awakened in the operating room and taken to the recovery room in good condition.

Midface Lift & Blepharoplasty

Ophthalmology

ophthalmology, cosmetic surgery, jaeger lid plate, lacri-lube, q-tip, blepharoplasty, conjunctiva, facial asymmetry, fat pad, lower lid, midface lift, regional field block, temporal fascia, temporal fossa, vasoconstriction, true temporal fascia, gingivobuccal sulcus, gingivobuccal,

Right lower lobectomy, right thoracotomy, extensive lysis of adhesions, mediastinal lymphadenectomy.

PREOPERATIVE DIAGNOSIS: ,Right lower lobe mass, possible cancer.,POSTOPERATIVE DIAGNOSIS: , Non-small cell carcinoma of the right lower lobe.,PROCEDURES:,1. Right thoracotomy.,2. Extensive lysis of adhesions.,3. Right lower lobectomy.,4. Mediastinal lymphadenectomy.,ANESTHESIA: , General.,DESCRIPTION OF THE PROCEDURE: , The patient was taken to the operating room and placed on the operating table in the supine position. After an adequate general anesthesia was given, she was placed in the left lateral decubitus and the right chest was prepped and draped in the sterile fashion. Lateral thoracotomy was performed on the right side anterior to the tip of the scapula, and this was carried down through the subcutaneous tissue. The latissimus dorsi muscle was partially transected and then the serratus was reflected anteriorly. The chest was entered through the fifth intercostal space. A retractor was placed and then extensive number of adhesions between the lung and the pleura were lysed carefully with sharp and blunt dissection. The right lower lobe was identified. There was a large mass in the superior segment of the lobe, which was very close to the right upper lobe, and because of the adhesions, it could not be told if the tumor was extending into the right upper lobe, but it appeared that it did not. Dissection was then performed at the lower lobe of the fissure, and a GIA stapler was placed through here to separate the tumor from the upper lobe including a small segment of the upper lobe with the lower lobe. Then, dissection of the hilum was performed, and the branches of the pulmonary artery to the lower lobe were ligated with #2-0 silk freehand ties proximally and distally and #3-0 silk transfixion stitches and then transected. The inferior pulmonary vein was dissected after dividing the ligament, and it was stapled proximally and distally with a TA30 stapler and then transected. Further dissection of the fissure allowed for its completion with a GIA stapler and then the bronchus was identified and dissected. The bronchus was stapled with a TA30 bronchial stapler and then transected, and the specimen was removed and sent to the Pathology Department for frozen section diagnosis. The frozen section diagnosis was that of non-small cell carcinoma, bronchial margins free and pleural margins free. The mediastinum was then explored. No nodes were identified around the pulmonary ligament or around the esophagus. Subcarinal nodes were dissected, and hemostasis was obtained with clips. The space below and above the osseous was opened, and the station R4 nodes were dissected. Hemostasis was obtained with clips and with electrocautery. All nodal tissue were sent to Pathology as permanent specimen. Following this, the chest was thoroughly irrigated and aspirated. Careful hemostasis was obtained and a couple of air leaks were controlled with #6-0 Prolene sutures. Then, two #28 French chest tubes were placed in the chest, one posteriorly and one anteriorly, and secured to the skin with #2-0 nylon stitches. The incision was then closed with interrupted #2-0 Vicryl pericostal stitches. A running #1 PDS on the muscle layer, a running 2-0 PDS in the subcutaneous tissue, and staples on the skin. A sterile dressing was applied, and the patient was then awakened and transferred to the following Intensive Care Unit in stable and satisfactory condition.,ESTIMATED BLOOD LOSS: , 100 mL.,TRANSFUSIONS:, None.,COMPLICATIONS:, None.,CONDITION: , Condition of the patient on arrival to the intensive care unit was satisfactory.

Lobectomy & Lymphadenectomy

Cardiovascular / Pulmonary

cardiovascular / pulmonary, right lower lobe, gia stapler, mediastinal, non-small cell carcinoma, cancer, frozen section, hilum, lobectomy, lymphadenectomy, lysis of adhesions, pleura, thoracotomy, upper lobe, lower lobectomy, adhesions, chest